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Substance use during pregnancy is associated with poor health outcomes. This study assessed substance use, polysubstance use, and use of select prescription medications during pregnancy. We analyzed 2019 data from the Pregnancy Risk Assessment Monitoring System in 25 United States jurisdictions that included questions on prescription medications, tobacco, and illicit substance use during pregnancy. Alcohol and electronic cigarette use were assessed during the last three months of pregnancy, and all other substances and medications were assessed throughout pregnancy. Weighted prevalence estimates and 95% confidence intervals (CIs) were calculated. Nearly one-fifth of respondents who reported use of any substance reported use of at least one other substance during pregnancy. Cigarettes (8.1%; 95% CI 7.6–8.7%) and alcohol (7.4%; 95% CI 6.7–8.1%) were the most frequently reported substances, followed by cannabis (4.3%; 95% CI 3.9–4.7%). Substance use was higher among individuals who reported having depression or using antidepressants during pregnancy compared with those who did not report depression or antidepressant use. Illicit drug use prevalence was low (0.5%, 95% CI 0.4–0.7%); however, respondents reporting heroin use also frequently reported use of illicit stimulants (amphetamines: 51.7%, 95% CI 32.1–71.3% or cocaine: 26.5%, 95% CI 11.9–41.1%). Although prenatal clinician screening for alcohol and cigarette use was approximately 95%, fewer respondents (82.1%) reported being screened for cannabis or illicit substance use during pregnancy. One in five individuals who reported use of any substance during pregnancy engaged in polysubstance use, highlighting the importance of comprehensive screening and evidence-based interventions including harm reduction. • Approximately one in five people who used substances during pregnancy used more than one substance. • Cigarettes and alcohol were the substances most frequently used during pregnancy. • Those who reported heroin use often reported using illicit stimulants, though this was a small proportion of respondents. • Screening for cigarettes and alcohol during pregnancy was higher than screening for other substances. [ABSTRACT FROM AUTHOR]