While maternal mortality is declining in most developed countries, it is on the rise in the United States. In the US, the rate of pregnancy-related deaths (defined by the Centers for Disease Control as death during pregnancy up to one year after delivery) in 2021 was 32.9 deaths per 100,000 live births, a rate that is much higher than in other high-income countries. Pregnancy-related deaths are three times more common among American than Canadian women and six times more common than Scandinavian women.
Exactly why we are seeing this increase in maternal mortality is not entirely clear. Some attribute this increase in mortality to the fact that the average age of mothers is increasing. however, Maternal mortality rates have increased in all age groups. Others suggest that the increased mortality may reflect an increase in the prevalence of medical illnesses among pregnant women, including hypertension, cardiovascular disease, and diabetes.
One of the obstacles to a more complete understanding of these trends in maternal mortality has been the fact that only recently have states required death certificates to indicate pregnancy status. four states have not yet revised their death certificates to include this data.
Pregnant and postpartum overdose rates are increasing during the pandemic
A recent study by Han and colleagues examines pregnancy-related deaths as a result of overdose, focusing on the time period during the COVID-19 pandemic. In this study, researchers analyzed data from the 2018-2021 Multiple Cause of Death Records linked to the 2021 Area Health Resource Records and County Health Rankings 2018-2021 county-level data. This cross-sectional, exploratory study included 1,457 pregnant and postpartum women who died as a result of an overdose and 4,796 pregnant and postpartum women whose death was attributed to other causes and 11,205 non-pregnant women who died of an overdose (aged 10 to 44 years). from 2018 to 2021.
Between 2018 and 2021, pregnancy-related overdose death rates increased for all women in all age groups. Among pregnant and postpartum women aged 35 to 44 years, the death rate more than tripled, rising from 4.9 (95% CI, 3.0-8.0) per 100,000 mothers in January to June 2018 to 15 .8 (95% CI, 12.3-20.4) in July to December 2021. This increase parallels the sharp increases in overdose deaths seen in US populations.
Compared with pregnant women who died as a result of other causes, pregnant women who died of an overdose were more likely to be aged 10 to 34 (75.4% vs. 59.5%). Those who died of an overdose were more likely to be 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-healthcare settings (25.9% vs 4.5%, OR 2.5).
Maternal mortality and overdose deaths: Evidence from Massachusetts
Several recent studies have also looked at overdose deaths in pregnant and postpartum women at the state level. In Massachusetts, maternal mortality rates have increased over the past decade. To understand the contribution of overdose deaths to this upward trend, Researchers tracked pregnancy-related deaths that occurred in Massachusetts between 2005 and 2014 through the linking of birth certificates and fetal death registries with death certificates of women of reproductive age and through mandatory reporting to the Ministry of Public Health.
Between 2005 and 2014, about one in five pregnancy-related deaths (20.6%) were related to substance use. The researchers observed an increasing trend in the proportion of deaths related to substance use during the study period, rising from 8.7% in 2005 to 41.4% in 2014. More than a third (38.3%) of of deaths among women who gave birth live between 2011 and 2015 were fatal opioid-related overdoses.
Next steps
ACOG Releases Recommendations on Universal Screening for Opioid Use Disorders in Perinatal Women. This committee opinion includes a list of standardized screening tools for this purpose. In addition, the Massachusetts Perinatal Quality Partnership provides a helpful set of resources for obstetricians: Maternal opioid use during pregnancy.
The studies highlight the need to strengthen community outreach and maternal medical support to better address substance use in this population. The pandemic has contributed to an increase in overdose deaths. However, the overall number of opioid overdose deaths has been increasing over the past 20 years. In order to reduce pregnancy-related overdose deaths, we urgently need evidence-based interventions at the individual, health, local and national levels, as well as non-punitive approaches that encourage and motivate pregnant and postpartum women to seek substance use treatment disorders.
Ruta Nonacs, MD PhD
bibliographical references
Han B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and postpartum drug overdose deaths in the US before and during the COVID-19 pandemic. JAMA Psychiatry. March 1, 2024; 81(3):270-283.
