Inequities and Missed Opportunities: A National Analysis of Emergency Department Visits for Pregnant Individuals with Mental Health and Substance Use Disorder
Restricted accessResearch articleFirst published online July, 2025
Inequities and Missed Opportunities: A National Analysis of Emergency Department Visits for Pregnant Individuals with Mental Health and Substance Use Disorder
This study aims to identify whether there are inequities in care for pregnant individuals with mental health or substance use disorders (MH/SUDs) seeking treatment in emergency departments (EDs) for pregnancy-related concerns. Considering their risk for poor maternal and infant outcomes, we sought to examine their experiences in EDs to target future interventions and institute referrals to integrated care systems.
Methods:
This retrospective, exploratory analysis identified ED visits for pregnancy-related concerns using the National Hospital Ambulatory Medical Care Survey database from 2016 to 2020 (n = 1,233) to compare experiences of care by pregnant people with (n = 149) and without MH/SUD (n = 1,084).
Results:
11.9% (95% confidence interval [CI]: 9.8 − 15.1%) of ED visits for pregnancy-related concerns were cross-coded for MH/SUD. Compared to visits by pregnant individuals without MH/SUD, visits by pregnant people with MH/SUD were 70% less likely to be asked to return to the ED for follow-up treatment (p = 0.027), had 3.8 times greater odds of leaving the ED prior to completing care (p = 0.005), and received 40% more medication upon discharge (p = 0.049) after controlling for demographic variables. Of those visits by pregnant people with MH/SUD, only 6.8% were given a toxicology screen and only 1.2% were seen by an MH provider.
Conclusion:
This nationally representative analysis of ED visits for pregnancy-related concerns identified multiple opportunities to address care inequities that affect health outcomes. Special training and processes are needed within EDs to engage pregnant people with MH/SUD to provide effective, evidence-based care interventions and referrals.
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References
1.
CunninghamSD, MagriplesU, ThomasJL, et al.Association between maternal comorbidities and emergency department use among a national sample of commercially insured pregnant women. Acad Emerg Med, 2017; 24(8):940–947.
2.
MalikS, KothariC, MacCallumC, et al.Emergency department use in the perinatal period: An opportunity for early intervention. Ann Emerg Med, 2017; 70(6):835–839.
3.
MatenchukBA, RosychukRJ, RoweBH, et al.Emergency department visits during pregnancy. Ann Emerg Med, 2023; 81(2):197–208.
4.
WangE, GlazerKB, HowellEA, et al.Social determinants of pregnancy-related mortality and morbidity in the United States: A systematic review. Obstet Gynecol, 2020; 135(4):896–915.
5.
McDermottKW, ReidLD, OwensPL. and Expected Payers and Patient Characteristics of Maternal Emergency Department Care, 2019. Agency for Healthcare Research and Quality (US): Rockville (MD); 2022.
6.
PfeiferLR, HaileZT. Unmet mental health care needs and illicit drug use during pregnancy. J Addict Med, 2021; 15(3):233–240.
7.
FlynnHA, DavisM, MarcusSM, et al.Rates of maternal depression in pediatric emergency department and relationship to child service utilization. Gen Hosp Psychiatry, 2004; 26(4):316–322.
8.
PinchmanEV, LendeMN, FeustelP, et al.Evaluating the association between prenatal care visits and adverse perinatal outcome in pregnancies complicated by opioid use disorder. Am J Perinatol, 2024; 41(S 01):e2225–e2229.
9.
MarcusSM, FlynnHA, BlowFC, et al.Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health (Larchmt), 2003; 12(4):373–380.
ByattN, LevinLL, ZiedonisD, et al.Enhancing participation in depression care in outpatient perinatal care settings: A systematic review. Obstet Gynecol, 2015; 126(5):1048–1058.
16.
MurphyS, RosenbaumM. Pregnant Women on Drugs: Combating Stereotypes and Stigma. Rutgers University Press; 1999.
17.
PolandML, DombrowskiMP, AgerJW, et al.Punishing pregnant drug users: Enhancing the flight from care. Drug Alcohol Depend, 1993; 31(3):199–203.
18.
RobertsSC, Nuru-JeterA. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues, 2010; 20(3):193–200.
19.
RobertsSC, PiesC. Complex calculations: How drug use during pregnancy becomes a barrier to prenatal care. Matern Child Health J, 2011; 15(3):333–341.
20.
CourchesneNS, SmithLR, ZúñigaML, et al.Association of alcohol and other substance-related diagnoses with severe maternal morbidity. Alcohol Clin Exp Res, 2021; 45(9):1829–1839.
21.
KilfoyleKA, VreesR, RakerCA, et al.Nonurgent and urgent emergency department use during pregnancy: An observational study. Am J Obstet Gynecol, 2017; 216(2):181.e1–181.e7.
22.
VarnerCE, ParkAL, LittleD, et al.Emergency department use by pregnant women in Ontario: A retrospective population-based cohort study. CMAJ Open, 2020; 8(2):E304–E312.
23.
IsmailovaI, YagihashiE, SaadatN, et al.Pregnant black women and emergency department utilization: Assessing self-reported receipt of prenatal counseling. West J Nurs Res, 2022; 44(1):42–49.
24.
NelsonDB, LeporeSJ. The role of stress, depression, and violence on unintended pregnancy among young urban women. J Womens Health (Larchmt), 2013; 22(8):673–680.
25.
VladutiuCJ, StringerEM, KandasamyV, et al.Emergency care utilization among pregnant medicaid recipients in North Carolina: An analysis using linked claims and birth records. Matern Child Health J, 2019; 23(2):265–276.
TanabeP, GimbelR, YarnoldPR, et al.Reliability and validity of scores on the emergency severity index version 3. Acad Emerg Med, 2004; 11(1):59–65.
28.
Courchesne-KrakNS, KepnerW, RubanoA, et al.Differences in outpatient, emergency, and inpatient use among pregnant women with a substance-related diagnosis. Am J Obstet Gynecol MFM, 2022; 4(2):100559.
TamblingRR, D’AnielloC, RussellBS. Mental health literacy: A critical target for narrowing racial disparities in behavioral health. Int J Ment Health Addict, 2021:1–15.
31.
MoyerCL, JohnsonS, KlugMG, et al.Substance use in pregnant women using the emergency department: Undertested and overlooked? West J Emerg Med, 2018; 19(3):579–584.
32.
GreenmyerJR, StacyJM, KlugMG, et al.Pregnancy status is associated with screening for alcohol and other substance use in the emergency department. J Addict Med, 2020; 14(4):e64–e69.
33.
MarshmanA, SaundersE, ChavesD, et al.Barriers to perinatal mental health care experiences by midwives and obstetricians and their patients: A rapid review. Midwifery, 2023; 117:103544.
34.
HutnerLA, Yeaton-MasseyA, ToscanoM, et al.Cultivating mental health education in obstetrics and gynecology: A call to action. Am J Obstet Gynecol MFM, 2021; 3(6):100459.
35.
TenenbeinM. Do you really need that emergency drug screen? Clin Toxicol (Phila), 2009; 47(4):286–291.
36.
StellpflugSJ, ColeJB, GrellerHA. Urine drug screens in the emergency department: The best test may be no test at all. J Emerg Nurs, 2020; 46(6):923–931.
37.
TijdinkJK, van den HeuvelJ, VasbinderEC, et al.Does on-site urine toxicology screening have an added diagnostic value in psychiatric referrals in an emergency setting? Gen Hosp Psychiatry, 2011; 33(6):626–630.
38.
BhallaA. Bedside point of care toxicology screens in the ED: Utility and pitfalls. Int J Crit Illn Inj Sci, 2014; 4(3):257–260.
39.
LagerPS, Attema-de JongeME, GorzemanMP, et al.Clinical value of drugs of abuse point of care testing in an emergency department setting. Toxicol Rep, 2018; 5:12–17.
40.
KrollDS, SmallwoodJ, ChangG. Drug screens for psychiatric patients in the emergency department: Evaluation and recommendations. Psychosomatics, 2013; 54(1):60–66.
41.
OlshakerJS, BrowneB, JerrardDA, et al.Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med, 1997; 4(2):124–128.
42.
HiraiAH, KoJY, OwensPL, et al.Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010-2017. JAMA, 2021; 325(2):146–155.
ConnerSN, BedellV, LipseyK, et al.Maternal marijuana use and adverse neonatal outcomes: A systematic review and meta-analysis. Obstet Gynecol, 2016; 128(4):713–723.
45.
BandoliG, DelkerE, SchumacherBT, et al.Prenatal cannabis use disorder and infant hospitalization and death in the first year of life. Drug Alcohol Depend, 2023; 242:109728.
46.
CorsiDJ, DonelleJ, SuchaE, et al.Maternal cannabis use in pregnancy and child neurodevelopmental outcomes. Nat Med, 2020; 26(10):1536–1540.
47.
PaulSE, HatoumAS, FineJD, et al.Associations between prenatal cannabis exposure and childhood outcomes: Results from the ABCD Study. JAMA Psychiatry, 2021; 78(1):64–76.
48.
GouinK, MurphyK, ShahPS, Knowledge Synthesis group on Determinants of Low Birth Weight and Preterm Births. Effects of cocaine use during pregnancy on low birthweight and preterm birth: Systematic review and metaanalyses. Am J Obstet Gynecol, 2011; 204(4):340.e1–340.e12.
49.
PatraJ, BakkerR, IrvingH, et al.Dose-response relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, preterm birth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG, 2011; 118(12):1411–1421.
50.
ByattN, XuW, LevinLL, et al.Perinatal depression care pathway for obstetric settings. Int Rev Psychiatry, 2019; 31(3):210–228.
51.
GrosgurinO, CramerB, SchallerM, et al.Patients leaving the emergency department without being seen by a physician: A retrospective database analysis. Swiss Med Wkly, 2013; 143:w13889.
52.
LingS, CleverleyK, BrennenstuhlS, et al.Predictors of leaving an inpatient medical withdrawal service against medical advice: A retrospective analysis. J Addict Med, 2018; 12(6):453–458.
53.
SiuAL, Bibbins-DomingoK, GrossmanDC, et al.;US Preventive Services Task Force (USPSTF). Screening for depression in adults: US preventive services task force recommendation statement. JAMA, 2016; 315(4):380–387.
54.
Anonymous. The American college of obstetricians and gynecologists committee opinion no. 630. screening for perinatal depression. Obstet Gynecol, 2015; 125(5):1268–1271.
55.
EarlsMF, Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics, 2010; 126(5):1032–1039.
56.
KendigS, KeatsJP, HoffmanMC, et al.Consensus bundle on maternal mental health: Perinatal depression and anxiety. Obstet Gynecol, 2017; 129(3):422–430.
57.
GriffenA, McIntyreL, BelsitoJZ, et al.Perinatal mental health care in the United States: An overview of policies and programs. Health Aff (Millwood), 2021; 40(10):1543–1550.
58.
ByattN, BiebelK, Moore SimasTA, et al.Improving perinatal depression care: The Massachusetts Child Psychiatry Access Project for Moms. Gen Hosp Psychiatry, 2016; 40:12–17.
59.
FlynnH, Deichen HansenM, Shabaka-HaynesA, et al.Case report: Implementation of a multi-component behavioral health integration program in obstetrics for perinatal behavioral health. Front Psychiatry, 2021; 12:734883.
60.
WichmanCL, LaszewskiA, DoeringJJ, et al.Feasibility of model adaptations and implementation of a perinatal psychiatric teleconsultation program. Gen Hosp Psychiatry, 2019; 59:51–57.
61.
StraubL, HuybrechtsKF, Hernandez-DiazS, et al.Chronic prescription opioid use in pregnancy in the United States. Pharmacoepidemiol Drug Saf, 2021; 30(4):504–513.
62.
Deichen HansenME, Londoño TobónA, Kamal HaiderU, et al.The role of perinatal psychiatry access programs in advancing mental health equity. Gen Hosp Psychiatry, 2023; 82:75–85.
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