Violence, Overdose Threaten Pregnant Women’s Lives

Is your pregnant or postpartum patient’s life at risk from a dangerous partner, for severe depression, or for a substance abuse problem? Recent research indicated that maternal homicides, suicides, and overdoses pose a greater threat than previously thought.

A study presented at the Society for Maternal-Fetal Medicine’s (SMFM) annual meeting found that between 2srcsrc5 and 2src22, homicide and suicide combined accounted for 11% of deaths of pregnant women and those up to 42 days postpartum.

The rates were surpassed only by deaths due to accidents (12%). Roughly 11% were due to drug overdose, whereas obstetric causes individually accounted for <11% each , said Hooman Azad, MD, MPH, a fourth-year resident in the Department of Obstetrics and Gynecology at Columbia University Irving Medical Center, New York City, and the study’s lead author . During the study period, homicide rates increased by an average of 2% per year for nonpregnant or nonpostpartum women compared with 7% per year for pregnant and postpartum women.

Until recently, cardiovascular disease, hypertension, and hemorrhage were thought to be the leading causes of adverse maternal morbidity and mortality, said Kecia Gaither, MD, Director of Perinatal Services and Maternal Fetal Medicine at NYC Health + Hospitals/Lincoln in the Bronx, New York.

“Pregnancy-associated deaths from homicide, suicide, and drug overdose are devastating tragedies — the worst possible outcomes — underscoring the urgent need to bolster prevention efforts through clinical, systems, and policy shifts,” said Misty Richards, MD, a perinatal psychiatrist and assistant clinical professor in the Department of Obstetrics and Gynecology at the David Geffen School of Medicine at UCLA in Los Angeles.

Why Are Pregnant and Postpartum Women Experiencing Tragic Deaths?

“This is a violent country,” said Stephen Crystal, PhD, Director of the Center for Health Services Research at Rutgers Health, New Brunswick, New Jersey.

Violent maternal deaths are associated with high rates of violence generally. According to a report published in JAMA Network Open , Mississippi has the highest homicide rate in the country as well as the highest pregnancy-related homicide mortality, whereas Montana has the highest rate of suicide mortality and the highest rate of pregnancy-related suicide mortality. Montana has the highest rate of gun ownership in the country.

An uptick in homicides, suicides, and overdoses in the United States results from complex factors, including untreated mental health issues alongside widespread gun possession, intimate partner violence, and failure to offer evidence-based treatment for opioid use disorder (OUD), said Crystal.

Risks for “deaths of despair” are heightened during a woman’s childbearing years, said Crystal. Pregnant and postpartum women are particularly vulnerable because of the “many stresses of the pregnancy itself and the well-known elevated risk of depression and other mental health challenges associated with it, including postpartum depression, which is under-identified and under-treated,” said Crystal.

Social isolation, intimate partner violence, preexisting substance use disorders, and other challenges make some women even more vulnerable, said Crystal. And women may be taken off of mental health or OUD medications to protect the developing baby, even though in many cases, experts do not recommend doing so. Stopping OUD medications abruptly is associated with relapse and overdose, he said.

Punitive state policies in some states may make women more reluctant to get help for substance abuse, said Jillian Neill, PhD, a perinatal psychologist in private practice in Winston-Salem, North Carolina. Punishment for drug abuse during pregnancy can include incarceration, loss of custody, and involuntary hospitalization.

The variation in maternal deaths across the country underscores the role structural and social determinants of care play as well as whether or not a state has policies in place to protect mothers, said Richards. Maternal mental health screening practices may vary widely, as only eight states mandate them.

Making Time to Screen in the OB/GYN Office Visit

Preventing tragedies from occurring requires addressing harms far upstream using screening for intimate partner violence and mental health concerns, including substance use, and offering referrals to mental health and social services early on, said Richards.

Screens for intimate partner violence include the hurt, insulted, threatened with harm and screamed domestic violence screening tool and women abuse screening tool. Edinburgh postnatal depression scale is commonly used for depression, while the American College of Obstetricians and Gynecologists offers options for substance use and additional mental health conditions.

But clinicians with whom Richards works express frustration that they have only 2src minutes with patients, she said. Often, much of their time is taken up with treating and planning for physical symptoms or problems in the pregnancy.

“OB/GYNS are feeling overwhelmed, burdened, and ill-equipped to treat mental health conditions,” said Richards. “There’s no time to screen, there’s no time to diagnose, there’s no time to treat. Without those things, catastrophic things can happen.”

Clinicians with time limitations can have patients complete screens in the waiting room, said Richards, then go over the results during the visit. An empathetic, patient-centered approach when going over results is essential, said Richards.

In the case of intimate partner violence, “they’re feeling shame and guilt, and they’re wondering what’s going to happen to them and their baby,” said Richards. “So if you are coming off rushed or cold or not disarming, they’re not going to trust you to give them this really sensitive information.” 

If a patient screens positive, Richards advises offering a list of three or fewer accurate, up-to-date, relevant referrals such as shelter, legal protection resources, and mental health providers. Keeping the list brief prevents patients from being overwhelmed, she said.

Empowering Clinicians to Help At-Risk Patients

System changes to help integrate OB/GYN and mental healthcare are critical to helping vulnerable patients, said Crystal.

“If a woman in prenatal or postnatal care is having depression, the OBs need to be alert to it,” said Crystal. “And there should be nothing stopping them from initiating an antidepressant or making a referral.” 

Inadequate training in addressing mental health concerns is another barrier to prevention in the OB/GYN office, said Neill.

“I have found that doctors do not know how to ask the questions that need to be asked or treat detected issues,” said Neill. She said they might be reluctant to ask about thoughts of suicide or fear prescribing mental health medication to pregnant women without knowing which ones are safe.

Screening is also complicated by the fact that clinicians are obligated to treat whatever they screen for — and some may not be equipped to do so, said Richards.

Barriers to treating behavioral health conditions in the OB/GYN setting could be mitigated through the use of programs that build the ability of clinicians to support their patients, said Crystal. States with such programs are models that could be more widely implemented, he said.

Programs That Provide Help

Massachusetts Child Psychiatry Access Program for Moms offers provider training and toolkits that help clinicians address maternal mental health needs, including depression screening, triage and referral, information about medications, and treatment options. Providers can get real-time support via a phone line to help with diagnosis, prescribing medications, and treatment planning.

One New Jersey program offers trauma-informed substance abuse care, residential services, and therapeutic support to address relationship issues, sexual and physical abuse, and parenting. Another offers free and confidential helplines and mental health resources for the uninsured, among other services.

Washington State’s Department of Health offers certification and grants to help providers better serve women with substance use disorders.