Pregnancy-associated mortality and morbidity due to drugs, self-harm, and violence in the United States

MODIFIED PROJECT SUMMARY Reducing pregnancy and postpartum morbidity is a clinical and public health priority in the United States (US). Although deaths due to drug overdose, suicidal behavior, and violence victimization during pregnancy and the first postpartum year have received less attention compared to obstetric causes, our team’s results show that such deaths make up a large and growing proportion of pregnancy-associated mortality, have increased in recent years, and differ substantially by both individual characteristics and geography. Moreover, deaths due to drugs, suicide, and violence represent only the tip of their public health iceberg: our team found that pregnancy-associated nonfatal drug overdoses, suicide attempts, and assaults in California outnumber their fatality counterparts by 60:1, 72:1, and 423:1. We currently know little about pregnancy-associated morbidity from these causes outside of California, although preliminary evidence demonstrates that estimates likely differ substantially by state and region. Moreover, critical next steps in reducing these morbidity outcomes include elucidating impacts of modifiable factors such as health care availability on pregnancy-associated drug overdoses, suicide attempts, and assaults. The overall goal of this R56 proposal is thus to quantify trends and patterns in pregnancy-associated morbidity due to drug overdose, suicidal behavior, and violence victimization across multiple US states and to identify area-level risk factors for these outcomes. To achieve this goal, we will use all-payer, longitudinally-linked inpatient and emergency department data from 7 states, years 2021-2023, to (1) quantify incidence of pregnancy-associated morbidity due to drug overdose, suicidal behavior, and violence victimization in multiple US regions; (2) quantify subgroup differences in these pregnancy-associated morbidity outcomes across US regions; and (3) identify modifiable, area-level healthcare availability risk factors for these morbidity outcomes. These state-level datasets will allow us to estimate incidence and risk factor associations using a novel linkage approach that follows mothers forward and backward in time from delivery. Achieving our aims will provide data that can inform and target public health, clinical prevention, and therapeutic intervention efforts as well as build empirical evidence to guide policymaking.