Substance Use, ACEs, and Mental Health Disorders as Contributors to Maternal Mortality

by Iris Smith, PhD

Based on a sample of 17,000 patients enrolled in the Kaiser Permanente health system, the first study of adverse childhood experiences (ACEs) was published 24 years ago [1] by Drs Robert Anda and Vincent Felitti. Their study identified 3 types of childhood experiences that were associated with an increased risk of physical and/or mental health problems in adulthood: household dysfunction due to divorce, parental substance use, mental illness or domestic violence; emotional or physical neglect; and emotional, physical, or sexual abuse.  Since the publication of the original study, there have been hundreds of studies corroborating the original results and expanding our understanding of the consequences associated with ACEs.   

Previous research has shown that growing up in a home with parental substance use is linked to poor health and lack of well-being in adulthood, making pregnancy an opportune time to break the cycle of intergenerational transmission of ACEs. Data from the 2009-2019 National Survey of Drug Use and Health (NSDUH) indicated that polysubstance use during pregnancy ranged from 31.3% in the first trimester to 7.8% in the third trimester.  A review of data collected by maternal mortality review committees in 36 states from 2017-2019 (1,018 deaths) found that mental health problems including suicide, substance use disorder, drug overdose/poisoning related to substance use disorder, and other deaths related to a mental condition were the leading causes of death, accounting for 22.7% of deaths reported. In this study, pregnancy-related death was defined as a death during pregnancy or within one year after the end of a pregnancy from a pregnancy complication, a chain of events initiated by the pregnancy, or aggravation of an unrelated condition by the physiologic effects of pregnancy.[2]  A subsequent study by Stewart et al. (2023) found that opioid-involved overdose mortality rates, depressive symptoms, depression, anxiety, adverse childhood experiences, and stressful life events were associated with higher substance use among post-partum women.  Substance use was most common among women who experienced six or more stressful life events in the year before giving birth (67.1%) or four household dysfunction adverse childhood experiences (57.9%), defined as parental separation or divorce, parental substance use or living with someone who had a mental illness. Overall, 25.6% of the women in the study reported using substances post-partum.3

Substance use during pregnancy is known to cause a wide range of developmental problems and lifelong disabilities in children. These studies highlight the importance of timely screening and access to appropriate treatment and support resources for substance using women before, during, and following pregnancy. Substance use can affect the entire family system including older siblings.




Cook JL (2022) Epidemiology of Opioid Use in Pregnancy.  Best Practice & Research Clinical Obstetrics and Gynaecology, 85; pg. 12-17. PMID: 36045026 DOI: 10.1016/j.bpobgyn.2022.07.008

Donagh B, Taylor J, Al Mushaikhi M, Bradbury-Jones C. (2022) Sibling Experiences of Adverse Childhood Experiences: A Scoping Review. Trauma Violence Abuse. doi: 10.1177/15248380221134289. Epub ahead of print.

Lowthian E (2022) The Secondary Harms of Parental Substance Use on Children’s Educational Outcomes: A Review.  Journal of Child and Adolescent Trauma 15; pg. 511-515.

Steward A, Ko J, Von Essen BS, Levcke M, D’Angelo D, Romero L, Cox S, Warner L, Barfield W (2023).  Association of Mental Health Conditions, Recent Stressful Life Events and Adverse Childhood Experiences- Seven States, 2019-2020.  Morbidity and Mortality 72 (16); pg. 416-420.

Tran EL, England LJ, Park Y, Denny CH, Kim SY. Systematic Review: Polysubstance Prevalence Estimates Reported during Pregnancy, US, 2009-2020. Maternal Child Health J. 2023 Mar;27(3):426-458. Epub 2023 Feb 8.

Trost SL, Beauregard J, Njie F, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022.

Wolfson L & Poole N (2023).  Supportive Alcohol Policy as a Key Element of Fetal Alcohol Spectrum Disorder Prevention.  Womens Health (Lond.) 2023 (19). PMID: 36718116; doi: 10.1177/17455057231151838


1 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245-258.

2 Trost SL, Beauregard J, Njie F, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022.

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