Among deaths of pregnant women and new mothers in Ontario, Canada, one of every 19 are suicides, according to a study published online today in the Canadian Medical Association Journal.
That rate, 2.58 per 100,000 live births, falls between the rates in the United Kingdom and those in the United States (2 and 3 per 100,000, respectively), Sophie Grigoriadis, MD, PhD, from the Women’s Mood and Anxiety Clinic, Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada and colleagues write. They note that maternal suicide is a leading cause of death during pregnancy and the first year after birth in developed countries.
The researchers linked health administrative databases with coroner death records from 1994 through 2008 in Ontario. Overall, they identified 1648 deaths by suicide among women who had a pregnancy during those 15 years. Of those deaths, 51 occurred in the perinatal period, 20 during pregnancy, and 31 up to 1 year after birth.
Women who committed suicide in the perinatal period used more lethal methods, such as jumping/falling (19.6%) or hanging (33.3%), than nonperinatal women, for whom the most common method is drug overdose.
“These findings suggest that perinatal women who are suicidal may be at higher risk for suicide completion than women outside the perinatal period,” the authors write.
About 70.6% of perinatal women who committed suicide had contact with a mental health professional in the year before death, but only 39.2% in the 30 days before, according to the study.
Those statistics are similar to those of nonperinatal women who commit suicide, the authors write, but they differed when the researchers looked at the kinds of providers the women saw.
“Women who died by suicide perinatally were less likely to have seen a psychiatrist ([odds ratio] 0.37, 95% [confidence interval] 0.17–0.79), but more likely to have seen a primary care provider for a mental health reason ([odds ratio] 1.80, 95% [confidence interval] 1.03–3.16) within the year before suicide compared with women who died by suicide non-perinatally,” they write.
That finding suggests suicide prevention strategies for perinatal women should be incorporated into primary care settings, they write.
Also, most of the women who died during this period had a mood or anxiety disorder, rather than a psychotic disorder, which is similar to other countries. “This serves as a reminder not to underestimate the possible serious consequences of nonpsychotic postpartum mental disorders,” they write.
Maternal suicide may be underestimated in Canada, the researchers say, because studies typically have included only deaths in pregnancy or up to 6 weeks after a birth, whereas the risk for suicide related to postpartum mental illness is likely to go beyond 6 weeks postpartum.
In this study, suicide occurred at an average 5 months in pregnant women and 7.5 months after giving birth.
In a podcast accompanying the study, Dr Grigoriadis pointed out that although women tend to be surrounded by family and have supports just after the birth, the supports often fade away weeks later.
In addition, European data suggest many death certificates may not have complete information and may underestimate perinatal suicide by as much as 26% to 56%. “[O]ur suicide surveillance and mental health intervention efforts must focus on pregnancy and must continue well into the first postpartum year,” the authors write.
Among study limitations are that the sample size was small and researchers did not have access to information on whether the women used other health services outside those covered by provincial health insurance, such as psychotherapists.
This study was funded by the Canadian Institutes of Health Research. Dr Grigoriadis has received personal fees from Sage, Eli Lilly Canada, Allergan/Actavis, Pfizer, and Bristol Myers Squibb for activities unrelated to the current manuscript. The other authors have disclosed no relevant financial relationships.
CMAJ. Published online August 28, 2017. Full text
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