Pregnancy-Associated Homicide and Suicide: An Analysis of the National Violent Death Reporting System, 2008-2019

"He gets mad that I'm sober": Experiences of substance use coercion among postpartum women in recovery

PURPOSE

The number of women with substance use disorders (SUDs) is growing in the U.S. Many women with SUDs are of childbearing age, and studies show that women who abstain from substance use during pregnancy often relapse in the postpartum period. Given the high overlap between substance use and intimate partner violence, these women may be in relationships that make recovery more challenging. This study aimed to better understand how substance abuse coercion in intimate relationships may affect substance use and to identify and describe the presence of substance use coercion in postpartum women.

METHODS

The study conducted qualitative interviews with 30 women with substance use disorders who had given birth within the past six months. Researchers recruited women from a larger intervention study providing home visit support to postpartum women in substance use recovery. Thematic analysis was then identified overarching themes in the interview data.

RESULTS

Analysis of the impact of IPV on substance use revealed four themes: 1) sabotaging sobriety, 2) making substance use a condition of the relationship, 3) portraying her as a "bad mom," and 4) furthering social isolation.

CONCLUSIONS

Findings showed that women with SUDs have specific vulnerabilities that partners may exploit as a way of exerting control. Implications for practice with postpartum women who are working toward recovery are discussed.

Switzerland's Midwifery Model of Postpartum Care

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Pregnancy-Associated Firearm Mortality in the U.S., 2008-2019

INTRODUCTION

This study analyzed the contribution of firearms to pregnancy-associated mortality from homicide and suicide.

METHODS

This was a retrospective cohort study using the Centers for Disease Control and Prevention's National Violent Death Reporting System from 2008 to 2019. Women aged 15-44 years who died by suicide (intentional self-harm) and homicide where a firearm was involved were included. Persons without known pregnancy status were excluded. Pregnancy-associated deaths were defined as those that occurred during pregnancy or within 1 year of pregnancy (early and late postpartum). Sociodemographic characteristics and social and circumstantial differences were compared between pregnancy-associated and nonpregnant-associated deaths. Data analysis was conducted in 2022-2023.

RESULTS

A total of 1,803 homicide and 1,929 suicide deaths from firearms were included. Twenty-two percent (n=388) and 11% (n=212) of firearm homicides and suicides, respectively, were pregnancy associated. Victims of pregnancy associated homicide were predominantly Black (54.8%), were single (76%), and had high school diploma or equivalent degree (41.2%). Victims of pregnancy-associated suicide were predominantly White (80.5%). Among pregnancy-associated homicides and suicides, deaths occurred more frequently during pregnancy (63.4% and 40.3%). Pregnancy-associated homicides more frequently occurred in the victim's home than nonpregnancy-associated homicides (51.5% vs 46.7%, p=0.02) and was related to ongoing conflict or violence between a current or former partner (61.6% vs 51.9%, p<0.001). Pregnancy-associated suicides more frequently occurred in those who experienced intimate partner violence within a month of death than non-pregnancy-associated suicide (4.2% vs 1.3%, p=0.005).

CONCLUSIONS

Although there are differences in demographic characteristics between victims, interpersonal violence is associated with both pregnancy-associated homicides and suicides where a firearm was involved.

Suicide Mortality During the Perinatal Period

Importance

The US has the highest maternal mortality rate among developed countries. The Centers for Disease Control and Prevention deems nearly all of these deaths preventable, especially those attributable to mental health conditions. Coordination between US health care and social service systems could help further characterize circumstances and risks associated with perinatal suicide mortality.

Objective

To examine contextual and individual precipitating circumstances and risks associated with perinatal suicide.

Design, Setting, and Participants

This cross-sectional observational study used a convergent mixed methods design to explore factors contributing to maternal suicides and deaths of undetermined intent (hereinafter, undetermined deaths) identified in National Violent Death Reporting System (NVDRS) data for January 1, 2003, to December 31, 2021. Analyses included decedents who were aged 10 to 50 years and pregnant or post partum at death (collectively, the perinatal group) and demographically matched female decedents who were not pregnant or recently pregnant (nonperinatal group) at death. Analyses were performed between December 2022 and December 2023.

Exposures

Pregnancy status at death (perinatal or nonperinatal).

Main Outcomes and Measures

The main outcomes included contributing circumstances associated with suicides and undetermined deaths cited in coroner, medical examiner, or law enforcement case narratives. The study examined quantitative differences between groups using a matched analysis and characterized key themes of salient suicide circumstances using qualitative content analysis.

Results

This study included 1150 perinatal decedents identified in the NVDRS: 456 (39.6%) were pregnant at death, 203 (17.7%) were pregnant within 42 days of death, and 491 (42.7%) were pregnant within 43 to 365 days before death, yielding 694 postpartum decedents. The nonperinatal comparison group included 17 655 female decedents aged 10 to 50 years. The mean (SD) age was 29.1 (7.4) years for perinatal decedents and 35.8 (10.8) years for nonperinatal decedents. Compared with matched nonperinatal decedents, perinatal decedents had higher odds of the following identified contributing circumstances: intimate partner problems (IPPs) (odds ratio [OR], 1.45 [95% CI, 1.23-1.72]), recent argument (OR, 1.33 [95% CI, 1.09-1.61]), depressed mood (OR, 1.39 [95% CI, 1.19-1.63]), substance abuse or other abuse (OR, 1.21 [95% CI, 1.03-1.42]), physical health problems (OR, 1.37 [95% CI, 1.09-1.72]), and death of a family member or friend (OR, 1.47 [95% CI, 1.06-2.02]). The findings of the qualitative analysis emphasized the importance of mental health and identified 128 decedents (12.4%) with postpartum depression.

Conclusions and Relevance

This study provides insights into complex factors surrounding maternal suicide, and it highlights opportunities for further research to understand long-term consequences of perinatal mental health. These findings also underscore the need for targeted evidence-based interventions and effective policies targeting mental health, substance use, and IPPs to prevent maternal suicide and enhance maternal health outcomes.

Stratifying Risk for Postpartum Depression at Time of Hospital Discharge

Objective

Postpartum depression (PPD) represents a major contributor to postpartum morbidity and mortality. Beyond efforts at routine screening, risk stratification models could enable more targeted interventions in settings with limited resources. Thus, we aimed to develop and estimate the performance of a generalizable risk stratification model for PPD in patients without a history of depression using information collected as part of routine clinical care.

Methods

We performed a retrospective cohort study of all individuals who delivered between 2017 and 2022 in one of two large academic medical centers and six community hospitals. An elastic net model was constructed and externally validated to predict PPD using sociodemographic factors, medical history, and prenatal depression screening information, all of which was known before discharge from the delivery hospitalization.

Results

The cohort included 29,168 individuals; 2,703 (9.3%) met at least one criterion for postpartum depression in the 6 months following delivery. In the external validation data, the model had good discrimination and remained well-calibrated: area under the receiver operating characteristic curve 0.721 (95% CI: 0.707-0.734), Brier calibration score 0.088 (95% CI: 0.084 - 0.092). At a specificity of 90%, the positive predictive value was 28.0% (95% CI: 26.0-30.1%), and the negative predictive value was 92.2% (95% CI: 91.8-92.7%).

Conclusions

These findings demonstrate that a simple machine-learning model can be used to stratify the risk for PPD before delivery hospitalization discharge. This tool could help identify patients within a practice at the highest risk and facilitate individualized postpartum care planning regarding the prevention of, screening for, and management of PPD at the start of the postpartum period and potentially the onset of symptoms.

Listening to Black Pregnant and Postpartum People: Using Technology to Enhance Equity in Screening and Treatment of Perinatal Mental Health and Substance Use Disorders

Perinatal mood and anxiety disorders (PMADs), perinatal substance use disorders (PSUDs), and intimate partner violence (IPV) are leading causes of pregnancy-related deaths in the United States. Screening and referral for PMADs, PSUDs and IPV is recommended, however, racial disparities are prominent: Black pregnant and postpartum people (PPP) are less likely to be screened and attend treatment compared to White PPP. We conducted qualitative interviews to better understand the experience of Black PPP who used a text/phone-based screening and referral program for PMADs/PSUDs and IPV-Listening to Women and Pregnant and Postpartum People (LTWP). We previously demonstrated that LTWP led to a significant reduction in racial disparities compared to in-person screening and referral, and through the current study, sought to identify facilitators of PMAD/PSUD symptom endorsement and treatment attendance. Semi-structured interviews were conducted with 68 Black PPP who were or had been pregnant within the last 24 months, and who either had or did not have a PMAD or PSUD. Participants were enrolled in LTWP and provided feedback on their experience. Using a grounded theory approach, four themes emerged: usability, comfort, necessity, and recommendations. Ease of use, brevity, convenience, and comfort in discussing mental health and substance use via text were highlighted. Need for a program like LTWP in Black communities was discussed, given the reduction in perceived judgement and access to trusted information and resources for PMADs/PSUDs, which may lessen stigma. These qualitative findings illuminate how technology-based adaptations to behavioral health screening and referral can reduce perceived negative judgment and facilitate identification and referral to treatment, thereby more adequately meeting needs of Black PPP.

Pregnancy-associated homicide, suicide and unintentional opioid-involved overdose deaths, North Carolina 2018-2019

OBJECTIVE

Rates of death due to homicide, suicide and overdose during pregnancy and the first year postpartum have increased substantially in the USA in recent years. The aims of this study were to use 2018-2019 data on deaths identified for review by the North Carolina Maternal Mortality Review Committee (NC-MMRC), data from the North Carolina Violent Death Reporting System (NC-VDRS) and data from the Statewide Unintentional Drug Overdose Reporting System (NC-SUDORS) to examine homicide, suicide and unintentional opioid-involved overdose deaths during pregnancy and the first year postpartum.

METHODS

We linked data from the 2018-2019 NC-MMRC to suicide and homicide deaths among women ages 10-50 years from the 2018-2019 NC-VDRS and to unintentional opioid-involved overdose deaths among women ages 10-50 years from the 2018-2019 NC-SUDORS. We conducted descriptive analyses to examine the prevalence of demographic characteristics and the circumstances surrounding each cause of death.

RESULTS

From 2018 to 2019 in North Carolina, there were 23 homicides, nine suicides and 36 unintentional opioid-involved overdose deaths (9.7, 3.8 and 15.1 per 100 000 live births, respectively) during pregnancy and the first year postpartum. Most homicide deaths (87.0%) were by firearm, and more than half (52.5%) were related to intimate partner violence. More than two-thirds of women who died by suicide had a current mental health problem (77.8%). Less than one-fourth (22.2%) of those who died by unintentional opioid-involved overdose had a known history of substance use disorder treatment.

CONCLUSION

Our approach to quantifying and describing these causes of pregnancy-associated death can serve as a framework for other states to inform data-driven prevention.

Partnering for the future clinic: A multidisciplinary perinatal substance use program

OBJECTIVE

The current model of obstetric care does not integrate multiple subspecialty services for high-risk pregnancies with substance use disorder (SUD), resulting in fragmented care. We describe the framework of our multidisciplinary and integrated perinatal substance use clinic and provide recent clinical outcomes.

METHODS

We detail the Partnering for the Future (PFF) clinic, which integrates numerous subspecialty and support services for patients with SUDs and complex mental health needs. Additionally, a retrospective chart review of patients receiving care in the PFF clinic from 2017 to 2021 was completed.

RESULTS

Seven integrated services are detailed with a focus on reducing stigma, providing trauma-informed care and mitigating harm. During the study period, 182 patients received care in PFF clinic, with opioid use disorder the most common indication for care. Co-occurring mental illness was common (81%). NICU admissions and severe NOWS diagnosis declined after the implementation of Eat-Sleep-Console. Social services identified care coordination, transportation assistance and adjustment counseling as the most common needs. A novel virtual behavioral health consultation service was successfully launched.

CONCLUSIONS

Our integrated care model supports the holistic care of pregnant people with SUD and mental health disease. Patient-centered care and co-located services have improved perinatal outcomes, particularly for opioid-exposed pregnancies.