Identifying women at risk for postpartum drug-related death and suicide

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Efforts to reduce pregnancy-related maternal mortality have received much publicity recently but not as much attention has been focused on deaths following delivery. A study in the American Journal of Obstetrics & Gynecology examined maternal drug-related deaths and suicide in California and reveals opportunities for identifying at-risk new mothers. 

Using nonpublic emergency department (ED) and inpatient discharge data from the California Office of Statewide Health Planning and Development, the authors identified more than 1 million women who delivered a live-born infant in California hospitals between 2010 and 2012. Primary outcomes of interest were drug-related deaths and suicide within the 12 months after an index delivery. Sociodemographic factors examined were the women’s age at delivery, race/ethnicity, insurance status, and urbanicity of residential ZIP code. 

A total of 300 women died within 1 year of follow-up (28.33 deaths per 100,000 person-years). The leading cause of postpartum death was obstetric-related disease (69 women died from direct or indirect obstetric complications and pregnancy-related disease, as defined by the World Health Organization). Drug-related deaths (n = 39) were the second leading cause of mortality. Postpartum suicides ranked as the seventh leading cause of death (n = 15). However, when combined, drug-related and suicide deaths comprised 18% of all postpartum deaths, and two-thirds of these deaths occurred between 6 and 12 months postpartum.

The authors noted quite a bit of heterogeneity by maternal sociodemographic factors in the incidence of deaths overall and from drug-related/suicide causes. However, they noted that the precision of these estimates was low because of the small numbers of cases in each subgroup. The four factors that were associated with higher overall mortality risk were maternal older age, non-Hispanic black race, nonprivate insurance, and residence in a micropolitan ZIP code. 

In regard to drug-related and suicide deaths, maternal age and mortality risk were not associated. Compared with non-Hispanic white women, Hispanic women had significantly lower risk of drug/suicide death (RR 0.35, 95% CI 0.18–0.70). Associations with other races were not significant. 

Women who used Medicaid to cover their index deliveries were approximately three times more likely to die from drugs or suicide than women with private insurance (RR 3.36, 95% CI 1.80–6.28). Women with other forms of insurance (non-private, non-Medicaid, and non-self-pay) had a 7-fold increased risk (RR 7.76, 95% CI 2.80–21.56). However, the authors noted that this estimate was based on just five deaths. Residence in a micropolitan (≥ 10% of commuting flow was to a large urban center of 10,000-49,999 residents) area was associated with a 3-fold increase in risk of drug/suicide death (RR 3.74, 95% CI 1.69–8.31).

Of the 300 women who died during follow-up, 66% had at least one ED or inpatient visit between their index delivery and death (mean 2.2, SD 3.9). Among the 54 women who died of drug-related causes or suicide, these metrics were significantly higher (74% made at least 1 ED or hospital visit and 39% made ≥ 3 visits [mean 3.5, SD 6.4]). 

Among the more than 1 million births in California hospitals between 2010 and 2012, drug-related causes and suicide were responsible for one in six postpartum deaths. There is a critical need to identify women in the first year after delivery, and beyond, who may be at increased risk for drug overdose or suicide. The overwhelming majority of participants in the study who died from drug-related causes or suicide made at least one ED or hospital visit after delivery, and the authors believe that those encounters may be critical to identifying women at risk of postpartum death.