SALT LAKE CITY — Drug overdoses ranked as the leading cause of pregnancy-associated maternal deaths in Utah from 2005 to 2014, with most caused by opioid use during the postpartum period when infants were six weeks to 1-year-old.
Those facts — revealed in a recent University of Utah analysis of 136 maternal deaths recorded in the Utah Perinatal Mortality Review Committee database — could help improve outcomes for women during this vulnerable stage in life.
Dr. Marcela Smid, assistant professor of maternal and fetal medicine at U of U Health, served as first author on the study that was published this May in the medical journal Obstetrics & Gynecology.
By email, Smid said she views opioids as a tool that comes with both benefits and challenges.
“In some cases, opioids are entirely appropriate for moms to be on during pregnancy, delivery and the postpartum period,” Smid said by email. “In some cases, opioids may be over-prescribed. In other cases, they may be under-prescribed.”
Bill Hughes, a Layton obstetrician-gynecologist who retired four years ago, recalled cautiously prescribing opioids to pregnant and postpartum women.
“It wouldn’t be uncommon to give them a small prescription for pain relief from a C-section or an episiotomy,” Hughes said. “But we’re always careful not to do refills. You get one prescription and that’s it.”
For patients with chronic pelvic pain due to endometriosis or some other cause, Hughes said prescriptions were tightly metered month-by-month “so the chance for abuse was pretty small.”
However, he said that didn’t stop incoming calls from women claiming to need narcotics.
“We just refused them out of hand. The last thing you want ... is having an office full of people thinking you’re an easy drug prescriber. You’ll get a reputation for being an easy touch,” he said.
The U of U study detailed Utah’s pregnancy-associated deaths, referring to maternal deaths during pregnancy or within the first year after giving birth.
Of the 136 total pregnancy-associated deaths, thromboembolic disease (strokes caused by blood clots) resulted in 18, while vehicle accidents claimed 17.
The remaining 66 deaths stemmed from heart conditions, high blood pressure, infection, homicide/suicide, hemorrhage, malignancy and other causes.
The analysis acknowledged the connection between the pregnancy/postpartum period with new onset or exacerbation of underlying health conditions such as depression, anxiety, chronic pain and substance use disorders.
It also suggested that systematic screening for drug use and intimate partner violence could provide avenues for intervention. Other recommendations included relapse prevention counseling, naloxone prescriptions, and extended continuity of care with substance use and mental health care specialists.
Laurie Baksh manages the Maternal and Infant Health Program for the Utah Department of Health.
“In looking at our data — our causes for pregnancy-associated deaths — accidental overdose and suicide were two of the largest contributors in that time period,” Baksh said. “So yes, it’s definitely concerning ... it really leaves a hole for families, the spouses and children that mother may have left behind.”
According to UDOH, two areas in Utah show significantly higher prescription opioid death rates overall compared to the rest of the state: Carbon/Emery counties and downtown Ogden. But in terms of pregnancy-associated deaths, the U of U data did not get that geographically specific except to tag 28 of the 35 drug-induced deaths as urban, six as rural and one as “frontier.”
The societal cost of those deaths prompted Utah’s public health officials to seek ways to prevent them in the future.
“One of the things we’ll be doing in the next year is working with our hospitals to implement protocols for women who use opioids during pregnancy and postpartum,” Baksh said.
During this year’s legislative session, UDOH received funding to address maternal mental health, Baksh added. Some of those dollars will help screen and treat women for depression, anxiety and substance use disorder before and after giving birth.
Funding from the Centers for Disease Control and Prevention also came through for enhanced surveillance of opioid use during pregnancy and postpartum. Baksh said they’ll be adding key questions to UDOH’s Pregnancy Risk Assessment Monitoring System (PRAMS) survey.
For Smid, she hopes the study she helped spearhead will spur several preventative measures for pregnant and postpartum moms:
Universal screening for substance use disorders (including any history of overdose) and mental health concerns (including any history of suicide.)
Strengthening referral networks of providers who are knowledgeable and comfortable with perinatal addiction and mental health care.
Coordinating care for substance use and mental health
Extending Medicaid up to a year postpartum
Expanding housing and residential treatment options for women with children
Expanding access to telehealth and other remote services
Decreasing stigma among healthcare providers and facilities about substance use
“We cannot do anything for the moms who died, but as a health care institution, we can identify the holes in care and plug them,” Smid said on the U of U website. “We need to develop an addiction-knowledgeable obstetrics workforce.”