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Analysis

Maternal suicide: rates and trends

2008-06-02 12:51

Maternal suicide: rates and trends

Lecturer in nursing Iain McGowan, professor of midwifery research Marlene Sinclair and staff nurse Mark Owens provide a descriptive study of maternal suicide in the UK.

Lecturer in nursing Iain McGowan, professor of midwifery research Marlene Sinclair and staff nurse Mark Owens provide a descriptive study of maternal suicide in the UK.  

 

Midwives magazine: April 2007

 

Pregnancy and childbirth are traditionally recognised as life events that are to be cherished and celebrated. However, recent media coverage and official reports of deaths by suicide, including the last report of the Confidential Enquiry on Maternal and Child Health (CEMACH) (2004) have raised public and health professionals’ awareness of the potential dangers of mental health problems to mothers during pregnancy and in the first year after giving birth. Suicidality has been reported as a common symptom in postpartum psychosis (PPP) (Burt and Stein, 2002).  

 

While PPP is a rare event following birth, other more common mental health issues associated with childbirth are correlated positively with suicide. This has led to the US Congress introducing a ‘House Resolution’ (H.Res 51) encouraging the US National Institutes of Health to investigate the mental health issues associated with postpartum mental health problems (Lindahl et al, 2005). Surprisingly, there is a paucity of literature investigating the prevalence of suicide during pregnancy and the year after giving birth. Lindahl et al (2005), in a systematic review of prevalence studies of maternal suicide, identified only nine studies globally that have attempted to identify the scope of the problem of maternal suicide.  

 

Prevalence of maternal suicide  

 

There is conflicting evidence on the prevalence of suicide in pregnancy. Rizzi et al (1998) found that 7% of violent deaths among pregnant women in Cordoba, Argentina were due to suicide.  

 

In New York City between 1990 and 1993, suicide risk among pregnant women was one-third of that which could be expected in the general population (Marzuk et al, 1997). Suicide was the second most common cause of death in pregnant women in Bangladesh between 1976 and 1986 (Fauveau and Blanchett, 1989).  

 

In the first postpartum year, suicide rates vary from 11/100 000 pregnancies in Finland (Gissler et al, 1996) to 0.7/100 000 pregnancies in Canada (Turner et al, 2002). Suicide accounted for 9% of deaths following childbirth in New York City between 1987 and 1991 – just under half of the suicide rate seen in the general female population (Dannenberg, 1995).

 

In what appears to be the only UK-based study on suicide in pregnancy and the first postpartum year, Appleby (1991) sought to calculate the age-adjusted mortality ratios for death by suicide and to identify the characteristics of those women that died by suicide.   Using the reports of the Confidential Enquiries into Maternal Deaths in England and Wales from 1973 to 1984, in conjunction with population figures and suicide figures published by the Office of Population Censuses and Surveys for the same period, Appleby reports that the standardised mortality ratio for postnatal suicide was 0.17. This is six times lower than expected given the rates of suicides in the general population – the standardised mortality ratio for suicides in pregnancy was 0.05. This led Appleby (1991) to suggest that motherhood protects against suicide and that concern for dependents may play a factor in reducing suicides in the general population. More recently CEMACH (2004) found that in the period 2000 to 2002, suicide was the leading cause of death of new mothers.  

 

The prevalence of parasuicide (apparent attempt at suicide without the intention to actually kill oneself) in pregnancy is thought to be comparable to that of the general population (Whitlock and Evans, 1986). Catalan (2000: 302) suggests that the prevalence of parasuicide post childbirth decreases, suggesting a protective effect against deliberate self-harm and attempted suicide. In a complementary piece of work to this article, the authors sought to update Appleby’s statistics.  

 

They recorded a prevalence rate over the period under review of 0.9/100 000 maternities, although suicide accounted for 7% of all maternal deaths (McGowan, Sinclair and Owens, 2006). The aim of this paper is to compile, for the first time, information about the deaths by suicide of all pregnant women and new mothers in the UK during the period 1985 to 2002.  

 

Methods  

 

Maternal suicides – details of postnatal suicides and suicides occurring in pregnancy in the UK, are recorded in the reports of the ConfidentialEnquiries into Maternal Deaths (see: www.cemach.org.uk). For the purposes of this paper, the authors use the terms ‘maternal death’ and ‘maternal suicide’ to include all deaths/suicides in the reports including late deaths (those which occur after 40 days postpartum) and fortuitous deaths. Suicide numbers were calculated by taking the sum of recorded suicides and recorded deaths of undetermined cause as is conventional in statistical enquiry regarding suicide (Appleby, 1991).

 

The reports of the Confidential Enquiries covering the period 1985 to 2002 were trawled. Data regarding age, method of suicide, presence of psychiatric disorder, history of psychiatric disorder, obstetric outcome and timing of death in relation to delivery were extrapolated for each individual death by suicide. Data was coded, listed in a spreadsheet and subject to descriptive analysis.

 

Results

 

In the period 1985 to 2002, there was a total of 129 suicides. One case of infanticide associated with suicide is included in these cases. The methods of the reporting of the suicides changed in the reports from 1997 onwards. Earlier reports listed, as far as possible, anonymous descriptions of each individual suicide. This generally included method of suicide, number of days postpartum or gestation period, previous history of psychiatric disorder and if there was any evidence of current (at the time of death) psychiatric illness.

 

The later reports produce a composite picture in which the characteristics of individual decedents cannot be extrapolated.

 

Age

 

The age of decedent is only reported from 1997 onwards. Of the 54 suicides in the period 1997 to 2002, one was aged less than 18 years old, 28 between 19 and 29 years, with 24 women aged over 30. Data was missing for one case.

 

Methods of suicide

 

Across the 17 years under review, violent methods of suicide appear to be commonplace. Hanging (n=28), jumping from a high place (n=15), cut throat/self stabbing (n=7), self-immolation (n=5), deliberate road traffic accident (n=3) drowning (n=10), gunshot wounds (n=2) and jumping in front of a train (n=2) accounted for 68% of all suicides. Overdose of a variety of substances, including psychotropic medication and illicit drugs (n=31), and carbon monoxide (n=3) poisoning accounted for the remaining 32% where the method was recorded.

 

Previous history of psychiatric disorder

 

From the reports, it was difficult to ascertain the true prevalence of previous psychiatric disorder among the women that died by suicide. From 1997, half of the suicides up to 1999 and 66% from 2000 had been treated by their GP or psychiatrist for a mental health issue.

 

Current presence of psychiatric disorder

 

Of the 129 women to die by suicide, 90 had a probable diagnosis of psychiatric disorder and data was missing in 16 cases. Table 1 highlights numbers and percentages of psychiatric diagnosis.

 

Timing of suicide in relation to delivery

 

More accurate recording of this is apparent in the reports from 2000 onward. Prior to this, some of the detail is scant. For example, the report for the period 1991 to 1993 records the suicide of a woman during a puerperal psychotic episode as jumping in front of a train ‘some months following birth’. Hence the accuracy of the timings of suicide prior to 1997 is questionable. The report from 1997 to 1999 does not appear to report timings of suicides. Since 2000, there were five suicides in pregnancy, five suicides in the first six postnatal weeks and 18 deaths by suicide after 42 days. Data was not available on two deaths.

 

Discussion

 

Given the current focus on mental health issues and suicide in pregnancy and the postpartum period, it is appropriate to review maternal suicide over that last 17 years. The findings of this review suggest that suicide should be a major concern for midwives and others charged with caring for pregnant women and new mothers. Further in-depth analysis of suicides among this population is in preparation.

 

That psychiatric diagnosis is implicated in nearly 80% of the suicides in this review is unsurprising, given that it has been suggested that psychiatric illness is present in 95% of all suicides (Foster et al, 1999). It is worth pointing out that only 25% of all suicides in the UK were carried out by people in contact with mental health services in the 12 months preceding death (Appleby, 2001).

 

Consequently those caring for this client group need to be aware that the presence of psychiatric disorder alone may not indicate a propensity to suicide. Perhaps more surprisingly is the apparent trend toward increasing lethality (potential to kill) in suicide methods, which does not appear to be replicated in the general population, although it is consistent with other studies of maternal suicide.

 

Further investigation of this is necessary. However it would not be amiss to suggest that any assessments involving potential suicide risk should include the access the mother has to the means of suicide, for example car, gun or rope. Assessment of suicide risk should be a priority for midwives (CEMACH, 2004). Suicide has been described as the leading cause of premature death (Maris et al, 2001) and while there is limited evidence for the efficacy of any particular intervention (Crowley, 2005), there is little doubt that where those at risk of suicide are identified, the possibility of prevention is greatly increased (US Department of Health and Human Services, 2001).

 

Conclusion

 

Suicide in pregnancy in the first postpartum year has increased over the last 17 years from 0.05 to 0.09/100 000 maternities. Approximately 70% (90/129) of the women that died by suicide had an underlying mental health problem at the time of their death. Accordingly, assessment of suicide risk and mental health status should be a major consideration when planning antenatal care pathways.It is imperative to have clear recording and reporting procedures of deaths by suicide in order to develop more robust data to inform policy, practice and research in this field.

 

Recommendations for midwifery practice and education

 

Midwifery students should be adequately informed of the risk of maternal suicide in pregnancy and the puerperium and provided with relevant education. Pre- and post-registration training for midwives should be made available and such programmes should be provided by appropriately-trained professionals with mental health experience. All midwives should have access to valid and reliable suicide risk assessment tools such as those reviewed by Brown (2002) with appropriate training in their use. Clear unambiguous referral systems for midwives to refer women to mental health professionals, where a need is identified, should be developed.

 

References

 

Appleby L, Shaw J, Sherratt J, Amos T, Robinson J, McDonnell R, McCann K, Parsons R, Buring J, Bickly H, Kennark, Wren J, Hunt I, Davies S, Harris C. (2001) Safety first: report of the national confidential inquiry into suicide and homicide by people with mental illness. HMSO: London.

Brown G. (2002) A review of suicide assessment measures for intervention research with adults and older adults. The National Institute of Mental Health: Bethesda, US. See: www.nimh.nih.gov/ suicideresearch/adultsuicide.pdf (accessed 5 March 2007).

Catalan J. (2000) Sexuality, reproductive cycle and suicidal behaviour: In: Hawton K, Kees van Heeringen K. (Eds.). (2002) The international handbook of suicide and attempted suicide. John Wiley and Sons: New York. Confidential Enquiry into Maternal and Child Health. (2004) Why mothers die 2000 to 2002: report on confidential enquiries into maternal deaths in the UK. HMSO: London.

Crowley PA. (2005) Evidence on youth suicide prevention highlights research gaps. British Medical Journal 330(7501): 1210.

Dannenberg AL, Carter DM, Lawson HW, Ashton DM, Dorfman SF, Graham EH. (1995). Homicide and other injuries as causes of maternal death in New York City: 1987 to 1991. American Journal of Obstetrics and Gynaecology 172(5): 1557-64.

Fauveau V, Blanchett T. (1989) Deaths from injuries and induced abortion amongst rural Bangladeshi women. Social Science and Medicine 29: 1121-7. Foster T, Gillespie K, McClelland R, Patterson C. (1999) Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland. British Journal of Psychiatry 175: 175-9.

Lindahl V, Pearson JL, Colpe L. (2005) Prevalence of suicidality during pregnancy and the postpartum. Archive of Women’s Mental Health 8(2): 77-87. Maris R, Berman A, Silverman M. (2000) The comprehensive textbook of suicidology. Guildford Press: New York.

Marzuk PM, Tardiff K, Leon AC, Hirsh SC, Portera L, Hartwell N, Iqbal MI. (1997) Lower risk of suicide during pregnancy. American Journal of Psychiatry 154: 122-3.

McGowan IW, Sinclair M, Owens M. (2006) Maternal suicide: an overview of suicide in pregnancy and the first postnatal year in the UK 1985 to 2004 (oral presentation). Irish Association of Suicidology Conference: Ennis, County Clare. Rizzi RG, Cordoba RR, Maguna JJ. (1998) Maternal mortality due to violence. International Journal of Gynaecology and Obstetrics (63)supp 1: 19-24.

Turner LA, Krame MS, Li S. (2002) Cause specific mortality during and after pregnancy and the definition of maternal death. Chronic Disease Canada 23: 31-6. US Department of Health and Human Services. (2001) National strategy for suicide prevention: goals and objectives for action. US Department of Health and Human Services: Rockville, US. Whitlock F, Edwards J. (1986) Pregnancy and attempted suicide. Comprehensive Psychiatry 9: 1-12.  

 

 

 

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