Overdose deaths during pregnancy spiked over the past few years, study says

Overdose deaths among pregnant or postpartum people skyrocketed between 2018 and 2021, according to new research published Wednesday in JAMA Psychiatry.

The study, conducted by the National Institute on Drug Abuse (NIDA) and the National Institutes of Health, compared the incidence of maternal deaths for overdose of commonly misused psychotropic drugs (such as heroin and other opioids, including synthetic ones, or cocaine) among girls and women aged 10 to 44.

The spike in overdose deaths was especially high among women ages 35 to 44. In 2018, the rate was 4.9 overdose maternal deaths per 100,000 mothers with a live birth; in 2021, the rate was 15.8 per 100,000. The rate of overdose death for all age groups also increased significantly, from 6.9 per 100,000 mothers in the first half of 2018 to 12.2 in the second half of 2021.

The increase in pregnancy-related overdose deaths overall is in line with the worsening of the public health crises stemming from opioids and other drugs, according to the study.

“As drugs have become more dangerous and people are dying from both what they think is opioids or sometimes what they think is stimulants, or what they think might be pills that they have no idea are going to be fatal, we’re seeing that pregnant women are not immune to that,” said Wilson Compton, NIDA’s deputy director.

The cross-sectional study looked at data from roughly 1,500 pregnant and postpartum overdose deaths, as well as 4,800 maternal deaths and 11,200 non-pregnant overdose deaths. Overdose deaths were classified as postpartum if they occurred within one year after the person had given birth.

Details about the affected demographics, as well as where the deaths occurred, provide important insight into the pregnant and postpartum people most vulnerable to overdoses and what kind of intervention would be most needed.

Compared with pregnant or postpartum people who died in general, those who died of overdose were younger and more likely to be between the ages of 10 and 34 (76%) than those who died of other causes during or after pregnancy (59%). Maternal death by overdose also occurred more frequently among women without a college education and who were unmarried, suggesting the socioeconomic factors leading to the overdose deaths may differ from those causing maternal deaths overall.

One factor that is especially telling is that maternal overdose deaths tended to occur more frequently than maternal deaths overall in states that had adopted Medicaid expansion, often outside health care settings. “Somewhat to our surprise, we saw that there were services available in the areas where the decedents lived. So this suggests to us that they’re not able to access those services, that they’re not taking advantage of them,” said Compton. “Our data don’t say anything about whether the people who died personally had availability. But on average it tells us that simply by putting another hospital in place, that probably wouldn’t solve the problem.”

Even where services are available, said Compton, that doesn’t mean individual people can necessarily access them, especially since treatment for pregnant people with substance use disorder — in particular with opioids — is often riddled with stigma and misconceptions, including among physicians.

“Substance and treatment programs may or may not feel that they’re equipped to take care of women who are pregnant … even though the evidence is very clear that in the case of an opioid use disorder, that treatment with medications can improve the outcomes for the women and for their eventual offspring,” said Compton.

Doctors often try to avoid treating pregnant women, rather than stabilizing them with methadone or other harm reduction interventions, for fear of leading to neonatal abstinence syndrome (NAS) in their children. But research shows that treatment for NAS is available and effective, typically eliminating the risk of long-term damage for the children. Encouraging women to quit during pregnancy, however, has been shown to increase risk of relapse and overdose.

The trends for maternal overdose deaths look more similar to that of overdose deaths — which have stabilized somewhat over the past couple of years starting in the second half of 2021 —  than that of maternal deaths, which continue to increase. Yet Compton said it’s important to think of the crisis as an intersection of both issues, and not focus on the solutions to just one.

“The NIH is supporting research in the maternal health space around integration of substance abuse treatment into obstetrical care,” he said. The hope is that this kind of dual approach would allow pregnant people to access the treatment they need without needing to seek out additional health care, while reducing the stigma around substance use disorder during pregnancy.