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Background: Mothers and pregnant women who use opioids are particularly vulnerable. Mothers often fear surveillance, stigma, and loss of custody of their children when seeking treatment. Although opioid agonist therapy (OAT) has been shown to be effective, access varies regionally, and not all mothers can cease using opioids. This study compares outcomes of mothers who use opioids in the UK with universal healthcare and OAT access, and mothers in the U.S. with restricted healthcare and OAT access, focusing on their interactions with services. Methods: This is a secondary data analysis of two studies on mothers who use opioids. Data were collected from nine mothers in Scotland (UK) and 20 mothers in New Jersey (US) through ethnographic, longitudinal studies spanning one year. The UK study used a “Learning Alliance” engagement approach, a patient/public engagement model that involves stakeholders in developing objectives and the dissemination of findings. The US study engaged “community-based consultants,” who are paid individuals with lived experience from the study field communities to assist researchers in recruitment and ethnographic fieldwork. Ethical approval was received from review boards. Data were anonymized before analysis, and people with lived experience provided feedback on findings. Grounded theory methods were used for analysis. Results: Findings reveal both convergent and divergent experiences. Mothers in Scotland had more access to healthcare and social housing but faced increased surveillance, while New Jersey mothers often experienced housing insecurity and difficulty obtaining healthcare. Shared challenges included trust issues, stigmatization, inconsistent practitioner engagement, responsibilization, and unclear expectations from child protection services. While Scottish mothers had better access to OAT, both groups faced child custody loss due to unregulated drug use. Mothers in both studies were struggling to meet reunification requirements of abstinence (with or without OAT) within the required time frame. Conclusions: Differing governance structures create persistent challenges across national boundaries. While health practitioners generally support harm reduction strategies, it does not go beyond OAT for mothers. Our findings indicate the need for radical harm reduction approaches with social justice for mothers who use drugs, including safer parental drug use strategies. © The Author(s) 2025.