While maternal mortality is declining in most developed countries, it’s on the rise in the USA. Within the US, the speed of pregnancy-related deaths (defined by the Centers for Disease Control as death occurring while pregnant up to at least one 12 months after delivery) in 2021 was 32.9 deaths per 100,000 live births, a rate that is way higher than in other high-income countries. Pregnancy-related deaths are 3 times more common in American women than in Canadian women and 6 times more common than in Scandinavian women. 

Exactly why we’re seeing this increase in maternal mortality is just not entirely clear. Some attribute this increase in mortality to the incontrovertible fact that the common age of moms is increasing; nonetheless, maternal mortality rates have increased in all age groups. Others suggest that increased mortality may reflect a rise within the prevalence of medical illness amongst pregnant women, including hypertension, heart problems, and diabetes. 

Certainly one of the obstacles to a more complete understanding of those trends in maternal mortality has been the incontrovertible fact that only recently have states required death certificates to point pregnancy status; 4 states still haven’t revised death certificates to incorporate this data. 

Increasing Rates of Overdose in Pregnant and Postpartum Women Through the Pandemic

A recent study from Han and colleagues looks at pregnancy-related deaths because of this of overdoses, specializing in the time frame throughout the COVID-19 pandemic. On this study, researchers analyzed data from the 2018-2021 Multiple Reason for Death Files linked to the 2021 Area Health Resources Files and the 2018-2021 County Health Rankings data on the county level. This cross-sectional, exploratory study included 1,457 pregnant and postpartum women who died because of this of overdose and 4,796 pregnant and postpartum women whose deaths were attributed to other causes, and 11,205 nonpregnant women who died by overdose (aged 10 to 44 years) from 2018 to 2021. 

Between 2018 and 2021, pregnancy-associated overdose mortality rates increased amongst all women in all age groups. Amongst pregnant and postpartum women 35 to 44 years of age, the mortality rate greater than tripled, increasing from 4.9 (95% CI, 3.0-8.0) per 100,000 moms in January to June 2018 to fifteen.8 (95% CI, 12.3-20.4) in July to December 2021. This increase parallels the sharp increases in overdose deaths seen across US populations. 

In comparison with pregnant women who died because of this of other causes, pregnant women who died by overdose were more more likely to be 10 to 34 years of age (75.4% vs 59.5%). Those that died by overdose were more more likely to be non–college graduates (72.1% vs 59.4%), to be single (88.0% vs 62.1%; OR 4.5), and to have died in a non-home, non–health care settings (25.9% vs 4.5%; OR 2.5). 

Maternal Mortality and Overdose Deaths: Data from Massachusetts

Several recent studies have also examined overdose deaths in pregnancy and postpartum women on the state level. In Massachusetts, maternal mortality rates have increased over the past decade. With a view to understand the contribution of overdose deaths to this upward trend, researchers identified pregnancy-associated deaths occurring in Massachusetts during 2005–2014 through the linkage of birth certificates and fetal death records to death certificates of reproductive-age women and thru mandatory reporting to the Department of Public Health. 

Between 2005 and 2014, roughly one in five pregnancy-associated deaths (20.6%) were related to substance use. Researchers observed an increasing trend within the proportion of substance use-related deaths over the study period, rising from 8.7% in 2005 to 41.4% in 2014. Greater than a 3rd (38.3%) of the deaths amongst women delivering a live birth between 2011 and 2015 were fatal opioid-related overdoses. 

Next Steps

ACOG released recommendations regarding universal screening for opioid use disorders in women throughout the perinatal period. This Committee Opinion includes a listing of standardized screening tools for this purpose. As well as, the Massachusetts Perinatal Quality Collaborative provides a useful set of resources for obstetric providers: Maternal Opioid Use During Pregnancy.

The studies highlight the necessity for strengthening community outreach and maternal medical support to higher address substance use on this population. The pandemic has contributed to a rise in overdose deaths; nonetheless, the overall variety of opioid overdose deaths has been increasing over the past 20 years. With a view to reduce pregnancy-associated overdose deaths, we urgently need evidence-based interventions at individual, health care, local, and national levels, in addition to non-punitive approaches that encourage and incentivize pregnant and postpartum women to hunt treatment for substance use disorders.

Ruta Nonacs, MD PhD

References
Han B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and Postpartum Drug Overdose Deaths within the US Before and Through the COVID-19 Pandemic. JAMA Psychiatry. 2024 Mar 1; 81(3):270-283.