Even as perinatal mood and anxiety disorders have garnered more attention over the past several years, the most feared consequence of these disorders, suicide, remains a phenomenon that requires greater understanding. While suicide is a leading cause of death in perinatal women, suicide during pregnancy or the postpartum period is often underreported and under-researched. As a result, providers are still learning how to best identify and treat those women at greatest risk of suicide in the perinatal period.
A recent study published by Grigoriadis and colleagues used a retrospective, population-based cohort study to explore rates of suicide in women during pregnancy and the first postpartum year. Most prior studies that have defined perinatal suicide as suicides that occur during pregnancy and up to six weeks postpartum. However, as maternal psychiatric illness most often persists beyond six weeks postpartum, this study expanded the definition of perinatal suicide to include the entire first postpartum year.
Researchers used health administrative databases and coroner death records to identify the perinatal suicide rate for Ontario, Canada during a 15-year period (1994-2008). The demographic and clinical information of women who completed perinatal suicide was compared to age-matched, living perinatal women, as well as to women who completed suicide outside the perinatal period.
Ultimately, they found that suicide accounted for 5.3% (51 of 966) of perinatal deaths, or approximately 1 out of every 19 deaths in pregnant or postpartum women during that time period. Perinatal women most frequently completed suicide at 9 to 12 months postpartum. Women who completed perinatal suicide were more likely to do so by lethal methods, like hanging, jumping, or falling, compared to women who completed suicide outside of the perinatal period. As expected, those women who completed suicide, either during or outside of the perinatal period, had higher rates of prior psychiatric illness compared to the control group of living perinatal women.
Accessibility to health care providers varied amongst the groups of women studied. The highest rates of perinatal suicide occurred in those women who lived in rural areas of Ontario. Women who completed suicide in the perinatal period were just as likely to have sought out primary (non-mental health) care or obstetric care in the preceding month or year as the group of living perinatal women. However, women who completed suicide in the perinatal period had lower rates of contact with a pediatrician in the preceding month compared to those women in the living perinatal group.
Less than 40% of women who completed suicide in the perinatal period had seen a provider for mental health issues in the 30 days prior to their death, though this rate is similar to those women who completed suicide outside of the perinatal period. However, mental health contact was defined here as either seeing a psychiatrist or seeing a primary care physician specifically for mental health issues. Interestingly, those women who completed suicide in the perinatal period were more likely to have seen a primary care doctor for their mental health issues and less likely to have seen a psychiatrist in the year prior to their suicide, compared to women who completed suicide outside of the perinatal period.
This study identifies suicide as the cause of death in over 5% of perinatal women who died in Ontario, Canada during this time period. By expanding the definition of perinatal suicide to include the entire first postpartum year, this study has found that 9 to 12 months postpartum may be a time when women are particularly vulnerable and at risk for completing suicide. While psychiatrists regularly screen for suicide, the findings from this study highlight how important it is to screen perinatal women for suicide in primary care or obstetric offices, as many of the women who go on to complete suicide may never see a psychiatrist. Moreover, pediatricians may play a particularly helpful role in helping identify women at risk for suicide as at-risk women may be less likely to engage in pediatric care for their children. Reducing the rate of perinatal suicide will undoubtedly be an interdisciplinary effort, and this study raises possible starting points for intervention.
Kathryn Zagrabbe, MD
Grigoriadis S, Wilton AS, Kurdayak PA et al. Perinatal suicide in Ontario, Canada: a 15 year population-based study. CMAJ 2017; Aug 28;189(34):E1085-1092.
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