Maternal self-harm deaths: an unrecognized and preventable outcome

Published:March 05, 2019DOI:
      Maternal mortality continues to be a public health priority in national and international communities. Maternal death rates secondary to medical illnesses such as cardiovascular disease, preeclampsia, and postpartum hemorrhage are well documented. The rates of maternal death secondary to self-harm, including suicide and overdose, have been omitted from published rates of maternal mortality, despite growing attention to the prevalence of perinatal mood disorders, estimated at up to 15% of pregnant and postpartum women in the United States. Underlying psychiatric disorder, including depression, is consistently identified as a risk factor in substance abuse and suicide. The rate of opioid-associated morbidity and mortality has recently been deemed a national crisis. Pregnancy does not protect against these risks, and the postpartum period has been identified as a particularly vulnerable time. The lack of consistent and inclusive data on self-harm deaths in the pregnancy-postpartum period is alarming. This review will identify barriers to reporting and ascertainment of maternal suicide and overdose deaths, summarize geographic-specific data available, address potential social and psychological biases that have led to neglect of the topic of maternal self-harm deaths, and suggest recommendations that incorporate the whole woman in prenatal care and thus prevention of this devastating outcome.

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        • MacDorman M.F.
        • Declercq E.
        • Cabral H.
        • Morton C.
        Recent increases in the US maternal mortality rate: disentangling trends from measurement issues.
        Obstet Gynecol. 2016; 128: 447-455
        • Khalifeh H.
        • Hunt I.M.
        • Appleby L.
        • Howard L.M.
        Suicide in perinatal and non-perinatal women in contact with psychiatric services: 15 year findings from a UK national inquiry.
        Lancet Psychiatry. 2016; 3: 233-242
        • Smith K.
        • Lipari R.
        Women of childbearing age and opioids. Rockville (MD: Substance Abuse and Mental Health Services Administration.
        Center for Behavioral Health Statistics and Quality, 2017
        • Lindahl V.
        • Pearson J.L.
        • Colpe L.
        Prevalence of suicidality during pregnancy and the postpartum.
        Arch Womens Mental Health. 2005; 8: 77-87
      1. Pregnancy Mortality Surveillance System. Centers for Disease Control and Prevention, Atlanta (GA)2017
      2. Medicode. ICD-9-CM: International Classification Of Diseases, 9th revision, Clinical Modification. Medicode, Salt Lake City (UT)1996
        • Hoyert D.L.
        Maternal mortality and related concepts. Vital Health Stat Series 3.
        Anal Epidemiol Stud. 2007; : 1-13
        • Grigoriadis S.
        • Wilton A.S.
        • Kurdyak P.A.
        • et al.
        Perinatal suicide in Ontario, Canada: a 15-year population-based study.
        Can Med Assoc J. 2017; 189: E1085-E1092
        • Horon I.L.
        • Cheng D.
        Effectiveness of pregnancy check boxes on death certificates in identifying pregnancy-associated mortality.
        Public Health Rep. 2011; 126: 195-200
        • MacKay A.P.
        • Rochat R.
        • Smith J.C.
        • Berg C.J.
        The check box: determining pregnancy status to improve maternal mortality surveillance.
        Am J Prev Med. 2000; 19: 35-39
        • Zaharatos J.
        • St Pierre A.
        • Cornell A.
        • Pasalic E.
        • Goodman D.
        Building US capacity to review and prevent maternal deaths.
        J Womens Health (Larchmt). 2018; 27: 1-5
        • Esscher A.
        • Högberg U.
        • Haglund B.
        • Essën B.
        Maternal mortality in Sweden, 1988–2007: more deaths than officially reported.
        Acta Obstet Gynecol Scand. 2013; 92: 40-46
        • Palladino C.L.
        • Singh V.
        • Campbell J.
        • Flynn H.
        • Gold K.
        Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System.
        Obstet Gynecol. 2011; 118: 1056
        • Wallace M.E.
        • Hoyert D.
        • Williams C.
        • Mendola P.
        Pregnancy-associated homicide and suicide in 37 US states with enhanced pregnancy surveillance.
        Am J Obstet Gynecol. 2016; 215: 364.e1-364.e10
        • Cantwell R.
        • Clutton-Brock T.
        • Cooper G.
        • et al.
        Saving mothers' lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.
        BJOG. 2011; 118: 1-203
        • Davis N.L.
        • Hoyert D.L.
        • Goodman D.A.
        • Hirai A.H.
        • Callaghan W.M.
        Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978–2012.
        Am J Obstet Gynecol. 2017; 217: 352.e1-352.e7
        • Baeva S.
        • Archer N.P.
        • Ruggiero K.
        • et al.
        Maternal mortality in Texas.
        Am J Perinatol. 2017; 34: 614-620
        • Metz T.D.
        • Rovner P.
        • Hoffman M.C.
        • Allshouse A.A.
        • Beckwith K.M.
        • Binswanger I.A.
        Maternal deaths from suicide and overdose in Colorado, 2004–2012.
        Obstet Gynecol. 2016; 128: 1233-1240
        • Bronson J.
        • Reviere R.
        Pregnancy-associated deaths in Virginia due to homicides, suicides, and accidental overdoses compared with natural causes.
        Violence Against Women. 2016; (1077801216663658)
        • Mehta P.K.
        • Bachhuber M.A.
        • Hoffman R.
        • Srinivas S.K.
        Deaths from unintentional injury, homicide, and suicide during or within 1 year of pregnancy in Philadelphia.
        J Inform. 2016; 106
        • Comtois K.A.
        • Schiff M.A.
        • Grossman D.C.
        Psychiatric risk factors associated with postpartum suicide attempt in Washington State, 1992–2001.
        Am J Obstet Gynecol. 2008; 199: 120.e1-120.e5
        • Koch A.R.
        • Geller S.E.
        Addressing maternal deaths due to violence: the Illinois experience.
        Am J Obstet Gynecol. 2017; 217: 556.e1-556.e6
        • Schiff D.M.
        • Nielsen T.
        • Terplan M.
        • et al.
        Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts.
        Obstet Gynecol. 2018; 132: 466-474
        • Gemmill A.
        • Kiang M.V.
        • Alexander M.J.
        Trends in pregnancy-associated mortality involving opioids in the United States, 2007–2016.
        Am J Obstet Gynecol. 2019; 220: 115-116
        • Joseph K.
        • Lisonkova S.
        • Muraca G.M.
        • et al.
        Factors underlying the temporal increase in maternal mortality in the United States.
        Obstet Gynecol. 2017; 129: 91-100
        • Zhong Q.-Y.
        • Gelaye B.
        • Miller M.
        • et al.
        Suicidal behavior-related hospitalizations among pregnant women in the USA, 2006–2012.
        Arch Womens Mental Health. 2016; 19: 463-472
        • Golding J.M.
        Intimate partner violence as a risk factor for mental disorders: a meta-analysis.
        J Fam Violence. 1999; 14: 99-132
        • Hardt N.
        • Wong T.D.
        • Burt M.J.
        • Harrison R.
        • Winter W.
        • Roth J.
        Prevalence of prescription and illicit drugs in pregnancy-associated non-natural deaths of Florida mothers, 1999-2005.
        J Forensic Sci. 2013; 58: 1536-1541
        • Bagley S.M.
        • Cabral H.
        • Saia K.
        • et al.
        Frequency and associated risk factors of non-fatal overdose reported by pregnant women with opioid use disorder.
        Addict Sci Clin Pract. 2018; 13
        • Unger A.
        • Jung E.
        • Winklbaur B.
        • Fischer G.
        Gender issues in the pharmacotherapy of opioid-addicted women: buprenorphine.
        J Addict Dis. 2010; 29: 217-230
        • Terplan M.
        Women and the opioid crisis: historical context and public health solutions.
        Fertil Steril. 2017; 108: 195-199
        • Fillingim R.B.
        • King C.D.
        • Ribeiro-Dasilva M.C.
        • Rahim-Williams B.
        • Riley 3rd, J.L.
        Sex, gender, and pain: a review of recent clinical and experimental findings.
        J Pain. 2009; 10: 447-485
        • Kilpatrick D.G.
        • Acierno R.
        • Resnick H.S.
        • Saunders B.E.
        • Best C.L.
        A 2-year longitudinal analysis of the relationships between violent assault and substance use in women.
        J Consult Clin Psychol. 1997; 65: 834-847
        • Conway K.P.
        • Compton W.
        • Stinson F.S.
        • Grant B.F.
        Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions.
        J Clin Psychiatry. 2006; 67: 247-257
        • McCarthy M.
        Opioid overdose deaths rose fivefold among US women in 10 years.
        BMJ (Online). 2013; : 347
        • Bateman B.T.
        • Hernandez-Diaz S.
        • Rathmell J.P.
        • et al.
        Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.
        J Am Soc Anesthesiol. 2014; 120: 1216-1224
        • Desai R.J.
        • Hernandez-Diaz S.
        • Bateman B.T.
        • Huybrechts K.F.
        Increase in prescription opioid use during pregnancy among Medicaid-enrolled women.
        Obstet Gynecol. 2014; 123: 997
        • Kroll-Desrosiers A.R.
        • Skanderson M.
        • Bastian L.A.
        • et al.
        Receipt of prescription opioids in a national sample of pregnant veterans receiving Veterans Health Administration care.
        Womens Health Issues. 2016; 26: 240-246
        • Centers for Disease Control and Prevention NCfHS
        Births—method of delivery.
        Centers for Disease Control and Prevention, Atlanta (GA)2017
        • Bateman B.T.
        • Cole N.M.
        • Maeda A.
        • et al.
        Patterns of opioid prescription and use after cesarean delivery.
        Obstet Gynecol. 2017; 130: 29-35
        • The Guttmacher Institute. Substance Abuse During Pregnancy. State Policies in Brief
        (Available at:) (Accessed April 30, 2019)
      3. Substance Abuse and Mental Health Services Administration, Medicaid Coverage and Financing of Medications to Treat Alcohol and Opioid Use Disorders. HHS Publication No. SMA-14-4854. Rockville (MD): Substance Abuse and Mental Health Services Administration 2014.

        • Prevatt B.-S.
        • Desmarais S.L.
        Facilitators and barriers to disclosure of postpartum mood disorder symptoms to a healthcare provider.
        Matern Child Health J. 2017; : 1-10
        • Angelotta C.
        • Appelbaum P.S.
        Criminal charges for child harm from substance use in pregnancy.
        J Am Acad Psychiatry Law. 2017; 45: 193-203
        • Kendler K.S.
        Toward a philosophical structure for psychiatry.
        Am J Psychiatry. 2005; 162: 433-440
        • Hamilton J.A.
        • Parry B.L.
        • Blumenthal S.J.
        The menstrual cycle in context, I: affective syndromes associated with reproductive hormonal changes.
        J Clinl Psychiatry. 1988; 49: 474-480
        • Elliott S.A.
        • Rugg A.J.
        • Watson J.P.
        • Brough D.I.
        Mood changes during pregnancy and after the birth of a child.
        Br J Clin Psychol. 1983; 22: 295-308
        • Grote N.K.
        • Katon W.J.
        • Russo J.E.
        • et al.
        Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial.
        Depress Anxiety. 2015; 32: 821-834
        • Byatt N.
        • Biebel K.
        • Moore Simas T.A.
        • et al.
        Improving perinatal depression care: the Massachusetts Child Psychiatry Access Project for Moms.
        Gen Hosp Psychiatry. 2016; 40: 12-17
        • Curry S.J.
        • Krist A.H.
        • et al.
        • US Preventive Services Task Force
        Interventions to prevent perinatal depression: US Preventive Services Task Force Recommendation Statement.
        JAMA. 2019; 321: 580-587
        • Byatt N.
        • Xu W.
        • Levin L.L.
        • Moore Simas T.A.
        Perinatal depression care pathway for obstetric settings.
        Int Rev Psychiatry. 2019; : 1-19
        • Rafferty J.
        • Mattson G.
        • Earls M.F.
        • Yogman M.W.
        • Committee on Psychosocial Aspects of Child And Family Health
        Incorporating recognition and management of perinatal depression into pediatric practice.
        Pediatrics. 2019; 143
        • American College of Obstetricians and Gynecologists
        Screening for depression during and after pregnancy.
        ACOG Committee opinion no. 453. Obstet Gynecol. 2010; 115: 394-395
        • American College of Obstetricians and Gynecologists
        Screening for perinatal depression. ACOG Committee opinion no. 630.
        Obstet Gynecol. 2015; 5: 1268-1271
        • Siu A.L.
        • Bibbins-Domingo K.
        • Grossman D.C.
        • et al.
        Screening for depression in adults: US Preventive Services Task Force recommendation statement.
        JAMA. 2016; 315: 380-387
        • O'Connor E.
        • Rossom R.C.
        • Henninger M.
        • Groom H.C.
        • Burda B.U.
        Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force.
        JAMA. 2016; 315: 388-406
        • Cox J.L.
        • Holden J.M.
        • Sagovsky R.
        Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale.
        Br J Psychiatry. 1987; 150: 782-786
        • Wisner K.L.
        • Sit D.K.
        • McShea M.C.
        • et al.
        Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings.
        JAMA Psychiatry. 2013; 70: 490-498
        • Chisholm C.A.
        • Bullock L.
        • Ferguson 2nd, J.E.J.
        Intimate partner violence and pregnancy: screening and intervention.
        Am J Obstet Gynecol. 2017; 217: 145-149
        • Young-Wolff K.C.
        • Alabaster A.
        • McCaw B.
        • et al.
        Adverse childhood experiences and mental and behavioral health conditions during pregnancy: the role of resilience.
        J Womens Health (Larchmt). 2018; 28: 452-461
        • Mahenge B.
        • Stockl H.
        • Mizinduko M.
        • Mazalale J.
        • Jahn A.
        Adverse childhood experiences and intimate partner violence during pregnancy and their association to postpartum depression.
        J Affect Disord. 2018; 229: 159-163
        • American College of Obstetricians and Gynecologists
        ACOG Committee opinion no. 666: Optimizing Postpartum Care.
        Obstet Gynecol. 2016; 127 (e187-92)
        • American College of Obstetricians and Gynecologists
        ACOG Committee opinion no. 736.
        Obstet Gynecol. 2018; 131: e140-e150
        • Goodman J.H.
        Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression.
        Birth. 2009; 36: 60-69
        • Dennis C.L.
        • Chung-Lee L.
        Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review.
        Birth. 2006; 33: 323-331
        • Byatt N.
        • Simas T.A.
        • Lundquist R.S.
        • Johnson J.V.
        • Ziedonis D.M.
        Strategies for improving perinatal depression treatment in North American outpatient obstetric settings.
        J Psychosom Obstet Gynaecol. 2012; 33: 143-161
        • Werner E.A.
        • Gustafsson H.C.
        • Lee S.
        • et al.
        PREPP: postpartum depression prevention through the mother-infant dyad.
        Arch Womens Ment Health. 2016; 19: 229-242
        • Kim J.J.
        • La Porte L.M.
        • Corcoran M.
        • Magasi S.
        • Batza J.
        • Silver R.K.
        Barriers to mental health treatment among obstetric patients at risk for depression.
        Am J Obstet Gynecol. 2010; (312.e1-312.e5): 202
        • St Pierre A.
        • Zaharatos J.
        • Goodman D.
        • Callaghan W.M.
        Challenges and opportunities in identifying, reviewing, and preventing maternal deaths.
        Obstet Gynecol. 2018; 131: 138-142
        • Dannenberg A.L.
        • Carter D.M.
        • Lawson H.W.
        • Ashton D.M.
        • Dorfman S.F.
        • Graham E.H.
        Homicide and other injuries as causes of maternal death in New York City, 1987 through 1991.
        Am J Obstet Gynecol. 1995; 172: 1557-1564