How the U.S. Can Better Understand — and Prevent — Maternal Deaths Related to Substance Use

A pregnant woman in the United States is over three times more likely to die of related complications than her peers in Germany, France, or the United Kingdom. While Black and Indigenous women die at the greatest rates, even when limiting the comparison to a lower risk group — non-Hispanic white women ages 25 to 34 — the U.S. would still have a 2021–2023 maternal mortality rate more than double the same three countries’ overall maternal mortality rate. In addition to factors such as limited access to health services, higher rates of uninsurance, and the lack of continuity of care, the use of substances like fentanyl and heroin during and after pregnancy has become one of the leading causes of maternal deaths in the U.S.

There are two main sources of data on maternal deaths: national-level data, which give us an overview of current rates and trends but less insight on what can be done to address poor outcomes, and reports from state maternal mortality review committees (MMRCs). MMRCs are multidisciplinary groups typically housed in state departments of public health. These committees are charged with comprehensively reviewing any deaths within their jurisdiction that occur during pregnancy or within one year of birth, largely to ascertain preventability and recommend solutions. MMRCs examine more granular state-level information, such as medical records and autopsy reports, that can fill in the gaps of national-level analyses. Together, both national and MMRC data paint a picture of a growing substance use crisis among pregnant women, one that must be confronted to bring down the country’s unacceptably high rate of maternal deaths.

The Growing Impact of Substance Use on Maternal Mortality

Between 1999 and 2023, drug- and alcohol-related deaths more than doubled for women of reproductive age — 15 to 44 — with wide variation across states. Fatal drug overdoses tripled for the same group between 2003 and 2022. Pregnant women were not immune to this upswing, with a 76 percent increase in pregnancy-associated deaths between 2018 and 2021.

State MMRCs paint an even bleaker picture. MMRC data are captured in periodic CDC reports and the most recent one, with data from 38 MMRCs, found substance use contributed to more than one in five pregnancy-related deaths. We compiled the latest reports from all 50 states, largely from 2020 onward, to document pregnancy-related deaths in which substance use or overdose was the cause, pregnancy-related deaths with substance use as a contributing factor, and overdose deaths where the person was pregnant.

While the 38-state CDC report found that substance use was a contributing factor in 24.8 percent of pregnancy-related deaths in 2020, the situation in many states is far worse. Ten of the 21 states presenting data on factors contributing to maternal deaths report substance use played a part in at least 40 percent of pregnancy-related deaths. This included 100 percent of pregnancy-related deaths in Wyoming, 56 percent in Massachusetts, 42 percent in Arizona, and 40 percent in Mississippi. Substance use or overdose was reported as the leading cause of pregnancy-related death in eight states, led by New Hampshire (52.4%), Ohio (44.4%), Utah (38.5%), Massachusetts (36.0%), and Delaware (33.3%).

High rates of substance use–related maternal deaths are reflective of several factors, including the overall growth of substance overuse in the state’s general population, the challenges of continuity of care during pregnancy at a time when women are struggling to not use substances to protect their baby, stigmatizing attitudes of providers, and racial bias in screening and reporting of substance use among Black mothers.

The Way Forward

A large majority of the state maternal mortality reports made recommendations to combat substance use deaths on a provider, hospital, or policy level.

Many state MMRCs limit their analysis to pregnancy-related deaths. One step to better understand the impact of substance use would be to broaden the focus to include pregnancy-associated deaths, which are twice as common as pregnancy-related deaths. Pregnancy-associated deaths are more likely than pregnancy-related deaths to occur in the year after birth and be related to substance use. Pregnancy-associated deaths also involve more interactions with social services and emergency room care, which provide opportunities for prevention efforts. Examining pregnancy-associated deaths involving substance use will allow states to comprehensively document the factors leading to these maternal deaths and identify state and local interventions for prevention.

There have been promising developments in several areas. States are engaging in a variety of interventions, including increased screening and wider access to substance use care (such as medication-assisted treatment) during pregnancy and postpartum, educating patient-facing practitioners on trauma-informed care, and developing recovery housing to keep families together. Not only can states learn from their own MMRC data, but comparable data and procedures across states can more comprehensively inform intervention strategies to address this national problem.