Overdose deaths increased in pregnant and postpartum women from early 2018 to late 2021

Among those aged 35 to 44, overdose mortality more than tripled during this period, NIH study reports

A pregnant young woman is sitting on the bed at home, tenderly holding her belly.
©Getty Images/The Good Brigade

Drug overdose deaths rose markedly between January to June 2018 and July to December 2021 among 10- to 44-year-old girls and women who were pregnant or pregnant within the previous 12 months, according to a new study by researchers at National Institute on Drug Abuse (NIDA) at the National Institutes of Health. Overdose mortality more than tripled among those aged 35 to 44 during the study period, from 4.9 deaths per 100,000 mothers aged 35 to 44 with a live birth in the 2018 period to 15.8 in the 2021 period. Over 60% of these pregnancy-associated overdose deaths occurred outside healthcare settings, though often in counties with available healthcare resources, such as emergency and obstetric care. Published today in JAMA Psychiatry, the findings suggest that, while treatment is available to pregnant women with substance use disorders, significant barriers – such as penalization, stigma, discrimination, and limited socioeconomic resources – may obstruct the path to care, the authors note.

“The stigma and punitive policies that burden pregnant women with substance use disorder increase overdose risk by making it harder to access life-saving treatment and resources,” said Nora Volkow, M.D., NIDA Director and senior author on the study. “Reducing barriers and the stigma that surrounds addiction can open the door for pregnant individuals to seek and receive evidence-based treatment and social support to sustain their health as well as their child’s health.”

While it’s well documented that overdose mortality rose sharply in association with the COVID-19 pandemic, little is known about the specifics of pregnancy-associated overdose mortality during this time. Moreover, the differences in the characteristics of pregnant and postpartum women who died from a drug overdose and those who died of childbirth-related, or obstetric, causes are unknown.

To fill these knowledge gaps, NIDA scientists analyzed U.S. data on multiple cause of death, county-level area health resources, county health rankings, and U.S. births before and during the COVID-19 pandemic – January to June 2018 and July to December 2021. This study focused on individuals aged 10 to 44 belonging to three groups: 1,457 at the pregnant and postpartum stage who died from a drug overdose involving the most common drugs of misuse, excluding alcohol and antidepressants; 4,796 who died of obstetric causes; and 11,205 who died from a drug overdose and were not pregnant in the past 12 months. The study assessed trends in “pregnancy-associated mortality ratios,” which were defined as the number of deaths during or within one year of the end of pregnancy per 100,000 mothers with a live birth.

The researchers found that overdose mortality ratios increased substantially for women who were pregnant or postpartum during the study period, across almost all examined age, racial/ethnic, educational, and marital status groups. The largest increase was observed in pregnant and postpartum women aged 35 to 44, for whom overdose mortality ratios tripled—from 4.9 in the 2018 period to 15.8 in 2021 period. Among those aged 10 to 44 who died between 43 days and one year after pregnancy, overdose mortality ratios almost doubled from 3.1 in the 2018 period to 6.1 in the 2021 period.

Girls and women who died from a drug overdose during pregnancy, compared to those who died from obstetric causes, were more likely to be aged 10 to 34 (75.4% compared with 59.5%), be non-college graduates (72.1% versus 59.4%), be unmarried (88.0% vs. 62.1%), and die in “non-home, non-healthcare settings” (25.9% vs. 4.5%). Unlike most individuals who died from obstetric causes and in a hospital inpatient setting, 60% to 73% of pregnant and postpartum women who died from an overdose were either at home or other non-healthcare places.

Overdose deaths among pregnant and postpartum women also often occurred in areas where there were medical services available, but potentially not accessed. Pregnant and postpartum women who died from an overdose, compared to those who died from obstetric causes, were more likely to reside in counties with doctors practicing obstetrics and gynecology ranking within the 48 to 75th percentile among U.S. counties (32.9% vs. 25.5%). Roughly 51% to 53% of pregnant and postpartum women who died from overdoses resided in counties with at least two general hospitals ranked at the 95th percentile for obstetric care among U.S. counties, and 58% to 67% resided in counties with numbers of practicing psychiatrists per 100,000 county residents ranking over the 75th percentile among U.S. counties.

“These results reflect the persistent national overdose crisis and demonstrate that pregnancy is an urgent time for interventions that can reduce the risk of overdose,” said Emily Einstein, Ph.D., NIDA Science Policy Branch Chief and study co-author. “Stigmatizing and penalizing women with substance use disorders makes it very hard for them to seek help for drug use and receive routine prenatal care. Effective treatments and medical services exist – unfettered access is needed to help mothers and children survive.”

Previous research has shown that pregnant women are less likely to receive an appointment to an addiction treatment center; have difficulties obtaining child care at treatment facilities; and in many states, face punitive policies for their substance use, including fines, loss of custody of their children, involuntary commitment, and incarceration. In states with punitive policies, pregnant women who use drugs have a lower likelihood of receiving timely or quality care. These policies can result in adverse outcomes for their families as well, as children in states with these punitive policies are less likely to be reunited with their parents than those in other states – a system that disproportionately affects Black and American Indian/Alaska Native children.

Future studies are needed to better understand and address these disparities, and to build upon accumulating evidence on the association of overdose mortality in pregnant and postpartum women with poverty and lack of adequate healthcare. More research is also needed on the risk and protective factors of pregnancy-associated mortality among people with and without drug use

For more information on substance and mental health treatment programs in your area, call the free and confidential National Helpline 1-800-662-HELP (4357) or visit www.FindTreatment.gov.



About the National Institute on Drug Abuse (NIDA): NIDA is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world’s research on the health aspects of drug use and addiction. The Institute carries out a large variety of programs to inform policy, improve practice, and advance addiction science. For more information about NIDA and its programs, visit www.nida.nih.gov.

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

About substance use disorders: Substance use disorders are chronic, treatable conditions from which people can recover. In 2022, nearly 49 million people in the United States had at least one substance use disorder. Substance use disorders are defined in part by continued use of substances despite negative consequences. They are also relapsing conditions, in which periods of abstinence (not using substances) can be followed by a return to use. Stigma can make individuals with substance use disorders less likely to seek treatment. Using preferred language can help accurately report on substance use and addiction. View NIDA’s online guide.

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