In This article

• National mortality data show that nearly one-third of pregnancy-associated suicides occur during pregnancy, with the remainder in the first year postpartum.
  
• A California cohort of almost 4 million deliveries found that 0.13% of birthing individuals had an ED visit suicide attempt during pregnancy or within 12 months postpartum.
• Postpartum suicide attempt risk increased with the number of ED visits during pregnancy and was highest after ED visits for suicide attempt, psychiatric concerns, or assault.
• Psychiatric diagnoses recorded at delivery—especially psychotic disorders, bipolar disorder, major depression, and alcohol use disorder—were strongly associated with later suicide attempts, particularly when multiple diagnoses were present.
• Findings highlight ED and hospital encounters as key opportunities for screening, safety planning, and connection to perinatal mental health care, with the goal of preventing self-harm and maternal suicide.

In the United States, suicide accounts for about 1 in 20 deaths that occur during pregnancy and the first year postpartum. Beginning in 2018, all 50 states and the District of Columbia implemented a pregnancy checkbox on death certificates, indicating whether the decedent was pregnant or within 1 year of the end of pregnancy at the time of death. Using these data, Wallace and Jahn analyzed national mortality files from 2018–2022 and identified 579 suicides among 10,715 pregnancy?associated deaths; about 31.8% of pregnancy?associated suicides occurred during pregnancy, with the remainder in the first year postpartum.

While suicide is now recognized as a leading contributor to maternal mortality, comparatively few studies have focused on the incidence and risk factors for nonfatal suicide attempts during the perinatal period. Because a prior suicide attempt is one of the strongest predictors of death by suicide, understanding which patients are at greatest risk for attempts during pregnancy and the postpartum period is of critical clinical importance.

Incidence of Suicide Attempts in the Perinatal Period

In a recent population-based study, Goldman-Mellor and colleagues used linked, all-payer hospital and emergency department (ED) records from California (2010–2020) to examine nonfatal suicide attempts during pregnancy and the 12 months following delivery. The cohort included all California residents who delivered a live-born infant in a hospital (N = 3,737,792).

Pregnancy-associated suicide attempts resulting in an ED visit were rare:

• 0.13% of birthing individuals (n = 4,968) had a documented suicide attempt during pregnancy or the postpartum period
• 67.9% of these events occurred after delivery
• Drug overdose was the most common method of suicide attempt (about 60%), followed by cutting or piercing injuries (about 26%).

Although the absolute risk of suicide attempt is low during the perinatal period, suicide attempts were not evenly distributed across demographic subgroups; higher rates were observed among adolescents aged 10–17 years, non-Hispanic Black patients, individuals with deliveries covered by Medicaid or self-pay insurance, and those living in micropolitan (small urban) areas.

Clinical Risk Factors for Suicide Attempt

Suicide attempt risk varied substantially according to healthcare utilization during pregnancy and the presence of psychiatric disorders. Nearly 30% of birthing individuals made at least one ED visit during pregnancy, and ED use for any reason was associated with higher risk of postpartum suicide attempt in a dose-dependent fashion:

• One ED visit during pregnancy: 2.00-fold higher risk of postpartum suicide attempt (adjusted risk ratio [aRR] = 2.00).
• Two ED visits: 2.92-fold higher risk (aRR = 2.92).
• Three or more ED visits: 5.80-fold higher risk (aRR = 5.80).

Whether the ED visits were for medical conditions, psychiatric concerns, or assault, ED visits, as well as inpatient hospitalizations, conferred increased risk. The strongest predictors of postpartum suicide attempt were:

• ED visit for suicide attempt during pregnancy: ~30-fold increased risk of postpartum suicide attempt
• ED visit for psychiatric concern: 14.7-fold increased risk
• ED visit related to assault: 5.43-fold increased risk
• Inpatient hospitalization: 2.65-fold increased risk

In addition, psychiatric diagnoses recorded at the time of delivery were strongly associated with risk of postpartum suicide attempt. About 5% of delivering individuals had at least one psychiatric diagnosis noted at the time of delivery; 1.1% had two, and 0.1% had three or more. (Note: These were diagnoses noted in the medical record but did not necessarily reflect active illness.)

• Psychotic disorders: adjusted risk ratio (aRR) =17.3, 95% CI=13.8–21.8
• Bipolar disorder: aRR =10.9 (95% CI=9.5–12.5)
• Major depressive disorder: aRR = 7.0 (95% CI=6.4–7.7)
• Alcohol use disorder: aRR = 7.0 (95% CI=5.1–9.6)
• Anxiety and drug use disorders also carried elevated risk.

Implications for Pregnancy and Postpartum Care

In this large, population-based cohort of nearly 4 million pregnancies, suicide attempts resulting in an ED visit were uncommon, occurring in approximately 0.1% of delivering individuals, and were more likely to occur during the postpartum period than during pregnancy. Although rare, suicide attempts are highly traumatic events for patients and their families, and they represent one of the most robust predictors of future death by suicide.

This study underscores the vulnerability of pregnant and postpartum patients with psychiatric illness, particularly those with multiple comorbid psychiatric diagnoses. It also highlights ED and inpatient encounters as key opportunities to identify individuals at elevated risk for suicide attempts. Many of the patients who later attempted suicide had contact with acute care settings, suggesting that these visits may represent missed opportunities for intervention.

Prior work from Wallace and colleagues using national data similarly found that most individuals who died from suicide or drug overdose within a year of delivery had at least one ED or hospital visit between delivery and death. Together, these findings suggest that enhanced screening and follow-up in emergency and inpatient settings could be a critical strategy for reducing pregnancy-associated suicide and overdose deaths.

Collectively, these findings reinforce the need for:

• Routine screening for suicidal ideation and mental health symptoms not only during prenatal visits but also at the time of delivery and at postpartum encounters.
• Follow-up care pathways after ED visits for psychiatric or assault-related concerns.
• Improved collaboration between obstetric and behavioral health services, especially for those with multiple psychiatric diagnoses or social vulnerabilities.

Future research is needed to determine whether particular interventions, in addition to increased monitoring, could be used to improve maternal mental health and reduce risk of self-harm and suicide.

– Ruta Nonacs, MD PhD