Associations of Depression with Opioid Use Among Pregnant Individuals, and Rural-Urban Differences in the Relationships: An Analysis of PRAMS Data

Abstract

Background: Depression during pregnancy affects approximately 15–20% of pregnancies and is associated with poor maternal and infant outcomes, including increased risk for preterm birth and inadequate prenatal care. It is also linked to adverse health behaviors, including opioid use. While research has documented associations of depression with opioid use during pregnancy, limited work has examined how this relationship may differ based on geographic residence. Individuals in rural areas face distinct barriers, such as limited access to healthcare, greater stigma, and increased isolation, that may impact both depression and substance use patterns. This study aimed to investigate association of depression with opioid use during pregnancy and whether rural versus urban residence modifies the association. Methods: This cross-sectional study used 2016–2022 data from Phase 8 of the Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based survey of individuals who recently gave birth. We included respondents (N = 44,048) from 17 jurisdictions that asked about both depression and opioid use, representing a weighted total of 1,760,357 individuals. Depression during pregnancy and opioid use were self-reported. Residence was classified as rural or urban. Survey-weighted logistic regression models estimated odds ratios (ORs) for the association between depression and opioid use. Analyses adjusted for maternal age, race/ethnicity, education, and household income. Rural/urban status stratified models and models with an interaction term were used to examine effect modification. Results: Depression during pregnancy was reported by 19.6% of participants. Participants with depression were younger, had lower education, and were more likely to live in rural areas and low-income households, compared with participants who did not report depression. Opioid use was reported by 11.4% of individuals with depression, compared to 5% without depression. Participants with depression had two-fold higher odds of opioid use during pregnancy compared with participants without depression (adjusted OR = 2.02; 95% CI: 1.61–2.55). Although the depression-opioid use association appeared slightly stronger among rural residents (adjusted OR = 2.06; 95% CI: 1.62-2.62), compared with association among urban residents (adjusted OR = 1.82; 95% CI: 1.54-2.17), the interaction term between depression and rural/urban status was not statistically significant (p > 0.05). Conclusion: Depression is strongly associated with increased odds of opioid use during pregnancy, highlighting the need for integrated mental health and substance use screening and treatment during prenatal care. While the observed association was stronger among rural residents, geographic residence did not significantly modify the depression-opioid association. Expanded investment in maternal mental health infrastructure and policies can promote equitable access to care across geographic settings.