Overdoses causing more pregnancy-related deaths, NC study shows. The reality is complex
Drug overdoses and violence were the top killers of pregnant and recently pregnant women in North Carolina during the two years prior to COVID-19.
That’s according to a new report released this month by the state’s Maternal Mortality Review Committee (MMRC), a volunteer group that examines the death of every woman during pregnancy or up to a year after.
At first glance, the group’s latest analysis appears to show a stark rise in drug overdoses, homicides and suicides, compared to the committee’s previous report on deaths from 2014 to 2016. Combined, those causes made up nearly half of the pregnancy-related deaths from 2018 to 2019.
But maternal health experts say the trends aren’t so clear-cut.
Rising opioid abuse is likely among the drivers of these deaths in recent years, experts say. But more screening for substance-abuse disorders and other mental health issues is identifying more cases.
And across the country, the last decade has seen a seismic shift in how such committees count and classify deaths during pregnancy and months after.
That’s true in North Carolina, where an expanded MMRC has broadened its focus on the causes of maternal mortality to include everything from clinical conditions to issues with mental health and domestic violence.
A more accurate understanding of these deaths is critical to driving down North Carolina’s maternal mortality rate, which in 2019 surpassed the rate in the U.S. overall, according to a 2023 analysis by The News & Observer.
“This isn’t just a big-city problem or a rural health-care-access problem,” said Dr. Alan Rosenbaum, an OBGYN at UNC Rex who serves on the executive committee of the N.C. Obstetrical and Gynecological Society. “Maternal deaths are a North Carolina problem and an American problem.”
Counting deaths — and going further
The latest MMRC report notes that 181 women died during or within a year of pregnancy from 2018 to 2019. Those causes can vary, so the committee focuses primarily on deaths that its members agree are “pregnancy-related.”
In 2018 and 2019, the committee determined 76 of those 181 deaths were pregnancy-related.
That decision can be straightforward for clinical conditions like eclampsia, a seizure disorder, or hemorrhage.
But there’s often a gray area for cases involving overdoses, intimate-partner violence or other causes that can be exacerbated by pregnancy and new parenthood.
“A real plain-language kind of way to describe ‘pregnancy-related’ is, had she not been pregnant, would she still be alive?” said Dr. Kate Menard, a professor of obstetrics and gynecology at the UNC School of Medicine who joined the state’s MMRC when it was founded in 2015.
The committee weighs these decisions with an extensive review of each case — and the answer can depend on who’s in the room.
In 2022, the state legislature expanded the MMRC’s membership from nine to 20, adding language consistent with federal guidance that the groups include more than doctors and nurses. That means since its first report on deaths from 2014 to 2016, the MMRC now includes social workers, behavioral-health experts and maternal-health advocates.
“As we brought on committee members, we tried to be cognizant of the fact that not everything is related to clinical issues,” said Belinda Pettiford, who heads the state health department’s Women, Infant, and Community Wellness services. “It has broadened the focus.”
Of the 76 deaths in 2018 and 2019 that the committee determined were pregnancy-related, it found:
20 women died from a drug overdose, classified in the report under mental health conditions and injuries
8 died from homicide
5 died by suicide
The report also shows a lingering disparity between the rates of pregnancy-related death for white and Black women, who remain particularly vulnerable to worse health outcomes.
Nearly three-quarters of pregnancy-related deaths occurred during the postpartum period up to a year after the end of a pregnancy.
The report doesn’t specify how many of those postpartum deaths were caused by mental health and substance abuse. But it’s a time when women are particularly at risk, says Marie Thoma, a maternal health researcher at the University of Maryland.
“It’s clear a lot of pregnant and postpartum people are dealing with these underlying mental health conditions,” Thoma said. “It’s really that postpartum period where they drop out of care where we really see the spike in those deaths.”
That’s why so many of the report’s top recommendations include specifics for health-care providers and policymakers to support and destigmatize treatment for substance abuse.
“If I had a magic wand, I would help all of our care providers understand addiction as a condition like diabetes,” Menard said. “You bring them in, you take care of them in the hospital, and then you send them home without insulin — it’s not going to work.”
The combination of better screening for mental health issues and substance abuse, coupled with the committee’s more expansive look at the circumstances around each case, means it’s likely they’re catching more of those causes, Menard said.
Still, it’s hard to know how much of the latest figures are the result of better measurement or an actual rise in substance abuse and overdose nationwide, she said.
“The issues about fentanyl and opioids and that sort of thing have only gotten worse,” Menard said. “They were there in 2016. They’re still there in 2019. And they’re there in 2023.”
NC still years behind on analysis
An analysis of more recent deaths, though, is years away.
A review by The News & Observer in 2023 found that the state lagged far behind the rest of the country in its detailed review of pregnancy-related deaths. The latest examination of deaths from 2018-2019 still falls short of Centers for Disease Control and Prevention guidelines to examine cases within two years of each death.
Completing reviews quickly, the CDC says, is essential to “inform targeted actions preventing future deaths.”
“It’s unfortunate,” Menard said. “But I understand why it’s happening, and it’s a resource issue.”
By state law, volunteers on the committee can’t be paid. It receives no state funding, and federal grant money it does get to pay support staff to track down, remove identifying information and summarize complex medical records didn’t begin until 2019 — four years after North Carolina lawmakers established the group.
“We are concerned that we haven’t been able to get caught up yet,” Pettiford said. “But as we talk to other states, everybody is struggling with how do we catch this up?”
The committee and its staff members are currently working to review deaths in 2020 and 2021, Pettiford said.
But a report on those years, the first to capture the onset of the COVID-19 pandemic, isn’t due until at least 2025.
“Several things that were identified in this report as having contributed to maternal deaths in 2018-19 — such as mental health access, the opioid epidemic, gun access, and obesity — have gotten worse,” Rosenbaum said. “Unfortunately, I suspect that maternal deaths from 2020 and beyond will be worse, not better, than what is presented in this MMRC report.”
Menard notes there are potential good signs in the report: fewer cases of hemorrhage, hypertension and other clinical conditions that could be impacted by improvements in health-care quality and a statewide emphasis on improving maternal care.
They’re steps in the right direction, she said — even if some efforts are too recent to show up in the MMRC’s newest report.
Dated as it is, Pettiford said there are still important takeaways from the report, including its finding that the vast majority of deaths — over 85% — were preventable.
“One death is one death too many,” Pettiford said. “We need to remind people that this is still happening in 2024.”
NC Reality Check is an N&O series holding those in power accountable and shining a light on public issues that affect the Triangle or North Carolina. Have a suggestion for a future story? Email realitycheck@newsobserver.com
Maternal deaths just ‘one part of the story’ in NC. Pregnancy complications are rising
