Female injecting drug use, structural determinants, and maternal and newborn outcomes: a cross-country ecological analysis

Background Women who inject drugs (PWID) face substantial health risks; however, their contribution to population-level maternal and newborn outcomes remains unclear. This study examined the association between female PWID indicators and maternal, neonatal, and stillbirth outcomes across 18 countries between 2016 and 2023.Methods Secondary international data were analyzed to examine female PWID prevalence and proportion in relation to maternal mortality ratio (MMR), neonatal mortality, and stillbirth rates. Structural indicators included GDP per capita, fertility, urbanization, health expenditure, literacy, antenatal care, and skilled birth attendance. Spearman correlation and linear regression analyses were performed.Results Female PWID indicators were not significantly associated with maternal, neonatal, or stillbirth outcomes. In contrast, several structural and socioeconomic indicators showed significant and more consistent associations with maternal, neonatal, and stillbirth outcomes. Fertility was the strongest predictor of maternal mortality (β = 0.711, p < 0.001), explaining 50.5% of the variance. GDP significantly predicted neonatal mortality (β = −0.797, p < 0.001) and stillbirth rates (β = −0.790, p < 0.001). Urbanization was associated with a higher proportion of women among PWID but not with overall PWID prevalence.Conclusions The findings suggest that, in this cross-country sample, maternal and newborn outcomes were more consistently associated with structural and socioeconomic indicators than with female PWID indicators.