Substance Use After Childbirth: Links to Depression, Anxiety and Life Stress

Most pregnancy-related deaths from mental health conditions — including overdoses and poisonings linked to substance use disorder — happen late in the postpartum period, between 43 and 365 days after the birth. Adverse childhood experiences and stressful life events are already known to be linked with more substance use during pregnancy. A CDC report asked whether the same holds after the baby is born.

The survey

The Pregnancy Risk Assessment Monitoring System (PRAMS) is run by CDC and participating states to track women's experiences before, during and after pregnancy among those who have recently had a live birth. To learn more about opioid use and its risks after childbirth, PRAMS went back to women in seven states with high rates of opioid-involved overdose deaths — Kentucky, Louisiana, Massachusetts, Missouri, Pennsylvania, Utah and West Virginia — 9–10 months after they gave birth in 2019.

They were asked about:

• Opioid pain relievers since the birth, including where they came from and why they were taken. Misuse meant taking them for a reason other than pain, or getting them somewhere other than a health care provider.
• Alcohol: binge drinking (more than four drinks in a single 2-hour episode) or excessive drinking (eight or more drinks a week).
• Tobacco, and other substances: CBD products, marijuana, synthetic marijuana, heroin, amphetamines, cocaine, tranquilizers, hallucinogens and inhalants.
• Mental health: current depression or anxiety, and depressive symptoms in the previous 30 days.
• Household dysfunction in childhood, before age 18: parents separating or divorcing, or living with someone who had a drinking or drug problem, a mental illness, or who was jailed.

Earlier in the core PRAMS survey, respondents in six of the states (West Virginia's data were not available) had also been asked about 14 stressful life events in the year before the birth — among them a family member's illness, separation or divorce, moving, losing housing or a job, cuts in pay or hours, arguments with a partner, trouble paying bills, jail, someone close having a substance problem, and a death.

Postpartum substance use meant misuse of opioid pain relievers, unhealthy drinking, or any use of tobacco or other substances since the birth; polysubstance use meant two or more of them. Of 1,990 respondents, 1,920 (96%) answered the substance use questions, and the results were weighted to represent women who gave birth in each state during about 5 months of 2019.

What they found

Overall, 25.6% of the women reported substance use after giving birth, and 5.9% reported polysubstance use. Substance use differed significantly by education, health insurance and state; polysubstance use differed by race and ethnicity and by insurance.

Mental health. Substance use was about twice as common among women with each of these conditions as among those without:

After adjusting for age, race and ethnicity, education, insurance and state, women with depressive symptoms were 1.8 times as likely to report substance use and 3.0 times as likely to report polysubstance use; the figures for depression and anxiety were similar.

Childhood adversity. Among women who reported all four kinds of household dysfunction in childhood, 57.9% reported substance use after the birth and 26.3% polysubstance use. Women with two to four such experiences were 2.1 times as likely as those with none to use substances and 5.5 times as likely to use more than one.

Recent stress. Among women with six or more stressful life events in the year before the birth, 67.1% reported substance use and 20.8% polysubstance use. Compared with women who reported no stressful events, they were 3.6 times as likely to use substances and 9.1 times as likely to use more than one.

In context

Other surveys point the same way, though their methods and definitions differ enough to make direct comparison hard. In the 2006–2014 National Survey on Drug Use and Health, 5.1% of pregnant women and 24.3% of women who were not pregnant reported using more than one substance in the previous month. In the 2009–2019 survey, polysubstance use during pregnancy fell from 31.3% in the first trimester to 7.8% in the third. The link with stress and childhood adversity matches studies of alcohol and marijuana use around pregnancy.

What can help

• A full postpartum visit. The American College of Obstetricians and Gynecologists recommends a comprehensive visit within 12 weeks of the birth that screens for depression, anxiety and substance use disorder, checks needs such as housing, utilities and food, and refers the mother for follow-up care. It stresses that postpartum care should be an ongoing process, fitted to each woman and coordinated between obstetric and primary care.
• Screening. The U.S. Preventive Services Task Force gives guidance on screening for unhealthy substance use and depression, including in pregnant and postpartum women.
• Addressing childhood adversity. Family-centered treatment for substance use disorders and services centered on victims can reduce the postpartum harms of adverse childhood experiences, and evidence-based strategies can prevent those experiences in the first place.
• Community and system support. Maternal mortality review committees recommend more social, family and peer support and education for patients, providers and communities. Learning collaboratives share good practice, and perinatal quality collaboratives help multidisciplinary teams screen, treat and coordinate care for pregnant and postpartum women with opioid use disorder and their babies.

Limitations

The authors listed five: the results apply only to the seven states surveyed, all with high overdose death rates; substance use was self-reported and may be undercounted; misuse of prescription drugs other than opioid pain relievers was not included; childhood abuse and stressful events after the birth were not asked about; and polysubstance use meant using two or more substances at any time since the birth, not necessarily together.

Sources

• Stewart A, Ko J, Salvesen von Essen B, et al. "Association of Mental Health Conditions, Recent Stressful Life Events, and Adverse Childhood Experiences with Postpartum Substance Use — Seven States, 2019." MMWR 72(16). CDC.