May 1, 2024, marked World Maternal Mental Health Day, and on May 12, 2024, we will celebrate Mother’s Day. While maternal health is a recognized public health crisis in the United States, mental health, substance misuse, and substance use disorder (SUD) are often overlooked as part of the crisis. Mental health conditions, substance misuse, and SUD that occur during the perinatal period (before, during, and up to one year after pregnancy) are the leading cause of maternal mortality. Unfortunately, barriers to care result in poor health outcomes for parents and their children, and, while growing, limited clinical research on effective interventions in this area results in fewer opportunities for prevention.
The Biden-Harris Administration has demonstrated that addressing the maternal mental health and substance use crisis is a national priority, with government agencies like SAMHSA and the Centers for Disease Control and Prevention (CDC) recognizing the importance of this issue. Professional organizations, members of Congress, and advocates also have helped to advance this area as a public health priority. In 2023, the Department of Health and Human Services launched the Maternal Mental Health Task Force, a group of federal and non-federal experts seeking to identify ways to reduce barriers to care for pregnant and parenting individuals with mental health conditions and co-occurring SUD. Current barriers to improving the state of maternal mental health, substance misuse, and SUD in the United States, such as a lack of available data (PDF | 1.6 MB), can be overcome, but facilitating a response to this crisis of maternal health requires that stakeholders, government agencies, and experts convene and share resources, knowledge, and experience.
Maternal Mental Health, Substance Misuse, and SUD in the United States
CDC research indicates that the most frequent underlying cause of pregnancy-related deaths is a mental health condition, which is defined by the CDC to include SUD, overdoses, and suicide. The CDC also found that over 80 percent of pregnancy-related deaths were preventable. In some instances, these conditions appear to be increasing: analysis of the 2000-2015 National Inpatient Sample revealed a 7-fold increase in recorded diagnoses of depressive disorders nationwide, from 4.1 per 1,000 delivery hospitalizations in 2000 to 28.7 per 1,000 delivery hospitalizations in 2015.
While not everyone who uses a substance will develop or has a substance use disorder, professional organizations such as the American College of Obstetrics and Gynecology recommend avoidance of any substance use, including nicotine, during pregnancy. Data suggests this message may not be consistently reaching its intended audience. A study conducted using the 2016, 2017, and 2018 National Survey of Drug Use and Health found that 22.3 percent of pregnant women reported using at least one substance in the previous month. Perinatal SUD has been estimated to appear in 5.5 percent of deliveries, according to a study analyzing deliveries in Massachusetts from 2003-2007. Between 1999 and 2014, the number of pregnant women with opioid use disorder, alone or in combination with other substance use disorders, increased from an estimated 1.5 to 6.5 cases per 1,000 hospital births. Experts have associated this change with a steep increase in the number of infants born with neonatal abstinence syndrome from 1.2 to 8.0 per 1,000 hospital births, with some areas reaching 20.0 per 1,000 hospital births.
Maternal mental health, substance misuse, and SUD are affected by various structural and social factors, such as race and racism. A study of Black women associated gendered racial stress with increased depressive symptoms in early pregnancy. Similarly, in an Asian and Pacific Islander cohort of pregnant women, experiencing racial discrimination was associated with a higher risk of postpartum depression. Other research showed a greater association with perinatal substance use, depression, and anxiety with women who identified as indigenous.
Other factors, such as trauma experienced before or during the perinatal period, have been shown to have an impact. Research has associated distress during labor and delivery as the most important risk factor for postpartum post-traumatic stress disorder, followed by other factors such as low support during labor and delivery, previous traumatic experiences, and obstetrical emergencies. Other research identified a greater instance of postpartum depression following cesarean deliveries.
The Impact of Maternal Mental Health Conditions, Substance Misuse, and SUD on Parents and Infants
Mental health conditions, substance misuse, and SUD can complicate pregnancy and have deleterious effects on pregnant and postpartum individuals and their infants, particularly when left undetected, untreated, or undertreated. Research has found an association between perinatal depression and preterm birth. In addition, suicidal behavior by the pregnant individual has been linked with a greater risk for antepartum hemorrhage, placental abruption, postpartum hemorrhage, premature delivery, and poor fetal outcomes. A cohort study of 7,542 women with eating disorders showed an increased risk of preterm birth and microcephaly among infants born to women with any diagnosed eating disorder compared with those without this condition.
Reports of any substance use during pregnancy correspond with reports of delayed or inadequate prenatal care and low rates of postpartum follow-up visits, which increased risk of obstetric complications. The stigma associated with substance use and fear of legal repercussions may prevent patients with SUD from seeking care early in pregnancy. In addition, having SUD during pregnancy, particularly opioid use disorder, correlates with a higher risk of dying by overdose and suicide. In utero exposure to alcohol has been frequently studied and is associated with a range of long-term developmental and physical disabilities characterized as fetal alcohol spectrum disorder.
SUD and mental health conditions often co-occur and further exacerbate negative health outcomes for parents and babies. Pregnant and postpartum individuals with SUD disproportionately experience co-occurring psychosocial issues that can negatively affect maternal and infant outcomes, including comorbid mental health conditions. These findings are also associated with other structural issues, including limited availability and quality of care.
Barriers to Treatment Services and Prevention
Treatment and prevention initiatives for addressing the maternal mental health, substance misuse, and SUD crisis are limited. There are numerous barriers, including stigma, lack of training, siloed healthcare and social services systems, and a dearth of relevant research. Each of these factors, and the many others at play, intersect and interact. As a result, these health conditions and their consequences are not treated, nor are they prevented.
Pregnant individuals are frequently untreated or undertreated for their conditions, even when there is a recognized standard of care for treatment: one study has found that women are less likely to receive treatment for a mental health condition if they are pregnant. Likewise, pregnant individuals are often not treated for their SUD. Only about one-third of pregnant persons with opioid use disorder receive treatment in the form of methadone and buprenorphine, despite these medications being the standard of care for treatment of opioid use disorder, including during pregnancy. Even when individuals do initiate treatment, it is more likely to be obtained during the postpartum period than prior to or during pregnancy.
Negative and stigmatizing attitudes create a barrier to mental health and SUD treatment. Perceptions of gender and parenthood for individuals who are pregnant and may need services further exacerbate stigma. Stigma against people with these health conditions can also lead to healthcare providers’ refusal to undergo the training needed to treat pregnant and parenting people with mental health conditions, SUD, and co-occurring disorders. Health practitioners’ lack of knowledge, training (PDF | 748 KB), or comfort in how to treat perinatal persons safely and effectively are significant barriers to perinatal mental health and SUD identification and management. This often leads to inadequate care, such as practitioners wrongly advising their patients to discontinue needed medications.
Pregnant and postpartum people with opioid use disorder may experience discrimination and even criminalization. Healthcare providers have reported ethical concerns about screening, reporting, or treating opioid use disorder during pregnancy because some states require reporting to child welfare or protection agencies. This reporting can—and has—led to wrongful removal of the child, separating families and further traumatizing both parent and child, despite evidence that family-focused interventions for parents with SUD result in better outcomes. Other barriers may be financial in nature; further, patients may lack access to health care or to coordinated care between obstetricians, primary care providers, and mental health and SUD treatment providers.
Despite the negative impacts and the many barriers to treatment, the causes behind most perinatal mental health conditions, as well as SUD, are not well-studied (PDF | 1.6 MB), so there is limited opportunity for prevention. People who are pregnant have been called “therapeutic orphans” due to the infrequency of clinical research conducted with pregnant individuals and the resulting lack of clinical understanding of pregnant bodies. Although existing literature has aimed to identify the relationships between various risk factors, there is a dearth (PDF | 1.6 MB) of evidence reporting strong associations between these factors and health-related outcomes. Bias in medical research and the pathologizing of the female body has led to a paucity of research on women’s health and the health of people capable of becoming pregnant, so much so that a recent Executive Order by President Biden mandated a greater focus on women and the female body in clinical health research. This bias, in concert with a similar bias against people with mental health conditions and SUD, is likely a cause of the lack of adequate evidence that could be applied into actionable policy change.
Existing Efforts to Address this Crisis
There are numerous federal initiatives to coordinate across the government and support individuals with maternal mental health conditions, substance misuse, and SUD and the providers who help care for them. SAMHSA’s residential and outpatient Pregnant and Postpartum Women programs use a family-first model to provide comprehensive services for perinatal individuals with SUD. The Health Resources and Services Administration’s National Maternal Mental Health Hotline offers free and confidential mental health support 24/7 for individuals and their families before, during, and after pregnancy.
In 2023, the U.S. Department of Health and Human Services formed the Task Force on Maternal Mental Health as a subcommittee of SAMHSA’s Advisory Committee for Women’s Health. The purpose of the Task Force is to identify, evaluate, and make recommendations to the Advisory Committee for Women’s Health to coordinate and improve federal activities related to addressing maternal mental health conditions, substance misuse, and SUD. This Task Force, comprised of federal and non-federal members, including individuals with lived experience, is also developing a national strategy that will recommend to the Advisory Committee for Women’s Health ways to improve the prevention, identification, timely referral, intervention, and access to care and other supports for maternal mental health conditions, substance misuse, and SUD.
Conclusion
Within the maternal mortality crisis is a crisis of maternal mental health and SUD. Attention to this issue by the Biden-Harris Administration has enabled groups like the Maternal Mental Health Task Force to convene, share knowledge, and identify solutions to this pressing public health issue. However, there is more to be done. This issue requires greater amounts of relevant qualitative and quantitative data that can be used to develop policy and implement actionable change. Improved efforts by healthcare providers and the public at large to understand mental health and SUD can reduce stigma and empower individuals to seek treatment. Critically, continued national attention to this issue will enable lasting change for pregnant and parenting people with mental health conditions and SUD.