Abstract: For women who use drugs (WWUD) in the US, the months they are pregnant and postpartum are
among the most hazardous of their lives: the US has the highest maternal mortality rate of all industrialized na-
tions, and up to 26% of maternal deaths in multiple states are attributed to drug use. Disparities are complex.
Though all-cause maternal mortality rates are higher for Black women, rates of drug-related maternal mortal-
ity are far higher among White women. Rural/urban inequities are stark and widening. Public health scientists
have largely neglected this crisis. Since 2010, just 1.6% of articles in major addiction journals have addressed
pregnancy or the postpartum period; a parallel silence exists in maternal health research. The proposed 4-
year longitudinal qualitative study is thus designed to help lay the foundations for a new arena of mul-
tilevel epidemiologic research and interventions to help Black, White, urban, and rural WWUD survive
while pregnant and postpartum. Four pillars of the Intersectional Risk Environment Model (IREM) guide this
novel inquiry: harm reduction, intersectional equity, intersectional risk environments, and resistance.
Harm reduction principles invite us to recognize that pregnant/postpartum WWUD have vital insights into the
drug and sexual/reproductive (SR) harms that drugs can create for them, and may have crafted effective prac-
tices to prevent these harms (e.g., altering drug use frequency). Intersectional equity insists that pregnant/
postpartum WWUD’s drug and SR health concerns and practices may vary along intersecting dimensions of
their social position (e.g., race and rurality/urbanicity). IREM suggests that features of WWUD’s social, eco-
nomic, physical, policy, and healthcare/criminal legal intervention risk environments create these variations,
and that these environments are racialized and structurally urbanized–i.e., resources have been dispropor-
tionately allocated to urban and/or majority White areas, and hazards to rural and/or majority Black areas.
IREM posits that hazards can be resisted via individual and collective action. Guided by IREM and Advisory
Boards of WWUD, we will use Constructivist Grounded Theory and Qualitative Longitudinal Research
methods to “walk alongside” a cohort of Black, White, urban, and rural WWUD living in 4 racialized and struc-
turally urbanized regions of Georgia while they are pregnant and postpartum, gathering 5 waves of data, to:
Aim 1. Explore pregnant WWUDs’ (a) drug- and SR-related health concerns and practices, and how they vary
across pregnancy and by race, rurality/urbanicity, and socioeconomic status (SES); and (b) perceptions of their
racialized and structurally urbanized risk environments, how they evolve during pregnancy, and how these
evolving environments shape WWUD’s concerns and practices. Aim 2. Analyze postpartum WWUD’s (a)
drug- and SR-related concerns and practices, and how they vary in the postpartum months by race, rurality/ur-
banicity, and SES; and (b) perceptions of their racialized and structurally urbanized risk environments, how
they evolve postpartum, and how these evolving environments shape WWUD’s concerns and practices.
