Overdose deaths among some pregnant women tripled since 2018
Yasaswi Kislovskiy knows the expanse between those who have and those who do not, because she lived it.
Immigrating from India at age 2, her family of four lived humbly in a two-bedroom apartment in Pittsburgh’s Friendship neighborhood despite her father’s work as an assistant professor and researcher.
As an adult, she can loosely identify with “physical dependence” on a substance by observing her morning routine and noticing how much more effective she is after the cup of coffee her body expects.
While a reproductive infectious disease resident at MageeWomen’s Hospital of UPMC, parallels between substance use disorder and behaviors leading to obesity struck her. They’re both diseases, both uncontrollable, both marked by relapse and degrees of success, which is another reason those struggling with addictions to opioids and other substances don’t seem “other” to her.
Then, after becoming co-director of Allegheny Health Network’s Perinatal Hope program, which supports pregnant and postpartum women with substance use disorders, she began to understand why those patterns are so difficult to interrupt.
There are physiological draws, compulsions to continue using, ones that dwarf her urge for a morning cup of coffee, she knows. But users’ entanglements with opioids in particular are far more nuanced than neurons and receptors can explain.
“People often describe that their first use is with an intimate partner, and that using — especially after their partner, with the same equipment — is a sign of confidence in the relationship or trust,” she said.
As the addiction — and relationship — progresses, there can be an expectation of use. If the person resists, intimate partner violence can result, compounding their trauma and further perpetuating the cycle of substance use.
And sometimes, that violence takes the form of reproductive coercion, which can lead to unintended or unwanted pregnancies and, sometimes, tragic outcomes.
Those patterns of use and abuse don’t only belong to Pittsburgh women, but it wasn’t until a recent study published by researchers from the National Institutes of Health’s National Institute on Drug Abuse that those local anecdotes became startling national statistics — ones taken as a renewed call to action by practitioners such as Kislovskiy.
Numbing numbers
Looking at girls and women ages 10 through 44 who were pregnant or had been in the past 12 months, from early 2018 through late 2021, NIH researchers parsed out those who died from drug overdoses (excluding alcohol and antidepressants). Then, examining the same time interval and age ranges, they compared that group to those who died from obstetrical causes and those who died from overdoses but were not pregnant as “control” groups to elucidate which outcomes could truly be associated with substanceuse during pregnancy.
Previously, perinatal mortality and opioid use, during the COVID19 pandemic and not, had separately gotten their due, but little was understood about pregnancyassociated overdose deaths until these data were published.
The conclusions were many, but one stands out: Of the pregnant women studied, the rate of overdose mortality more than tripled
among 35- to 44-year-olds, jumping from 4.9 deaths per 100,000 mothers in 2018 to 15.8 in 2021.
While the study wasn’t designed to discover the causes of these overdoses, those supporting the recovery of this population can provide anecdotal explanations.
“For that age range of folks who are in their 30s and early 40s, a lot of their social supports had maybe been eroded,” Kislovskiy said. “They may have been reliant on a single partner who may have been physically or emotionally abusive, and it’s a very hard situation to either stop using substances or to seek financial or housing stability in that situation.”
Having worked in more rural parts of Pennsylvania, Kislovskiy knows the unique brand of isolation pregnant women in those areas can feel: traveling two or three hours for appointments and living in regions known to be hotbeds of substance use.
Of the women studied, however, access to health care was not the predominant issue.
According to the NIH research, roughly 51% to 53% of women in the perinatal period who died from overdoses lived in counties with at least two general hospitals, and 58% to 67% lived in counties ranked in the top quarter of the nation for numbers of psychiatrists per 100,000 residents, which signals a disconnect between struggling pregnant women and available care.
“As we saw the public health force really shift toward battling the pandemic, which was essential, we also saw a hollowing of other existing social services. We saw that especially around intimate partner violence or reproductive violence,” Kislovskiy said. “During the pandemic, we saw a rise in intimate parter violence and child abuse. As people were inside their homes, struggling with financial instability, there were no [recreational] placesfor them to go.”
But there are reasons why — no matter the availability or type of care — they could have chosen not to reach for assistance.
Mandated supporters?
Themandated reporter law varies from state to state, but generally tags certain professions — medical professionals, teachers, police and more — as sentinels, authorized protectors, of children. Not only is it their privilege, it’s theirlegal obligation.
“We have this [mandated reporter] law asking us to protect the children in our country, but it makes it very hard for parents to admit to or seek treatment,” Kislovskiy said. “I’ve personally experienced people who’ve gone through their whole pregnancy using methadone, not using illicit substances, and then having their child removed after the birth and feeling like it was for nothing.”
Pennsylvania’s Child Protective Services law requires those reporters to notify the Department of Human Services when involved in the delivery or care of a baby “born affected” by substance use or withdrawal resulting from prenatal drug exposure.
That notification occurs through ChildLine, the same service used to make claims of child abuse. By state law, this type of call does not necessarily constitute an allegation of child abuse, but it does initiate a cascade of reactions — a Plan of Safe Care — that can result in everything from genuine support to a mother losing custody of her child if abuseis suspected.
“The Plans of Safe Care was not meant to be punitive, but a lot of patients see it as punitive because they don’t necessarily want to acknowledge, even to health care professionals, that they’re struggling with opioid use because if the baby has withdrawal — even if only because they were using medications to avoid using illicit drugs, like Subutex or Suboxone — they could still earn a report,” said Krista Flaherty, licensed social worker and program manager for the Perinatal Hope program.
Years of Hope
While AHN’s Perinatal Hope program can’t shield patients from the law, it does provide a judgement-free environment and one-stop shop for the health care needed by a pregnant or postpartum woman battling substance use disorder.
Founded in 2016, the program was a response to “barriers to care” at the time.
Now, Perinatal Hope welcomes patients — either through obstetrics or substance use support referrals — from early pregnancy through two years after their Hope care begins with a cadre of obstetrical providers, a nurse navigator, peer recovery specialist, behavioral health consultants, social workers and voluntary doula services, to help manage labor.
Elsewhere in the region, UPMC Magee-Womens Pregnancy and Women’s Recovery Center’s outpatient program offers similar services, as does West Virginia University obstetrics and gynecology’s Assist, Connect and Encourage program.
“For some patients, pregnancy is a very good time to catch them because they’re very motivated to be substance-free,” Flaherty said. “The important thing is a lot of education. The more education people have, hopefully the less stigma and judgement there’s going to be because these patients really want to do the best for their babies. They just don’t always have the tools to do that.”
Evolving support
There’s no telling if the NIH will repeat this datadriven look at pregnant women in America. And according to Flaherty and Kislovskiy, there’s no predicting what it might say.
Flaherty points out that the “next big drug” is an unknown and, in theory, threatens to upend progress made post-COVID and with the wider distribution of Narcan, a medication that rapidly reversesan opioid overdose.
Kislovskiy hopes the next report will look different, not just in results but in parameters. Particularly because of xylazine, a veterinary tranquilizer now in the illegal drug supply and capable of causing severe wounds and infection, monitoring deaths may not tell a complete enough story in the future.
“As xylazine surfaces, and wesee national efforts to curb fentanyl, I’m not sure if death will be the outcome that’s rising, or if it will be chronic infection or illness from these wounds,”she said.
Going forward, Kislovskiy hopes for more pieces of social and health care infrastructure to reflect aspects of one another to create increasingly cohesive care.
“This all points to the availability of low-barrier, nonjudgmental services that do what Perinatal Hope does, but I’m kind of worried what will happen to the funding for programs like ours across the country,” she said. “These are my personal comments, but 2024 … is an election year. We’ll have to see what our voters do to shape our priorities across the country, including theneeds of these patients.”