Pregnancy-associated Mortality Research Articles

Pregnancy-associated mortality during the pandemic: disparities by rurality

IntroductionIn the US, rural areas experience higher rates of adverse maternal health outcomes, but little data exists on rural/urban differences in pregnancy-associated deaths (PAD, all deaths during pregnancy and postpartum) or rural/urban differences in those deaths during the COVID-19 pandemic. MethodsCross-sectional US vital statistics mortality data from 2018 to 2021 was used to identify PAD (analyzed in 2024). PAD ratios (deaths per 100,000 live births) and 95% confidence intervals (CIs) were calculated by year, cause, and rurality (urban, suburban, rural). The percent change in PAD ratios between the pre-pandemic (2018 and 2019) and pandemic (2020 and 2021) time periods was calculated by rurality. ResultsDuring the pandemic, rural—compared to suburban and urban—areas had the highest pregnancy-associated death ratios due to obstetric causes (53.9 deaths/100,000 live births, 95%CI: 48.8, 59.4), drug-related causes (19.0, 95%CI: 16.0, 22.4), suicide (4.4., 95%CI: 3.0, 6.2), and other causes (the majority of which are motor vehicle accidents, 16.4, 95%CI: 14.0, 19.6). Rural areas experienced increases in all causes of pregnancy-associated death from pre-pandemic (2018 and 2019) to pandemic (2020 and 2021) with increases of 48.1% in obstetric deaths, 115.9% in drug-related deaths, 17.8% in homicide, 25.7% in suicide, and 11.6% in other causes. Rural areas experienced the largest (compared to urban and suburban) increase in drug-related deaths, and only rural areas experienced an increase in suicide during the pandemic. ConclusionsRural areas experience a high burden of pregnancy-associated death, and this inequity was exacerbated during the COVID-19 pandemic.

Pregnancy-Associated Firearm Mortality in the U.S., 2008–2019

IntroductionThis study analyzed the contribution of firearms to pregnancy-associated mortality from homicide and suicide. MethodsThis was a retrospective cohort study using the CDC's National Violent Death Reporting System from 2008 – 2019. Women aged 15-44 years who died by suicide (intentional self-harm) and homicide where a firearm was involved were included. Persons without known pregnancy status were excluded. Pregnancy-associated deaths were defined as those that occurred during pregnancy or within 1 year of pregnancy (early and late postpartum). Sociodemographic characteristics, social, and circumstantial differences were compared in pregnancy-associated and non-pregnant deaths. Data analysis was conducted in 2022 – 2023. ResultsA total of 1,803 homicide and 1,929 suicide deaths from firearms were included. Twenty-two percent (n=388) and 11% (n=212) of firearm homicides and suicides respectively, were pregnancy-associated. Victims of pregnancy associated homicide were predominantly Black (54.8%), single (76%), and had high school diploma or equivalent degree (41.2%). Victims of pregnancy-associated suicide were predominantly White (80.5%). Among pregnancy-associated homicides and suicides, deaths occurred more frequently during pregnancy (63.4% and 40.3%). Compared to non-pregnancy associated homicides, pregnancy-associated homicides more frequently occurred in the victim's home (51.5% vs 46.7%, p=0.02) and was related to ongoing conflict or violence between a current or former partner (61.6% vs 51.9%, p < 0.001). Compared to non-pregnancy-associated suicide, pregnancy-associated suicides more frequently occurred in those who experienced intimate partner violence within a month of death (4.2% vs 1.3%, p=0.005). ConclusionsWhile there are differences in demographic characteristics between victims, interpersonal violence is associated with both pregnancy-associated homicides and suicides where a firearm was involved.

Pregnancy-associated mortality due to cardiovascular disease: Impact of hypertensive disorders of pregnancy.

Reported rates of maternal mortality in the United States have been staggeringly high and increasing, and cardiovascular disease (CVD) is a chief contributor to such deaths. However, the impact of hypertensive disorders of pregnancy (HDP) on the short-term risk of cardiovascular death is not well understood. To evaluate the association between HDP (chronic hypertension, gestational hypertension, preeclampsia, eclampsia, and superimposed preeclampsia) and pregnancy-associated mortality rates (PMR) from all causes, CVD-related causes both at delivery and within 1 year following delivery. We used the Nationwide Readmissions Database (2010-2018) to examine PMRs for females 15-54 years old. International Classification of Disease 9 and 10 diagnosis codes were used to identify pregnancy-associated deaths due to HDP and CVD. Discrete-time Cox proportional hazards regression models were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for mortality at delivery (0 days) and at <30, <60, <90, <180, and <365 days after delivery in relation to HDP. Of 33,417,736 hospital deliveries, the rate of HDP was 11.0% (n = 3,688,967), and the PMR from CVD was 6.4 per 100,000 delivery hospitalisations (n = 2141). Compared with normotensive patients, HRs for CVD-related PMRs increased with HDP severity, reaching over 58-fold for eclampsia patients. HRs were higher for stroke-related (1.2 to 170.9) than heart disease (HD)-related (0.99 to 39.8) mortality across all HDPs. Except for gestational hypertension, the increased risks of CVD mortality were evident at delivery and persisted 1 year postpartum for all HDPs. HDPs are strong risk factors for pregnancy-associated mortality due to CVD at delivery and within 1 year postpartum; the risks are stronger for stroke than HD-related PMR. While absolute PMRs are low, this study supports the importance of extending postpartum care beyond the traditional 42-day postpartum visit for people whose pregnancies are complicated by hypertension.

Perinatal mental health and pregnancy-associated mortality: opportunities for change.

Perinatal mental health conditions have been associated with adverse pregnancy outcomes, including maternal death. This quality improvement project analyzed pregnancy-associated death among veterans with mental health conditions in order to identify opportunities to improve healthcare and reduce maternal deaths. Pregnancy-associated deaths among veterans using Veterans Health Administration (VHA) maternity care benefits between fiscal year 2011 and 2020 were identified from national VHA databases. Deaths among individuals with active mental health conditions underwent individual chart review using a standardized abstraction template adapted from the Centers for Disease Control and Prevention (CDC). Thirty-two pregnancy-associated deaths were identified among 39,720 paid deliveries with 81% (n = 26) occurring among individuals with an active perinatal mental health condition. In the perinatal mental health cohort, most deaths (n = 16, 62%) occurred in the late postpartum period and 42% (n = 11) were due to suicide, homicide, or overdose. Opportunities to improve care included addressing (1) racial disparities, (2) mental health effects of perinatal loss, (3) late postpartum vulnerability, (4) lack of psychotropic medication continuity, (5) mental health conditions in intimate partners, (6) child custody loss, (7) lack of patient education or stigmatizing patient education, and (8) missed opportunities for addressing reproductive health concerns in mental health contexts. Pregnancy-associated deaths related to active perinatal mental health conditions can be reduced. Mental healthcare clinicians, clinical teams, and healthcare systems have opportunities to improve care for individuals with perinatal mental health conditions.

Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions.

The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011-2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43-365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.

Perinatal Psychoactive Substances Use: A Rising Perinatal Mental Health Concern.

A significant increase in psychoactive drugs use was observed in women of childbearing age and during the perinatal period worldwide. Yet, the use of illicit drugs, alcohol and tobacco during pregnancy is a serious health risk for the mother, developing fetus and newborn. This review of current trends and consequences of psychoactive substance use in the general population and in pregnant women was conducted using the English and French literature published during the years 2000 to 2022, supplemented by guidelines, meta-analyses and reviews. According to current rates of prenatal substances use, it was calculated that 380,000 offspring were exposed to illicit substances, more than 500,000 to alcohol and over one million to tobacco during uterine life. Alarmingly, drug-related pregnancy-associated mortality has shown a staggering 190% rise between 2010 and 2019 in the USA. Different drugs of abuse, when used during pregnancy, increase the risk of stillbirth, neonatal abstinence syndrome and sudden infant death. Adverse effects on pregnancy include premature rupture of membranes, placental abruption, preterm birth, low birth space? weight and small-for-gestational-age infants. There is also an increased risk of morbidity and mortality for the pregnant women. Long-term negative adverse effects of perinatal exposure to substances also include a number of neurocognitive, behavioral and emotional dysfunctions in infants. Each type of substance has its own specificities, which will be briefly summarized. All childbearing age women must be informed about the potential harm of the prenatal use of psychoactive substances and should be encouraged to stop their use when pregnancy is planned and, at least, when pregnancy is known. Questioning women about their alcohol consumption should be systematic at the first prenatal visit and then at every prenatal visit until delivery. Multidisciplinary prevention approaches as well as intervention measures targeted to each type of psychoactive substance can save mothers' lives and mitigate serious adversities to the offspring.

Animal Models for Studying Congenital Transmission of Hepatitis E Virus.

One of the most intriguing issues in the hepatitis E virus (HEV) field is the significant increase in mortality rates of the mother and fetus when infection occurs in the second and third trimesters of gestation. A virus that is normally self-limiting and has a mortality rate of less than one percent in otherwise healthy individuals steeply rises by up to 30% in these pregnant populations. Answering this pivotal question has not been a simple task. HEV, in general, has been a difficult pathogen to understand in the laboratory setting. A historical lack of ability to efficiently propagate the virus in tissue culture models has led to many molecular aspects of the viral lifecycle being understudied. Although great strides have been made in recent years to adapt viruses to cell culture, this field remains behind other viruses that are much easier to replicate efficiently in vitro. Some of the greatest discoveries regarding HEV have come from using animal models for which naturally occurring strains of HEV have been identified, including pigs and chickens, but key limitations have made animal models imperfect for studying all aspects of human HEV infections. In addition to the difficulties working with HEV, pregnancy is a very complicated biological process with an elaborate interplay between many different host systems, including hormones, cardiovascular, kidneys, respiratory, gastrointestinal, epithelial, liver, metabolic, immune, and others. Significant differences between the timing and interplay of these systems are notable between species, and making direct comparisons between animals and humans can be difficult at times. No simple answer exists as to how HEV enhances mortality in pregnant populations. One of the best approaches to studying HEV in pregnancy is likely a combinatorial approach that uses the best combination of emerging in vitro and in vivo systems while accounting for the deficiencies that are present in each model. This review describes many of the current HEV animal model systems and the strengths and weaknesses of each as they apply to HEV pregnancy-associated mortality. We consider factors that are critical to analyzing HEV infection within the host and how, despite no perfect animal model for human pregnancy mortality existing, recent developments in HEV models, both in vitro and in vivo, are advancing our overall understanding of HEV in the pregnant host.

Changes in Pregnancy-Associated Deaths in the US During the COVID-19 Pandemic in 2020

This cross-sectional study assesses changes in pregnancy-associated mortality from drug overdose, homicide, suicide, and other causes in the US from 2018 through 2020.

Incidence of VTE in Pregnant Women with Sickle Cell Gene Mutation(s): A Retrospective Database Analysis

Purpose/Objective(s): The leading cause of pregnancy-associated mortality in Western countries is venous thromboembolism (VTE) with an absolute incidence of 0.025 to 0.1 percent in the general pregnant population. Noubiap et al reported that sickle cell disease (SCD) patients had a significantly higher risk for VTE (pooled OR 4.4, 95%CI 2.6-7.5, p < 0.001), deep vein thrombosis (DVT) (OR 1.1, 95% CI 1.1-1.2, p < 0.001) and pulmonary embolism (PE) (pooled OR 3.7, 95% CI 3.6-3.8, p < 0.001) as compared to patients without SCD [1]. Although sickle cell trait (SCT) and SCD have an increased risk for VTE, the incidence of VTE during pregnancy has not been documented. Our primary objective was to record a composite incidence of VTE among pregnant patients with SCT/SCD. Material/Methods: A retrospective, cross-sectional analysis including pregnant patients with SCT and SCD was conducted at our tertiary care academic medical center. Data was collected between January 2011 and December 2020. Adult women up to 51 years old with hemoglobin electrophoresis proven SCT and SCD were included. Risk factors for VTE such as the patient's body mass index (BMI), COVID status, family history of VTE, and smoking history were included in the analysis. ANOVA and Chi-square tests were used for analysis and to calculate a composite incidence, odds ratio, confidence interval, and p-value. A p-value of <0.05 was considered statistically significant. Data was analyzed using the SAS system. Results: A total of 139 pregnant SCT/SCD patients were included for analysis, out of which, the majority of the patients were SCT (84/139, 60.4%). The mean age at pregnancy was 26.42 (standard deviation 5.72). The type of VTE included DVT 58.3% (14/24) and PE 41.7% (10/24). At our facility, the incidence rate of VTE in pregnancy for SCT/SCD was 17% as compared to 0.025 to 0.1% in the general population. There was no statistically significant difference in the odds of developing VTE between SCD and SCT (OR= 1.09, 95% CI [.45, 2.63]). Only 2.16% of patients had positive COVID infection, as most of the collected data predated the pandemic. Almost one-third of the patients were smokers (45/139) and only 2.88% (4/139) had a family history of VTE. BMI was divided into BMI <30 (38.13%, 53/139) and BMI >30 (61.87%, 86/139). Obesity (OR= 1.03, 95% CI [.4166, 2.56]) and COVID status (OR=2.45, 95% CI [.21, 28.23]) were not found to be significant in our population of patients. Patients with a family history of DVT had a greater odd of developing VTE (OR=50.70, 95% CI [2.63, 977.88]), although the sample may not provide a precise representation of the population mean. Conclusion: Currently, ASH guidelines recommend a conservative approach to VTE prophylaxis unless research suggests benefits [2]. Our analysis found a 17% incidence of pregnancy-associated VTE in our SCT/SCD patients, which is drastically higher than the general population. With such a significant increased incidence in this patient population, especially with current racial disparities in African American maternal mortality rates, more research should be conducted to evaluate the need for thromboprophylaxis/treatment. Additionally, evaluation for specific SCT/SCD guidelines and recommendations to decrease pregnancy-related VTE and mortality rates should be discussed.

Integrating National Violent Death Reporting System Data into Maternal Mortality Review Committees.

Background: With the Maternal Mortality Review Information Application (MMRIA) data system, the Centers for Disease Control and Prevention (CDC), alongside Maternal Mortality Review Committees (MMRCs), are developing comprehensive and uniform data collection to eradicate preventable maternal deaths. However, MMRIA is primarily focused on pregnancy-related deaths, and not pregnancy-associated deaths. Currently, the National Violent Death Reporting System Restricted Access Data (NVDRS-RAD) on pregnancy-associated homicides and suicides are not included in MMRIA and by extension the work of most MMRCs. This study examined the NVDRS-RAD data from 2014 to 2017 and argues that the data for pregnancy-associated maternal deaths should be integrated into the work of MMRCs. Methods: A secondary data analysis of the NVDRS-RAD from 2014 to 2017 was conducted. Pregnancy-associated mortality was identified using data available within the NVDRS-RAD and categorized according to period of pregnancy and manner of death. Descriptive statistics and risk ratios were calculated. Chi-square tests were also calculated. Results: The results indicate that pregnancy and the postpartum period show increased risk for homicide and suicide. Pregnant women were found to be five times more likely to die by homicide than their nonpregnant peers who died by violent means. The relationships between periods of pregnancy and manner of death were all found to be significantly associated although the association was weak. Conclusions: Integrating National Violent Death Reporting System data on pregnancy-associated deaths into MMRIA would improve the efficacy of MMRCs and address the intertwined risk factors driving the racial disparities of the United States' maternal mortality rate.

The Index of Concentration at the Extremes (ICE) and Pregnancy-Associated Mortality in Louisiana, 2016-2017.

Social and contextual factors underlying the continually disproportionate and burdensome risk of adverse health outcomes experienced by Black women in the US are underexplored in the literature. The aim of this study was to use an index based on area-level population distributions of race and income to predict risk of death during pregnancy and up to 1 year postpartum among women in Louisiana. Using vital records data provided by the Louisiana Department of Health 2016-2017 (n = 125,537), a modified Poisson model was fit with generalized estimating equations to examine the risk of pregnancy-associated death associated with census tract-level values of the Index of Concentration at the Extremes (ICE)-grouped by tertile-while adjusting for both individual and tract-level confounders. Analyses resulted in an estimated 1.73 (95% CI 1.02-2.93) times increased risk for pregnancy-associated death for those in areas which were characterized by concentrated deprivation (high proportions of Black and low-income residents) relative to those in areas of concentrated privilege (high proportions of white and high-income residents), independent of other factors. In addition to continuing to consider the deeply entrenched racism and economic inequality that shape the experience of pregnancy-associated death, we must also consider their synergistic effect on access to resources, maternal population health, and health inequities.

Improved Recognition of Maternal Deaths Using Modern Data Analytics.

To use a data-fusion approach to improve ascertainment of maternal deaths not detected with standard surveillance strategies. We conducted a retrospective cohort study from the electronic health records of a tertiary medical center from 2011 to 2018. Cases of maternal death were identified in two ways: 1) using a standard medical informatics service query of hospital data and 2) using the TriNetX discovery tool as patients with a vital status of "deceased" and evidence of antecedent pregnancy exposure based on such factors as obstetric diagnostic codes or obstetric-related procedures. Potential cases of maternal death identified by the latter method underwent chart review to confirm timing of death compared with timing of last appreciable pregnancy, and to characterize the details of these deaths. The primary outcome was pregnancy-associated mortality during pregnancy or within the first postpartum year in the discovery cohort compared with the hospital-identified cohort. Secondary outcomes included causes of death and comorbidities. During the study period, the standard service query identified 23 maternal deaths. The discovery tool identified 18 additional patients confirmed on subsequent chart review to represent pregnancy-associated deaths, a 78% increase in ascertainment of which a greater proportion represented postpartum deaths. The majority (61%) of newly ascertained mortalities were related to cardiac causes or other medical comorbidities. Although many hospital-ascertained cases were associated with deaths after delivery of a living newborn, more deaths after early pregnancy loss or termination were identified through the discovery tool. Improved recognition of pregnancy-associated deaths can be achieved with modern data analytics.

417 A difficult to tell reality: care improvement opportunities for fatal cases of placenta accreta spectrum

Almost all cases of maternal death (MD) due to postpartum hemorrhage (PPH) are preventable. Placenta Accreta Spectrum (PAS) is a common cause of massive PPH. Few studies analyze PAS cases that result in MD. This paper aims to identify “delays” in the care of patients who died because of PAS in Latin America. We conducted a retrospective, descriptive, observational multicentric study in Latin American hospitals. We analyzed the care of patients who died from PAS, under The California Pregnancy-Associated Mortality Review Committee model, and take into account management standards of centers of excellence in PAS. The information was collected through a predesigned survey and discussed by telephone contact between the principal investigators and each local team. Thirty-four patients in eight Latin American countries (Colombia, Guatemala, Paraguay, Bolivia, Peru, Ecuador, Brazil and Venezuela) were included. Delays were identified in all cases (Table 1). The most prevalent type of delay was associated with health providers (97%), followed by health institutions (94%) and related to patients (76.5%). The principal cause of death was PPH (31 cases), followed by sepsis (2 cases) and pulmonary thromboembolism (1 case). Most delays were associated with the quality of health services, identifying as the main factors associated with death: failure to diagnose PAS with prenatal ultrasounds (35.3%) and underestimation of risk on suspicion of PAS (35.3%). The analysis groups defined maternal deaths as avoidable in all cases and determined that the interventions needed to change the outcome would have low, moderate, and high difficulty in 29, 50, and 21% of cases, respectively In all cases of PAS related to maternal death, we identify multiple improvement opportunities. All maternal deaths due to PAS were preventable, most of them with low to moderate complexity interventions.

Suicide, Overdose Are Significant Contributors to Pregnancy-Related Maternal Deaths

Suicide, Overdose Are Significant Contributors to Pregnancy-Related Maternal Deaths

Addressing opioid use disorder among rural pregnant and postpartum women: a study protocol

BackgroundOpioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999–2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD.MethodsThis two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes.DiscussionThis article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities.Trial registration NCT04448015 clinicaltrials.gov.

Maternity Care Deserts and Pregnancy-Associated Mortality in Louisiana.

Maternal mortality is an issue of growing concern in the United States, where the incidence of death during pregnancy and postpartum seems to be increasing. The purpose of this analysis was to explore whether residing in a maternity care desert (defined as a county with no hospital offering obstetric care and no OB/GYN or certified nurse midwife providers) was associated with risk of death during pregnancy and up to 1year postpartum among women in Louisiana from 2016 to2017. Data provided by the March of Dimes were used to classify Louisiana parishes by level of access to maternity care. Using data on all pregnancy-associated deaths verified by the Louisiana Department of Health (n=112 from 2016 to 2017) and geocoded live births occurring in Louisiana during the same time period (n=101,484), we fit adjusted modified Poisson regression models with generalized estimating equations and exploratory spatial analysis to identify significant associations between place of residence and risk of death. We found that the risk of death during pregnancy and up to 1year postpartum owing to any cause (pregnancy-associated mortality) and in particular death owing to obstetric causes (pregnancy-related mortality) was significantly elevated among women residing in maternity care deserts compared with women in areas with greater access (adjusted risk ratio [aRR] for pregnancy-associated mortality, 1.91; 95% confidence interval [CI], 1.15-3.18; aRR for pregnancy-related mortality, 3.37; 95% CI, 1.71-6.65). A large racial inequity in risk persisted above and beyond differences in geographic access to maternity care (non-Hispanic Black vs. non-Hispanic White aRR for pregnancy-associated mortality, 2.22; 95% CI, 1.39-3.56; aRR for pregnancy-related mortality, 2.66; 95% CI, 1.16-6.12). Ensuring access to maternity care may be an important step toward maternal mortality prevention, but may alone be insufficient for achieving maternal health equity.

Pregnancy-Associated Mortality Due to Accidental Drug Overdose and Suicide in Ohio, 2009-2018.

Pregnancy-Associated Mortality Due to Accidental Drug Overdose and Suicide in Ohio, 2009-2018.

Substance Use in Pregnancy Remains a Challenge

Back to table of contents Previous article Next article Clinical & ResearchFull AccessSubstance Use in Pregnancy Remains a ChallengeTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:17 Jun 2020https://doi.org/10.1176/appi.pn.2020.6b2AbstractCigarette smoking and opioid use disorder in pregnant women illustrate the need for more screening, education, and treatment.Psychiatrists should screen all of their pregnant patients for substance use, including cigarette smoking, says Kimberly Yonkers, M.D.Yale University/Robert A LisakFour in five women who decrease or stop hazardous alcohol, tobacco, or drug use during pregnancy return to using those substances after their babies are born, but there are concrete steps psychiatrists can take to treat women both before and throughout their pregnancies. Kimberly Yonkers, M.D., director of the Division of Psychological Medicine and the Center for Wellbeing of Women and Mothers at Yale School of Medicine, discussed different substances, their impact on maternal and infant health, and the importance of tailored treatment in a presentation at the virtual APA Spring Highlights Meeting in April.Pregnant women tend to stop using alcohol earlier in their pregnancies than they stop using tobacco, cocaine, or marijuana, and they are slowest to stop smoking cigarettes, with many women smoking throughout pregnancy or resuming smoking shortly after delivery, explained Yonkers, who is also editor of the APA journal Psychiatric Research and Clinical Practice.“Cigarette smoking in general has been decreasing, but still between 10% and 15% of women [smoke], and it’s very, very difficult to discontinue smoking, even in pregnancy,” Yonkers said.She noted that pharmacological treatments have not shown a benefit in treating pregnant women who smoke. For patients who use nicotine replacement products, intermittent treatments like gum or inhalers may provide benefit with less nicotine exposure than patches. She cautioned against the use of e-cigarettes.“E-cigarettes are no panacea. The solvents can be a hazard to women,” Yonkers said.Illicit drug use, notably illicit opioid use, also takes a tremendous toll on pregnant women and their infants.“The rates of opioid use disorder have gone up in the general population, and pregnant women are not immune to this,” Yonkers said. She added that although pregnancy-associated mortality rose 34% between 2007 and 2019, pregnancy deaths related to opioids doubled during that time. “We have to be careful that we’re not just taking care of kids and offspring. We have to take care of moms.”To that end, the first step is to screen all pregnant women for substance use disorders, Yonkers said. “If you are not universally screening, you are missing people. That doesn’t mean grabbing a urine test from them. It just means asking them and, ideally, engaging them in treatment.”Yonkers discussed the benefits of medication treatment for opioid use disorder (OUD), noting that maintenance treatment increases the use of prenatal care among pregnant women and decreases craving for other illicit drugs. She added that medication treatment may increase birthweight in infants born to women who receive it, compared with birthweight in infants born to women who do not receive medication treatment.Yonkers highlighted guidance by the Council on Patient Safety in Women’s Health Care, a group of women’s health organizations, on working with pregnant women who use substances. In addition to universal screening, other key steps the Council recommends include the following:Providing education about substance use disorders, including explaining that they are chronic medical conditions and that medication treatment works for OUD, and explaining the risks of neonatal abstinence syndrome.Matching treatment with the woman’s stage of recovery.Ensuring that all patients with substance use disorders are enrolled in a treatment program, coordinating care among health professionals, and engaging child welfare in safe care protocols. ■ ISSUES NewArchived

Understanding Health Disparities in Cardiovascular Diseases in Pregnancy Among Black Women: Prevalence, Preventive Care, and Peripartum Support Networks

Black women have higher morbidity and mortality in pregnancy and postpartum, as compared with women of other races/ethnicities, including white and Hispanic women. Pregnancy-associated deaths are rising in the USA and are higher than in other developed nations. Pregnancy-associated mortality rates are disproportionately higher among non-Hispanic black women. The purpose of this paper is to (1) review the current literature regarding pregnancy-associated cardiovascular disease prevalence in black women compared with women of other races/ethnicities, (2) review proposed factors contributing to these health disparities, and (3) discuss potential avenues to address these disparities in the name of reproductive justice. There is a paucity of data regarding factors contributing to disparities in health among black pregnant women, but it is clear that these cannot be fully explained by differences in socioeconomic backgrounds, access to health insurance, or healthcare literacy. Additionally, although some cardiovascular-related pregnancy mortality etiologies such as hemorrhage, pulmonary embolism, and hypertensive disorders of pregnancy are decreasing in incidence, other pregnancy-associated cardiovascular diseases and cardiomyopathy rates are increasing. Although the pathophysiology behind peripartum cardiomyopathy is still unclear, its prevalence is high among black women. Studies are lacking probing the influence of psychosocial factors on patient-provider relationships and patient-centered decision-making among black women during pregnancy and postpartum. Black women disproportionately experience higher pregnancy-related cardiovascular morbidity and mortality compared with white women. More studies are needed to fill the gap in the literature data regarding the causes of this significant health disparity. A better understanding of the various factors driving these maternal health disparities could inform the development of holistic, multifaceted approaches to caring for black women in pregnancy and postpartum. Continued dialog—among healthcare professionals, patients, and their allies—is important to promote advocacy and to improve patient-provider relationships.

A life-course theory exploration of opioid-related maternal mortality in the United States.

Background and AimsBetween 2007 and 2016, pregnancy‐associated mortality resulting from overdose more than doubled in the United States. This study explored the circumstances surrounding maternal opioid‐related morbidity and mortality, using the life‐course theory as a sensitizing framework to examine how each participant's life‐course contributed to her substance use, relapse, recovery or overdose.DesignA mixed‐methods study using semi‐structured, in‐depth face‐to‐face interviews and focus groups were conducted.SettingTexas, United States.ParticipantsWomen who had relapsed into opioid use or experienced a ‘near‐miss’ overdose and family members of women who had died during the maternal period due to opioid overdose were interviewed (n = 99).MeasurementsA socio‐demographic questionnaire captured participants’ ethnicity, age, marital status, medical and mental health history and employment status. The Stressful Life Events Screening Questionnaire—revised (SLESQ‐R) assessed life‐time exposure to trauma.FindingsWomen reported histories of abuse and loss of a loved one through homicide or suicide. Participants indicated that limited social support, interpersonal conflict with their partner and unaddressed mental illness made recovery more challenging. Additionally, losing their children through the child welfare system was described as punitive and placed them at greater risk for relapse and overdose.ConclusionsA life‐course theory approach to examining maternal opioid‐related morbidity and mortality in Texas, United States reveals the complex needs of women at risk for opioid use relapse and overdose and the significant role of previous traumatic experiences.