It is estimated that suicide accounts for about 10% of all maternal deaths. While we have a fair amount of information to help us predict which women are at risk for depression during pregnancy and the postpartum period, few studies have identified risk factors for suicide in this vulnerable population.
Suicidal ideation is fairly common among pregnant and postpartum women. According to a recent study in which a total of 22,118 women completed the Edinburgh Postnatal Depression Scale (EPDS) at 24-28 weeks of gestation and at 6 weeks postpartum, 3.8% of the women reported having suicidal thoughts during pregnancy and/or the postpartum period.
But there is a big difference between having suicidal thoughts and actually acting on them. Only a small number of women who report suicidal thoughts will go on to make a suicide attempt and even fewer will commit suicide. At this point, we recommend closely monitoring women who report suicidal ideation and providing interventions to treat perinatal depression. But we have very little information to help us to predict who, in this population of women who report having suicidal thoughts, are at highest risk for attempting or committing suicide.
One way to gather information on suicide risk factors is to analyze the demographic and clinical characteristics of pregnant and postpartum women with hospitalizations related to suicidal behaviors.
A recent population-based case-control study used Washington State birth certificates land hospitalization records to identify risk factors for postpartum suicide attempt. The study compared women hospitalized for a postpartum suicide attempt (n = 355) with a group of controls who had not been hospitalized (n = 1420). Women previously hospitalized for a psychiatric disorder were approximately 27 times more likely to attempt suicide during the postpartum period than controls with no history. Those who were hospitalized within one year of delivery were at highest risk. Women with a substance use disorder were at a 6.2-fold increased risk, and those with a dual diagnosis were at an 11.1-fold increased risk of postpartum suicide attempt compared to controls.
In another study, a nationally representative sample of pregnant women aged 12-55 years were identified through pregnancy- and delivery-related hospitalization records from the National (Nationwide) Inpatient Sample. Women who were hospitalized with suicidal behavior during pregnancy were identified using the International Classification of Diseases codes.
Suicidal behaviors during pregnancy were most common in women in the 12-18-year group, showing the highest prevalence per 100,000 hospitalizations (158.8 in 2006 and 308.7 in 2012). Suicidal ideation was more prevalent in black women and in women in the lowest income quartile. The prevalence of suicidal behaviors was higher among hospitalizations with depression diagnoses; however, more than 30 % of hospitalizations were for suicidal behavior without depression diagnoses.
These studies give us some clues as to the women who are at higher risk for attempting suicide during pregnancy and the postpartum period — for example, women with histories of psychiatric hospitalization prior to pregnancy, women with substance abuse, and teen mothers. We need to make sure we identify these women and provide them with the support they need.
While many women who attempt suicide during the postpartum period have contact with a mental health provider at some point prior to making an attempt, a recent study from Sweden noted that about a quarter of the women who committed suicide had no history of psychiatric care. Moses-Kolko and Hipwell note the importance of engaging non-psychiatric health care providers, including obstetricians and pediatricians, in order to guarantee the early identification and treatment of women with perinatal mood disorders.
Ruta Nonacs, MD PhD
Comtois KA, Schiff MA, Grossman DC. Psychiatric risk factors associated with postpartum suicide attempt in Washington State, 1992-2001. American Journal of Obstetrics & Gynecology 2008. 199(2):120.
Kim JJ, Silver RK, La Porte LM, et al. Suicide risk among perinatal women who report thoughts of self-harm on depression screens. Obstet Gynecol. 2014; 123 Suppl 1:60S.
Zhong QY, Gelaye B, Miller M, Fricchione GL, Cai T, Johnson PA, Henderson DC, Williams MA. Suicidal behavior-related hospitalizations among pregnant women in the USA, 2006-2012. Arch Womens Ment Health. 2016 Jun;19(3):463-72.