Women of reproductive age with substance use disorder (SUD) have lower rates of contraceptive use and higher rates of unintended pregnancy than women without SUD. Understanding the barriers to reproductive health care faced by these women is essential to meeting their health needs. We examined the reproductive health care access and needs of women in treatment for SUD using key informant interviews and focus groups conducted in Maryland and Ohio in 2019 and 2020. Study participants identified many unique reproductive health needs for women in treatment for SUD, including competing social and general health needs; histories of domestic violence, transactional sex, and sexual trauma; and the risks of experiencing an unplanned pregnancy during the sensitive treatment and recovery periods. Barriers to care may include stigma from health care providers, distrust of the health care system, and a perceived lack of autonomy over reproductive decisions. The siloed nature of the health care system, in which SUD treatment and recovery services are typically separated from other health care, was also identified as a major access barrier; study participants suggested co-locating reproductive health services in SUD treatment clinics to improve access to such care. They also emphasized the importance of delivering reproductive health care to women in treatment for SUD in supportive, noncoercive ways, and suggested offering culturally effective reproductive health care as part of women’s overall health and well-being, rather than as a pregnancy prevention tool.