Overdose mortality rates spike in pregnant, postpartum people

The prevalence of drug overdose mortality substantially increased among pregnant and postpartum persons from 2017 to 2020, highlighting the need for more prevention, treatment and harm reduction efforts, researchers reported in JAMA.

While drug overdose deaths reached record highs in 2020 and 2021, “recent national trends in pregnancy-associated overdose mortality are undercharacterized,” Emilie Bruzelius, MPH, a PhD student in the department of epidemiology at the University of Columbia, and Silvia S. Martins, MD, PHD, the director of the substance abuse epidemiology unit in the department of epidemiology at the University of Columbia, wrote in a research letter.

To assess trends, the researchers retrieved data spanning from 2017 to 2020 from the National Vital Statistics System mortality files.

“We calculated annual overdose mortality rates, examining changes over time in absolute and relative terms and by drug type and pregnancy timing,” they wrote.

Bruzelius and Martins identified 7,642 pregnancy-associated deaths from 2017 to 2020. Among them, 1,249 were overdose-related, equaling a cumulative overdose mortality rate of 8.35 per 100,000 (95% CI, 7.89-8.83).

Overall, pregnancy-associated overdose mortality rates increased from 6.56 to 11.85 per 100,000, yielding a relative increase of 81% and an absolute change rate of 5.3 per 100,000 (95% CI, 3.9-6.72), according to the researchers.

Additionally, of reproductive-age persons who identified as female on death certificates, overdose mortality increased from 14.37 to 19.76 per 100,000 (95% CI, 4.94-5.85), an increase of 38%.

Higher overdose mortality was also seen among persons who identified as late postpartum (3.95 per 100,000; 95% CI, 3.64-4.28) compared with those who were pregnant at the time of death (2.99 per 100,000; 95% CI, 2.73-3.29) or who identified as early postpartum (1.39 per 100,000; 95% CI, 1.21-1.6).

Bruzelius and Martins pointed out that overdose deaths associated with heroine, prescription opioids and benzodiazepines remained stable throughout the study period, while large increases were seen in deaths associated with fentanyl, other synthetics and psychostimulants.

The researchers also noted that overdose mortality rates were highest in 2020, with 427 deaths in postpartum or pregnant persons and 12,756 deaths in reproductive-age persons. This, they added, was an apparent effect of the COVID-19 pandemic, which led to shutdowns in the health care system and “an increasingly volatile unregulated drug supply.”

“Pregnancy-associated overdose deaths were also progressively characterized by synthetic opioid and psychostimulant involvement, highlighting the roles of fentanyl and polysubstance use in shaping current overdose risk patterns,” the researchers wrote.

Several study limitations were acknowledged, which included small numbers in some subgroups, limited information on pregnancy and potential undercounting of postpartum persons and overcounting of late postpartum deaths.

The researchers concluded that “enhanced strategies supporting substance use prevention, treatment, and harm reduction efforts among pregnant and postpartum persons are needed.”