Pregnancy-Associated Mortality Due to Accidental Drug Overdose and Suicide in Ohio

Introduction:
Pregnancy-associated mortality (PAM) is a pressing public health concern. Prior research has shown maternal mortality increasing in the United States. A recent review of state-based studies found self-harm, including accidental overdose and suicide, is contributing to the rise of PAM. However, none of the states included in this review were among those reported to be in the upper quartile of accidental overdose death rate. The present study aims to describe PAM due to self-harm in Ohio, a state where accidental overdose has become the third leading cause of excess mortality.

Methods:
Death records were provided by the Ohio Department of Health. A serial cross-sectional analysis was performed for suicide, accidental overdose and all other causes among women of childbearing age (15-44) who died within one year of pregnancy from January 1, 2009, to December 31, 2018 (N = 132). Pregnancy status was taken from death records. Mortality burden was calculated in Years of Life Lost (YLL). YLL were found by subtracting decedents’ age at death in years from the standard life expectancy. Life expectancy was determined from the Social Security Administration Period Life Table.

Results:
Of the 6,347 women of childbearing age who died of accidental overdose or suicide during the study period, death records indicated 132 [2%] were pregnant during the past year, including 55 pregnant at time of death, and 22 deceased within 42 days of end of pregnancy. Accidental overdose and suicide accounted for 103 and 29 deaths and 5,466 and 1,579 YLL respectively. Opioids were involved in all 103 (100%) accidental overdoses. Firearm was the commonest mechanism of suicide (13 [45%]), followed by suffocation/hanging (9 [31%]) and intentional overdose (3 [10%]).
Mean age of death and mean YLL per decedent was 27.6 ± 6.1 and 54.5 ± 5.9 for suicide and 29 ± 5.3 and 53.0 ± 5.1 for accidental overdose. Accidental overdose most often occurred 43 days to one-year post-pregnancy (46 [45%]) or during pregnancy (40 [39%]) with notably fewer deaths in puerperium (17 [17%]). Suicide was commonest during pregnancy (15 [52%]), and within 43 days to one-year following end of pregnancy (9 [31%]). Accidental overdose YLL increased from 152 in 2009 to 1,544 in 2018. The percentage of all-cause pregnancy-associated YLL attributable to accidental overdose rose from 5% to 40%.

Discussion:
Over 6,300 Ohio women of childbearing age died of accidental overdose or suicide during the study period, including 132 perinatal deaths. Perinatal accidental overdose increased 10-fold and the percentage of all-cause pregnancy-associated YLL attributable to accidental overdose reached 40%. All accidental overdoses involved opioids and nearly half of suicides involved firearms. Deaths from either cause were commonest during pregnancy or 43 days to one-year post-pregnancy. These findings might inform future maternal and infant mortality reviews and ecologic interventions involving intimate partners, family and community. Although limited by the use of death records possibly misreporting pregnancy status, our findings demonstrate unacceptable mortality burden among perinatal women from accidental overdose and suicide.

References:
1. Mortality Rate: Disentangling Trends From Measurement Issues. Obstet Gynecol. 2016;128(3):447-455.
2. Mangla K, Hoffman MC, Trumpff C, O'Grady S, Monk C. Maternal self-harm deaths: an unrecognized and preventable outcome. Am J Obstet Gynecol. 2019;221(4):295-303.
3. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths - United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419-1427.
4. Hall OT, Hall OE, McGrath RP, Haile ZT. Years of Life Lost due to Opioid Overdose in Ohio: Temporal and Geographic Patterns of Excess Mortality. J Addict Med. 2019.
5. Administration USSS. Period Life Table, 2013. https://www.ssa.gov/oact/STATS/table4c6.html Web site. Published 2013. Accessed.