pregnancy associated suicideSince it’s National Suicide Prevention Week, I’d like to focus on a very critical issue: childbirth, pregnancy and suicide. (Trigger warning: If you are feeling fragile right now and think a discussion about the loss of new mothers will upset you, you can skip this one.)

I want to highlight an important statement made by Nancy C. Chescheir, MD, editor-in-chief of the journal Obstetrics & Gynecology, in her editorial in the September 2016 issue:

“… deaths from violent causes (motor vehicle accidents, homicide, suicide, and substance abuse) occur at a rate of about 15 per 100,000 live births, whereas deaths from the four leading pregnancy-related causes of maternal mortality (hemorrhage, embolic disease, hypertensive disease, and sepsis) occur at a rate of about 4.5 per 100,000 live births. Thus, the rate of maternal deaths from violent, pregnancy-associated causes was more than three times higher than those from the major pregnancy-related causes.”

These words in Chescheir’s editorial were made about a study conducted in the state of Illinois on the causes of death of women during the pregnancy and postpartum periods, but they are relevant to us all. Suicide leads to the loss of new mothers at least as often as some of the most common causes of maternal mortality. So why don’t we pay more attention to postpartum depression? Why don’t we invest more?

Part of the problem is in our country’s history of even tracking data on the death of pregnant and postpartum women.

It wasn’t until 2003 (yes, you read that right, 2003!!!!) that the U.S. Standard Certificate of Death began to include a checkbox to indicate whether a woman who had died had been pregnant within the last year. The checkbox was important because it helped to improve data on women whose causes of death might have had something to do with pregnancy or childbirth. Still, some states use that checkbox consistently and some don’t, which means we don’t have a completely accurate set of data.

Also, you might be surprised that the US doesn’t consider suicide in the first year postpartum as a pregnancy-related death. This is important because most of the news, awareness-raising and funding you see related to maternal mortality in our country has to do with pregnancy-related deaths.

What are those? The definition of pregnancy-related death is the death of a woman during pregnancy or within one year of the end of pregnancy due to a pregnancy complication, a chain of events caused by pregnancy or birth, or the worsening of an unrelated condition in the mother due to pregnancy or birth. This includes most of the things people talk about when they talk about maternal mortality, such as eclampsia, infection, embolism, and hemorrhage (bleeding out). Again, suicide in the first year postpartum is NOT considered as or counted as a pregnancy-related death in most places. Only causes of death that are “biologically related” to the pregnancy count.

Pregnancy-associated deaths, on the other hand, are deaths of women that occur during pregnancy or in the first year postpartum that are not necessarily “biologically related” to pregnancy and childbirth. They include motor vehicle accidents, homicide, substance abuse and … suicide.

I don’t know about you, but I’m having a hard time understanding why at least some suicides in the first year postpartum are not counted as biologically related to pregnancy and childbirth. I personally consider postpartum depression VERY MUCH a complication of childbirth. I don’t understand why suicide would be lumped into the same category as accidental car crashes when it comes to the death of new moms.

In some states conducting maternal mortality reviews, this thinking is starting to change. A recent Arizona maternal mortality report notes, for instance, that “… practice is evolving to the extent that if [a suicide death] occurred within the first 42 days postpartum and the woman had made suicidal threats or ideations, the [suicide] should be considered pregnancy related.”

So how does suicide rank when it comes to causes of maternal deaths?

A study published in Obstetrics & Gynecology in 2011 by Palladino et al found that the rate of death from suicide among pregnant and new mothers is 2.0 (2 out of every 100,000 births). Now compare: The rate of deaths due to hemorrhage/placenta previa is 1.7. For eclampsia/pre-eclampsia it’s 1.7.  And the rate of deaths due to amniotic fluid embolism is 1.1. This demonstrates that while there are still some complications of pregnancy that outrank suicide as causes of death among pregnant and new mothers, suicide is among the leading causes. And more and more states are finding this is true.

Colorado found that suicide is the 3rd leading cause of death in the first year postpartum, ahead of pulmonary embolism and hemorrhage. A 2012 study in the state of Georgia of pregnancy-related and pregnancy-associated deaths found more women died from suicide (8) than from hemmorhage (7), hypertension (4), cardiac problems (4) and embolism (4) during or in the year after pregnancy. A Michigan study of data from 1995-2005 found that deaths due to intentional self-harm (11%) were at a similar rate to amniotic embolism (11%) and greater than hemorrhage (7.1%) and obstetric blood clot embolism (4%). A Wisconsin review found that suicide represented 13% of all pregnancy associated deaths.

We HAVE to pay attention to this. We have to track it better. Something must be done. Here’s how Postpartum Progress looks at it: Would the mother have died if she had not been pregnant or had a baby? Did the suicide happen as a result of the symptoms of a maternal mental illness? If it did, we consider it pregnancy related.

We wish more organizations deeply involved in maternal child health included maternal mental illness and suicide prevention in their programming. So do the authors of this fantastic paper from 2013 called Grand Challenges: Integrating Maternal Mental Health Into Maternal and Child Health Programmes when they stated, “Addressing mental health concerns such as maternal depression could play an important role in achieving the Millennium Development Goals set by the United Nations (three out of the eight goals refer specifically to women and children). However, mental health care remains conspicuous by its absence in large scale global maternal and child health (MCH) programmes.” So. Very. Conspicuous.

You won’t find maternal or pregnancy-related/associated suicide mentioned even once by Merck for Mothers, a 10-year $500 million initiative focused on improving the health and well-being of mothers during pregnancy and childbirth. It’s also not an area of focus in the Bill & Melinda Gates Foundation’s Maternal, Newborn & Child Health strategy. And yet we KNOW the health of children, including their mental health and development, is linked to that of their mothers.

Over my years of advocating for maternal mental health I’ve had more than one person say to me, “I’m sure postpartum depression is important. But there are other maternal health issues that are so much more so. I mean, no one dies from PPD.”

Oh yes they do. Indeed they do. And we can prevent it.