A new study shows drug overdoses are the leading cause of death for pregnant and postpartum women in Utah — and overdoses appear to kill women as indiscriminately as blood clots and car wrecks do, heedless of their income, race or where they live.
“People assume that, ’They can tell who has a problem,'” said physician Marcela Smid, an assistant professor of maternal and fetal medicine at University of Utah Health. “You can’t — addiction affects every segment of society.”
Smid and other researchers focused on state health records that document the deaths of women who were pregnant, or were pregnant less than a year before they died — in all, 136 deaths from 2005 to 2014.
More than a quarter of those deaths were "drug-induced," researchers found. They also found that the rate of drug deaths among pregnant and postpartum women tripled during the decade they studied.
"This problem is big and getting bigger," Smid said.
The study, which is being published this week in the Journal of Obstetrics & Gynecology, could go a long way toward changing how doctors and public officials handle drug abuse by pregnant and postpartum women.
Right now, the vast majority of those drug deaths are deemed "unpreventable" in state health records because they occurred months after the women's last doctor visits, the study reports.
But researchers delved further into the women's medical records, as well as social service and criminal records, and found that more than half of them were diagnosed with substance abuse disorders or were known to have misused drugs during their pregnancies.
Three-quarters of the women’s delivery records mentioned “drug-related concerns” — for example, past drug abuse or worries about relapse — and more than three-quarters of the women who died had a mental health condition, researchers found.
Despite that, fewer than half of the women who died received social work counseling or mental health services. None received medications for opioid use disorder, even though 27 of the 35 overdose deaths involved opioids.
And there were no records of any of the women being screened for drug use during their pregnancies.
Worst of all, even women who had previously overdosed on drugs or attempted suicide apparently didn't get pre-emptive help.
“Alarmingly, while a quarter of [the] women ... had a previous history of overdose, none of [them] had documented either counseling regarding prevention of overdose or prescription for naloxone rescue medication,” researchers wrote. “More than one in five women who died ... had a prior suicide attempt, although suicide prevention and crisis hotline counseling was not documented in the prenatal or delivery records.”
Just over a quarter of the overdose deaths were deemed intentional, the report found. In another 20 percent, the woman's intent could not be determined.
The study already is changing how Utah’s medical community views overdose deaths among pregnant and postpartum women: State health officials have created criteria to classify some drug deaths as “pregnancy-related” — i.e., deaths where pregnancy was a contributing factor.
Utah may be the first state to classify overdose deaths that way, said Laurie Baksh, manager of the state’s maternal and infant health program. “We don’t know of any [others] at this point, but it is under discussion in several states,” Baksh said.
The topic of overdose death classification also is on the agenda for a meeting later this year, when the Centers for Disease Control and Prevention will bring together state maternal health officials nationwide.
Changing how those deaths are counted allows the data to reflect how drug addiction — and specifically the opioid crisis — plays out specifically as a maternal health problem.
“Historically, drug-related deaths and suicides were kind of considered just a mental health problem; it had nothing to do with the pregnancy, so they weren’t usually included in the count of pregnancy-related deaths,” said Jewel Maeda, who coordinates Utah’s perinatal mortality review.
“They were ‘associated’ because they happened in the time frame," she said, "but the idea that it might be that the pregnancy itself contributed to ... the suicide or the drug overdose — that’s kind of a new concept.”
The change is “based on the results of the study, and the evolving recognition that mental health conditions appear to be aggravated by pregnancy and delivery,” the study states, and could be “very” significant, Smid said.
“For postpartum women struggling with drug use, the demands of a newborn, loss of continuity with trusted providers, loss of insurance, increased risk of postpartum depression and anxiety, and sleep deprivation may result in the ‘perfect storm’ leading to drug use, overdose and death,” the study states.
If doctors and health officials recognize a link between drug overdose and having a baby, those overdoses may start to be seen as preventable, researchers wrote. And that could put more focus on interventions like screening, mental health and addiction services, and resources for extended postpartum care.
In Utah, state officials are now distributing a set of nationally recommended guidelines for best practices to care for patients with opioid addiction in labor and delivery wards statewide. The new guidelines will be “unrolled” throughout 2019, and include instructions for connecting mothers to social and mental health services, making sure the patients’ care providers all know about their addiction, planning for alternative pain remedies, and screening patients for drug abuse.
“More needs to be done to educate our patients, providers, community, hospitals and systems to be aware of perinatal addiction, how best to screen for it, how to treat and how to reduce stigma,” Smid said.