More than 1,200 pregnant and postpartum women died of a drug overdose in the US in 2020, with overdoses involved in more than 1 in 6 pregnancy-associated deaths that year, according to a new study.
Drug overdose deaths reached record levels nationwide during the Covid-19 pandemic, and research published Tuesday suggests an outsized effect on pregnant and recently pregnant people.
“We’ve made a lot of progress in better understanding addiction as a disease. But when it comes to pregnant and parenting people, it’s still an incredibly stigmatized issue,” said Emilie Bruzelius, a researcher at the Columbia University Mailman School of Public Health and co-author of the study. “It’s really important that pregnant people aren’t overlooked in some of the programs and policies that are being put in place to address overdose.”
In the new study, Bruzelius and Dr. Silvia Martins, director of Columbia University’s Substance Use Epidemiology Unit, tracked trends in the overdose mortality rate from 2017 to 2020 among both pregnant and postpartum people and compared that to others of reproductive age, between 15 and 44.
They found that the overdose mortality rate among pregnant and postpartum people has been lower than the rate for others of reproductive age, but it’s increasing faster for those who are pregnant or within one year of giving birth.
In 2020, there were about 12 pregnancy-associated overdose deaths for every 100,000 births – a 46% spike in one year and an 81% increase since 2017.
There were about 20 deaths for every 100,000 people in the broader reproductive age group, but the rate grew more slowly, increasing 38% since 2017.
Pregnancy-associated deaths are different from maternal mortality, in that they capture deaths among pregnant or recently pregnant people from all causes and not just those that are found to be directly related to pregnancy. Data like this has only been consistently available since 2017, when all 50 states included a checkbox on death certificates to indicate whether the individual was pregnant or postpartum at the time of death.
The lack of reliable information on pregnancy-associated overdose deaths has made it challenging to delve into how and why trends might be different for this group compared with others, Bruzelius said.
“Moving forward, now that all states have implemented this pregnancy checkbox, hopefully we’ll have better information to track these trends overall and make better decisions on programs and policies that could try to mitigate some of these trends.”
Barriers to treatment
Experts say that pregnant and parenting people can experience harmful discrimination when seeking treatment for substance-use disorder. And other unique barriers to access – such as medical needs while pregnant or child care after birth – can keep them away from care and at higher risk for a fatal overdose.
“Everybody that walks through our door cares about their health. But they’re scared to walk in our door because the stigma and the discrimination that they are facing in society – and sometimes in health care – is overwhelming,” said Hendrée Jones, executive director for UNC Horizons, a substance use disorder treatment program specifically for pregnant or parenting women and their children based out of the University of North Carolina School of Medicine.
“They’re scared that their child is going to be removed by child welfare once they have identified as needing help for substance use disorder. We’re seeing pregnant and parenting people that come in, that have overdosed three, four, up to 60 times previously before walking in our doors. And that can mean a lot of loss.”
In October, the Biden administration reported on their plan to “help facilitate universal access to treatment and reduce overdose deaths in pregnant women.”
The report highlighted earlier research that found that individuals posing as pregnant women with substance use disorder were 17% less likely to be accepted for outpatient treatment appointments than other women, and access to treatment can be even harder for women of color, those who live in rural areas and those who don’t speak English.
It also emphasized the importance of preventing unnecessary foster care placement, acknowledging that having substance use disorder in pregnancy is not, by itself, child abuse or neglect.
“Addressing this crisis requires a holistic approach focused on the unique needs of the maternal-infant dyad, addressing social determinants of health, physical and mental health needs, and fostering collaboration across agencies and service providers at all levels (federal, state, local, Tribal),” according to the report.
More deaths involve fentanyl
Jones said that it’s rare for women to begin using drugs while they’re pregnant. Instead, it’s most often the case that women become pregnant while experiencing a substance use disorder and have a hard time stopping.
Mirroring national trends, the new study found a large increase in pregnancy-associated overdose deaths that involved fentanyl and other synthetic drugs and psychostimulants in recent years. Those involving benzodiazepines, heroin and prescription opioids remained mostly stable.
Rates were found to be higher among those in the late postpartum stage – between 6 weeks and one year after giving birth – compared with those who were pregnant or in the early postpartum stage at the time of death.
More work is needed to understand this difference, but Bruzelius suggests that relapse might be a contributing factor.
“If someone is able to cease opioid use, for example, during pregnancy and then they relapse, they could have had a higher likelihood of fatal overdose,” she said – especially with the increase of deadlier drugs like fentanyl.
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Experts also point to the mental health challenges that face anyone experiencing the postpartum period.
“Somebody that has just given birth has had an incredibly life-changing moment. And often the way our health care system deals with them is the focus really changes from the pregnant person to the baby. So right from the beginning, we’ve set up this adversarial relationship with the mother versus child,” Jones said.
“Parenting, even in the best of circumstances, can be really stressful. And if you don’t have the support and care that you need, and the coping mechanisms that you need, it really sets you up for having much less positive outcomes.”