Suicide during pregnancy and postpartum
The death of pregnant women or postpartum women is a tragic event that we can prevent. Many resources are allocated worldwide through campaigns and actions to reduce maternal deaths due to obstetric causes such as preeclampsia, embolism, hemorrhages or cardiac disorders. However, it seems that this work is not enough, because in many cases the cause of death is not obstetric but psychosocial, such as suicide, homicide or overdose. These causes are not considered and, therefore, do not appear in the statistics.
Death by suicide during the perinatal period, the period from pregnancy to twelve months after childbirth , goes beyond the family sphere and deeply affects the entire society. The impact of these suicides, and especially if there are filicides, shakes the entire community and leaves a mark that lasts for a long time. Myths about motherhood and the stigma that hangs over mental health and suicide mean that the relationship between motherhood and suicide is unknown , and it makes it difficult for women and those around them to ask for help and, when they ask for it, they often do not get the necessary resources to deal with the situation.
A far-reaching problem with little recorded data
It is important to note that death by suicide continues to be one of the main causes of maternal mortality and, in some countries, is the main one. While other more recognized causes of maternal death such as hemorrhage or sepsis are decreasing, suicide is increasing and is responsible for 20% of postpartum deaths (Khalifeh et al., 2016). Despite these compelling data, in our country there are no specific preventive interventions to address this problem, even though its consequences are devastating.
Global data indicate that the maternal suicide rate is increasing in developed countries, although it affects women in unfavorable socioeconomic situations living in the first world much more. In the United States, it is the leading cause of maternal mortality and contributes to more than 8% of pregnancy-related deaths. In the same American report, they consider that more than 80% of these maternal deaths are preventable, including almost 25% of deaths from mental health problems, mainly suicides and overdoses related to substance use disorders (Margerison et al., 2022). There are few publications on this topic, but those that do exist find that pregnant or postpartum women who died by suicide were younger, less likely to have Caucasian ancestry, and more likely to be married than women who committed suicide outside the perinatal period.
Myths about motherhood and the stigma surrounding suicide mean that the relationship between motherhood and suicide is unknown, making it difficult for women and those around them to ask for help.
Despite the importance of the issue, we do not have data from our environment. Neither the National Institute of Statistics (INE) nor the Statistics Institute of Catalonia (Idescat) have data, and without data we cannot know the extent of the problem in our country . Accurately measuring the prevalence of death by suicide is a challenge for several reasons. Suicide is difficult to measure in any population and in the perinatal period there are some factors that make it even more difficult. Some of these factors are the lack of standardization of terms that describe the time or cause of maternal death and the lack of uniformity in the methods for determining maternal deaths. For example, until 1999 the International Classification of Diseases defined maternal death as that which occurs during pregnancy and up to 42 days after childbirth, but maternal suicide is more common after these days, or the definition of the postpartum period according to the source consulted can range from four weeks to a year after childbirth.
Preventing suicide with a gender perspective
In the general population worldwide, suicide is one of the main causes of external death. According to data from the National Institute of Statistics (INE), mortality by suicide in 2022 increased by almost 6% compared to 2021, with a particularly notable increase among people under 30 years of age, and dramatically in those under 19 years of age. Regarding the gender paradox in suicide, a worrying trend towards balance between men and women is observed. Traditionally, men have had a higher suicide rate, but it seems that this difference is gradually reducing. Given this reality, if in our country the mortality by suicide in people under 30 years of age is increasing and the suicide rate between women and men is equalizing, we can deduce that the increase is due to cases of women of reproductive age. This is, in fact, the only possible approach to estimating the number of suicides in the perinatal period in our country, because, as we have said, this data is not officially recorded and, therefore, we do not have direct information.
Maternal suicide risk factors
Maternal suicides during the perinatal period have some characteristics that differentiate them from suicides at other times in a woman's life. One of these differences is that more violent methods are used than those usually used by women. Another differential aspect that must be taken into account is that during pregnancy and the first year postpartum , women have more contact with health professionals than at any other time in their lives. This golden opportunity alone does not prevent the tragic outcome and suicide continues to be one of the main causes of death for mothers. Therefore, regular access to health services alone does not reduce the appearance of suicidal ideas or behaviors or prevent suicide.
Another characteristic of this population that may explain to some extent the high incidence of suicidal ideation and behavior is that mental disorders are the most common medical complication of motherhood , especially depression. The postpartum period is a time of particular risk for the onset of first episodes and recurrences of serious mental disorders. However, although mothers with a history of serious psychiatric disorders are at higher risk than mothers without a history of psychiatric disorders, most people with a mental health problem do not die by suicide, so having a mental health problem has little predictive power and other more specific risk factors for maternal suicidal ideation and suicide attempts need to be identified . One in five women, whether or not they have a psychiatric history, will develop postpartum depression. Postpartum depression leads to suicide in 3 out of every 100,000 women in the postpartum period. It should be noted that the postpartum period appears to be a period of greater risk of suicide than pregnancy , since two-thirds to three-quarters of all maternal deaths by suicide occur in the postpartum period, between week six and one year after birth.
Risk factors for suicide in women
Gender-based violence, a major risk factor
It is important to define other risk factors for suicide during the perinatal period. Studies show that experiences of gender-based violence , especially physical violence, are significantly associated with suicidal ideation, behavior, and completed suicide. This is the risk factor most robustly associated with completed maternal suicide. Furthermore, the results of this research suggest a persistent psychological effect of intimate partner violence and child abuse that may manifest during the perinatal period.
Intimate partner violence has also been found to be associated with both suicide attempts and death, and childhood abuse is a strong predictor of both suicidal ideation and attempts. This dose-response relationship between adult and childhood trauma and suicide risk has been found in large-scale studies in the general population. There is also evidence to suggest that the relationship between depressive symptoms and intimate partner violence is bidirectional, with women who experience violence being at increased risk of depression, and women who experience depressive symptoms being at increased risk of gender-based violence. Experiencing violence as a woman when she is about to become a mother or is already a mother may pose a particular risk, as the safe environment for the baby and for the woman herself is threatened. It is essential for the prevention of suicide in the perinatal period to identify women who have suffered or are suffering violence, either by their partner or by another member of the household. Apart from identifying these women, it is necessary to be able to offer psychological treatment. Having experienced traumatic events throughout life cannot be modified, but the psychological sequelae can.
Gender-based violence, especially physical violence, is the risk factor most robustly associated with completed maternal suicide.
Apart from the risk factors that have already been mentioned (gender violence, child abuse and postpartum mental disorder), different studies have found others such as:
- The youngest age.
- Low educational level.
- A history of suicidal behavior.
- A history of mental health disorders.
- Substance use, mainly alcohol.
Although there is some population-based research on the perinatal period, in general the theoretical basis for the involvement of psychological and social factors in the development of suicidal ideation and behavior is derived from research with the general population. It has been argued that the perinatal period is unique because women face many changes and challenges and that perinatal suicides are different from non-perinatal suicides. Therefore, in order to establish the psychological and social factors involved in perinatal suicide, research should focus specifically on perinatal samples rather than extrapolating information from the general population.
Suicide prevention in the perinatal stage
General hospital emergency departments are the main place where mothers with serious mental disorders go. It is estimated that 1 in 100 postpartum women will go to an emergency department for a psychiatric reason in the first year after childbirth. Of these, 7% present with some suicidal behavior on their initial visit. A visit to a psychiatric emergency department is a golden opportunity to ensure continuity of care and prevent the progression of suicidal behavior to suicide, but this opportunity is not always taken advantage of. A Canadian study (Barker et al., 2024) found that only 33% of women who went to the emergency department for suicidal behavior received subsequent outpatient care. Although these data are not from our population, we must think that in our environment they are probably not too different.
During pregnancy and the first year postpartum, women have more contact with health professionals, but regular access to health services alone does not reduce the appearance of suicidal ideas or behaviors.
Therefore, early identification and timely intervention of women in the perinatal period who are at high risk of suicide are essential to prevent the emergence of suicidal ideation and behavior. Prevention and intervention strategies specifically recommended to address perinatal suicide include: screening for mental health problems, treating underlying psychiatric disorders, and improving access to perinatal mental health care. There are many opportunities to screen for mental health problems and suicidal ideation among women of reproductive age. However, professionals outside the mental health field may not be comfortable assessing suicidal ideation. Hence the importance of training and working collaboratively with interdisciplinary teams.
Addressing mental health in maternal and child health services
Although increased screening is a key component in identifying suicide risk in pregnant or postpartum women, screening alone does not reduce suicide risk. To prevent suicide, those at risk should receive specific interventions to prevent and manage suicidal behavior. There is some research on this topic that shows us what is happening. A systematic review of 41 studies found that almost three-quarters of women who had depression during pregnancy or postpartum did not accept referral to conventional mental health services (Chin et al., 2022). Another 15-year follow-up study conducted in the United Kingdom found that women who died by suicide in the perinatal period were half as likely to be receiving pharmacological, psychological, or other treatment at the time of their death compared to women who were not in the perinatal period and who committed suicide. (Khalifeh et al., 2016)
Therefore, getting women at risk of suicide to receive treatment is of utmost importance. The entire suicide prevention process, from screening, assessment, and follow-up to early intervention, is essential for all women in the perinatal period.
