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Drug- and alcohol-related death rates among pregnant and recently pregnant American women increased sharply between 2015 and 2019, faster than among women of childbearing age in general, new research shows.

“We need to broaden our view and look beyond complications of childbirth and pregnancy to fully understand the threats to recently pregnant women’s lives,” says Alexis Santos, a professor with Penn State University’s Population Research Institute.

Santos is part of a team of researchers that examined newly available death certificate data on women who were pregnant at the time of death or within the previous year. The team found significant increases in deaths tied to drug/alcohol poisoning, the category that encompasses drug overdoses, and reported their findings in the Journal of the American Medical Association (JAMA) (see figure).¹

Other recent studies help identify which women face the highest risks related to the opioid crisis and underscore the importance of comprehensive policies that address more than the availability of opioid pills.

Steep Increases Seen in Alcohol and Overdose Deaths Among Pregnant and Recently Pregnant Women

In 2003, U.S. states began adding a checkbox to death certificates to indicate whether the person was pregnant or gave birth within the previous year. By 2015, all but two states (Alabama and West Virginia) had adopted the checkbox, enabling researchers to take a close look at mortality trends among recently pregnant women, explains Jeffrey T. Howard of the University of Texas at San Antonio, lead author of the JAMA report.

When the research team examined the more than 9,500 death certificates of pregnant or recently pregnant women from 2015 to 2019, they found that mortality rates rose steadily, but the primary causes of death were not related to pregnancy. In fact, the mortality rate from all pregnancy-related causes stayed relatively stable during the period, according to Howard.

However, the team found significant increases in the all-cause mortality rate among pregnant and recently pregnant women, which jumped from 44.4 deaths per 100,000 live births in 2015 to 53.9 in 2019, reflecting an increase of 4.4% per year. Among the drivers was the death rate from drug/alcohol poisoning, which rose from 4.3 to 8.8 during that period—a 17.4% annual increase (see figure). (Annual percentage changes in mortality rates were estimated using log-linear regression models.)

Mortality Rates Related to Alcohol and Drug Abuse Increased Sharply Among Pregnant and Recently Pregnant U.S. Women Between 2015 and 2019

Annual percentage change in mortality rates between 2015 and 2019 for pregnant and recently pregnant U.S. women, and for the U.S. female population of childbearing ages

Note: Includes 10-year age groups: 5-14, 15-24, 25-34, 35-44, and 45-54.
Source: Jeffrey T. Howard et al., “Trends in Mortality Among Pregnant and Recently Pregnant Women in the US, 2015-2019,” JAMA 326 no. 16 (2021): 1631-33. doi:10.1001/jama.2021.13971

By contrast, death rates among all women of childbearing age did not change significantly overall or for any specific cause between 2015 and 2019 (see figure).

In Santos’s view, these findings warrant new attention to the well-being of pregnant and recently pregnant women, including a greater focus on postpartum depression and so-called deaths of despair from drug overdose and suicide. “Why are so many recently pregnant women dying, and what role does the opioid crisis play?” he asks.

Rise in Births to Unmarried Women Linked to Opioid Epidemic’s Impact on Communities

New research is beginning to fill in the answers to Santos’ questions.

The opioid epidemic appears to be profoundly affecting the lives of many unmarried white women with low education levels, report Mónica L. Caudillo of the Maryland Population Research Center at the University of Maryland and Andrés Villarreal of the California Center for Population Research at the University of California, Los Angeles.

They found that births to unmarried U.S. women rose in communities that saw an increase in both opioid overdose deaths and the availability of prescription opioids between 2000 and 2016.³ A disproportionate number of these births were to white women with less education. “We found no effects among Hispanic or Black women of any education level,” Caudillo and Villarreal write.

Birth rates for married women in the same communities were unaffected, they report.

Pregnancies among women with opioid use disorders may contribute to a portion (less than one-third) of the increase in unmarried births, their analysis shows.Other research shows that opioid-dependent women are about twice as likely as their peers to have an unplanned pregnancy; are less likely to use contraceptives; and are more likely to engage in certain risky behaviors, such as exchanging sex for money or drugs, the researchers explain.

But most of the rise in births to unmarried women appears to be a response to the social disorder, violence, and stress the opioid epidemic has brought to communities, rather than personal opioid use and related economic distress, Caudillo says. In counties with high drug overdose rates, births among adolescents increased over the study period, while overdose death rates among adolescents remained flat and low.

In addition, Caudillo and Villarreal tested the connection between opioid overdose death rates and several economic well-being measures for young adults, including changes in the share employed, living below the poverty line, or with lower household income. They found no evidence of a relationship, suggesting that economic distress is not the mechanism linking opioid overdose death rates to higher unmarried birth rates.

Young adults who are unmarried and have no children—also called “disconnected adults”—are the group most likely to misuse opioid drugs, report Alexander Chapman and Ashton M. Verdery of Penn State University and Shannon M. Monnat of Syracuse University.³ Their recent analysis suggests that increases in the number of disconnected young adults may be accompanied by increases in substance use disorders and overdoses.

“Our findings reflect the importance of studying the relationship between social ties and substance misuse, especially given that social connections weakened for many during the pandemic,” Verdery says.

Policies That Only Target Opioid Pills May Be Counterproductive

To be effective, policies designed to address the opioid crisis need to be far reaching and multifaceted, argues a team of researchers from the Center for Family and Demographic Research at Bowling Green State University (BGSU).

“The opioid crisis is not only a substance use issue; it’s intertwined in complex ways with other social factors and problems—including homicide, intimate partner violence, unemployment, and poverty,” says Cori Pryor of the BGSU team. “Policymakers cannot adequately address the opioid crisis or, for example, intimate partner violence (IPV), without addressing the social context in which they exist and thrive.”

Using arrest and prescription data, the BGSU researchers found that increases in the number of opioid pill prescriptions per person were related to increases in arrests for IPV at the county level.⁴¹

In another study, the researchers showed that homicide arrests were dramatically higher over time in counties with high rates of arrests related to IPV.⁵ But advanced statistical analysis indicates that the strong connection between IPV arrests and homicide arrests is reduced in places that have seen increases in the number of opioid pills per person. Stated differently, “the already strong association between IPV and homicide may increase if policymakers tackle opioid pills without recognizing that opioids are tied to broader social problems,” explains John Boman of BGSU.

Violence and crime related to opioid withdrawal symptoms and individuals turning toward intravenous drugs, such as fentanyl and heroin, may contribute to the interwoven relationship among opioids, crime rates, and other social factors, suggests Chloe Wentzlof of BGSU. New policies aimed at combatting the opioid crisis should not oversimplify this complex dynamic, she says.

The opioid crisis overloads the criminal justice system, which is not designed to deal with a public health issue, adds Boman. “A simple answer to a complex problem—such as restricting prescription opioids—risks making other things worse.”

The BGSU researchers list a variety of proven strategies that could help prevent deaths from overdose.

“The health care community agrees that opioid agonist therapy [such as methadone, which eliminates withdrawal symptoms and relieves drug cravings] is the best tool we currently have,” reports Pryor. “Reducing stigma and boosting access to that would be imperative, along with the expansion of needle exchanges, safe injection sites, fentanyl test strips, and naloxone [a drug that can reverse opioid overdose symptoms]. These are immediate things we could do now to prevent death and mitigate harm.”

This article was produced under a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The work of researchers from the following NICHD-funded Population Dynamics Research Centers was highlighted: Pennsylvania State University (5P2CHD041025-19), University of Maryland (5P2CHD041041-18), University of California at Los Angeles (5P2CHD041022-19), and Bowling Green State University (5P2CHD050959-16).