By Marlynn Larkin
NEW YORK (Reuters Health) ? Maternal suicide constitutes a “substantial” part of perinatal mortality in Canada, as in other developed countries, and should be a public health priority, researchers say.
“Death by suicide during the perinatal period has been understudied in Canada,” according to Dr. Sophie Grigoriadis of the University of Toronto and colleagues. Therefore, the team investigated by linking health databases with coroner records in Ontario from 1994 to 2008.
As reported in CMAJ, online August 28, the perinatal suicide rate was 2.58 per 100,000 live births, with suicide accounting for 51 (5.3%) of 966 perinatal deaths (20 during pregnancy, 31 during the postpartum period).
That rate “was comparable to estimates from the UK and the U.S., and represents a substantial component (1 in 20) of perinatal mortality,” Dr. Grigoriadis told Reuters Health by email.
“Typically the postpartum period has been limited to the first month or up to six weeks,” she added. “In our study, the average time of suicide in the postpartum was 7.5 months.”
Perinatal women were more likely to die from hanging (33.3%) or jumping or falling (19.6%) than women who died by suicide outside the perinatal period (28.2% and 13.3%, respectively).
The majority of women (71%) who died from perinatal suicide had been in contact with the healthcare system for mental health needs in the year before death (vs. 22% of living perinatal women during a matched year). However, in the month before they died, only about 40% of the women who committed suicide had a mental healthcare contact.
“Our research showed that women who died by suicide in pregnancy or the first year postpartum were more often diagnosed with an affective, anxiety or related disorder compared to a psychotic disorder,” Dr. Grigoriadis noted. “Nonpsychotic mental disorders in pregnancy and the postpartum (period) are not to be underestimated.”
Those who died by suicide and living mothers had a similar likelihood of seeing a primary care and/or obstetric care provider before the matched date, but those in suicide group were less likely to have seen a pediatrician in the previous month (65% vs. 88%).
“The takeaway messages for clinicians,” Dr. Grigoriadis said, “are that we need to be doing more in terms of suicide surveillance for pregnant and postpartum women and that mental health intervention efforts must focus on pregnancy and continue well into the first year postpartum,” she stressed. “This must include family practice physicians, obstetricians and pediatricians.”
Dr. Catherine Monk, Director of Research, The Women’s Program at Columbia University Medical Center in New York City told Reuters Health, “These findings underscore the urgency to embed behavioral health services in obstetrical and pediatric practices as part of routine care, including knowledge of warning signs, provision of specialty services for those at risk, and ‘warm handoffs’ between obstetrical services so that women at risk do not get lost as they go to different medical providers.”
“They also draw attention to the potential lethality of mood disorders,” she said by email.
“Maternal suicide was the consequence of lethal means, hanging or jumping from heights - means that tend to be successful, versus drug overdoes or chemical exposures which often are less successful,” Dr. Monk continued.
“However, given that Canada has much stricter gun laws than the U.S., we need to be aware that there is a readily available alternative form of lethal suicide in the U.S. ? namely, guns,” she observed. “Putting this another way, as maternal deaths tend to be the result of more-lethal means, countries with greater access to guns will have that means as well as a method likely chosen for/available for maternal suicide.”
In addition to being alert for signs of maternal depression and anxiety in the perinatal, postpartum period, she said, “It also is important for us to move beyond a deep-seated cultural orientation that views pregnancy and motherhood as periods of primarily supreme joy.”
“This undoubtedly is true for many, particularly in certain moments, yet this orientation can bias our perceptions so as not to see pregnant and postpartum women in distress,” she explained. “It is as if we want to hold onto an idealized view of motherhood, each of us as individuals, and in our collective narratives, and accepting that women can be desperately depressed and anxious around the time of having a baby deeply disturbs our worldview, so we resist it.”
Preventive measures should include “integrating behavioral health services in OB and pediatric practices and mounting a public health campaign focused on signs of significant distress during pregnancy and postpartum so that, similar to breast cancer, we are all as aware of risk factors for, and signs of, this constellation of problems that can lead to maternal suicide,” Dr. Monk concluded.
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