The impact of reclassifying suicides in pregnancy and in the postnatal period on maternal mortality ratios

The contribution of suicide to maternal mortality: A nationwide population-based cohort study

OBJECTIVE

To identify the incidence and characteristics of maternal suicide.

DESIGN

Nationwide population-based cohort study.

SETTING

The Netherlands, 2006-2020.

POPULATION

Women who died during pregnancy or within 1 year postpartum, and a reference population of women aged 25-45 years.

METHODS

The Cause of Death Register and Medical Birth Register were linked to identify women who died within 1 year postpartum. Data were combined with deaths reported to the Audit Committee for Maternal Mortality and Morbidity (ACMMM), which performs confidential enquiries. Maternal suicides were compared with a previous period (1996-2005). Risk factors were obtained by combining vital statistics databases.

MAIN OUTCOME MEASURES

Comparison of incidence and proportion of maternal suicides among all maternal deaths over time, sociodemographic and patient-related risk factors and underreporting of postpartum suicides.

RESULTS

The maternal suicide rate remained stable with 68 deaths: 2.6 per 100 000 live births in 2006-2020 versus 2.5 per 100 000 in 1996-2005. The proportion of suicides among all maternal deaths increased from 18% to 28%. Most suicides occurred throughout the first year postpartum (64/68); 34 (53%) of the women who died by suicide postpartum were primiparous. Compared with mid-level, low educational level was a risk factor (odds ratio 4.2, 95% confidence interval 2.3-7.9). Of 20 women reported to the ACMMM, 11 (55%) had a psychiatric history and 13 (65%) were in psychiatric treatment at the time of death. Underreporting to ACMMM was 78%.

CONCLUSIONS

Although the overall maternal mortality ratio declined, maternal suicides did not and are now the leading cause of maternal mortality if late deaths up to 1 year postpartum are included. Data collection and analysis of suicides must improve.

[Maternal mortality in France, 2016-2018, frequency, causes and women's profile]

OBJECTIVE

To describe, for the 2016-2018 period, the frequency, causes and risk factors of maternal deaths in France.

METHOD

Data from the National Confidential Enquiry into Maternal Deaths for 2016-2018.

RESULTS

For 2016-2018, 272 maternal deaths occurred in France up to 1 year after the end of pregnancy, i.e a maternal mortality ratio of 11.8 per 100,000 live births (95 % CI 10.4-13.3), and 8.5 (IC 95 % 7.4-9.8) for maternal mortality up to 42 days. Compared to women aged 20-24, the risk of maternal death is multiplied by 2.6 for women aged 35-39, by 5 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (26 %) than in the general population of parturients (11 %). There are territorial disparities -the maternal mortality ratio in the French overseas departments is 2 times higher than in metropolitan France (significant difference but smaller than in 2013-2015)-, and social disparities -the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 3 times higher than that of native women. One in three women who died (34 %) had socio-economic vulnerability versus 22 % in the overall population of parturients. Among causes of maternal deaths, the predominant role of psychiatric conditions (mostly suicides) is confirmed for the period 2016-2018, leading cause of maternal mortality considered up to 1 year (17 %), MMR of 1.9/100,000 NV. i.e. approximately one death from psychiatric causes every 3 weeks. Cardiovascular diseases are the second leading cause of maternal mortality up to one year (14 %) and the leading cause up to 42 days (16 %), with 1.3 deaths per 100,000 NV. Amniotic fluid embolism ranks as the third cause (8 %) (2nd cause, 11 %, for MM limited to 42 days), i.e. MMR of 0.9 per 100,000 NV. After a regular decline over the last decade, maternal mortality from obstetric hemorrhage is at a stable level compared to the previous triennium 2013-2015, MMR of 0.9/100,000 NV, i.e 5th cause of MM up to one year (7 %) and 4th cause of MM up to 42 days.

CONCLUSION

The overall national maternal mortality ratio does not show a downward trend, even with constant surveillance method. Territorial inequalities persist but change in their magnitude and in the regions concerned. The profile of the causes of maternal mortality up to one year of the pregnancy end shows the leading role of suicides and cardiovascular diseases, which illustrates that the health of pregnant women or those who have recently given birth is not limited to the obstetric domain, and highlights the importance of multidisciplinarity in the management and organization of care for women in this period.

Cardiac disease in pregnancy and the first year postpartum: a story of mental health, identity and connection

Background

Women with cardiac disease in pregnancy and the first year postpartum often face uncertainty about their condition and the trajectory of their recovery. Cardiac disease is a leading cause of serious maternal morbidity and mortality, and the prevalence is increasing. Affected women are at risk of worsening cardiac disease, chronic illness, mental illness and trauma. This compounded risk may lead to significant and long-term negative outcomes. The aim of this study is to correct the lack of visibility and information on the experiences of women with cardiac disease in pregnancy and the first year postpartum.

Methods

A qualitative study using in-depth semi-structured interviews with twenty-five women who had acquired, congenital or genetic cardiac disease during pregnancy or the first year postpartum. Data were analysed and interpreted using a thematic analysis framework.

Results

Analysis of the interviews produced three major themes: 1) Ground zero: index events and their emotional and psychological impact, 2) Self-perception, identity and worthiness, and 3) On the road alone; isolation and connection. There was a narrative consistency across the interviews despite the women being diverse in age, cardiac diagnosis and cardiac health status, parity and timing of diagnosis. The thread prevailing over the temporal and clinical differences was one of distress, biographical disruption, identity, isolation, a necessitated re-imagining of their lives, and the process of multi-layered healing.

Conclusion

Acknowledging and understanding the breadth, complexity and depth of women’s experiences is fundamental to improving outcomes. Our findings provide unique insights into women’s experiences and challenges across a spectrum of diseases. Most women did not report an isolated trauma or distressing event, rather there was a layering and persistence of psychological distress necessitating enhanced assessment, management and continuity of care beyond the routine 6-week postpartum check. Further research is required to understand long-term outcomes and to refine the findings for specific disease cohorts to be able to respond effectively.

Confidential enquiry into maternal deaths in the Netherlands, 2006-2018

INTRODUCTION

To calculate the maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare this with 1993-2005, and to describe women's characteristics, causes of death and improvable factors.

MATERIAL AND METHODS

We performed a nationwide, cohort study of all maternal deaths between January 1, 2006 and December 31, 2018 reported to the Audit Committee Maternal Mortality and Morbidity. Main outcome measures were the national MMR and causes of death.

RESULTS

Overall MMR was 6.2 per 100 000 live births, a decrease from 12.1 in 1993-2005 (risk ratio [RR] 0.5). Women with a non-western ethnic background had an increased MMR compared with Dutch women (MMR 6.5 vs. 5.0, RR 1.3). The MMR was increased among women with a background from Surinam/Dutch Antilles (MMR 14.7, RR 2.9). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 171 pregnancy-related deaths within 1 year postpartum, 102 (60%) had a direct and 69 (40%) an indirect cause of death. Leading causes within 42 days postpartum were cardiac disease (n = 21, 14.9%), hypertensive disorders (n = 20, 14.2%) and thrombosis (n = 19, 13.5%). Up to 1 year postpartum, the most common cause of death was cardiac disease (n = 32, 18.7%). Improvable care factors were identified in 76 (47.5%) of all deaths.

CONCLUSIONS

Maternal mortality halved in 2006-2018 compared with 1993-2005. Cardiac disease became the main cause. In almost half of all deaths, improvable factors were identified and women with a background from Surinam/Dutch Antilles had a threefold increased risk of death compared with Dutch women without a background of migration.

Suicide and Maternal Mortality

PURPOSE OF REVIEW

Suicide is a leading cause of death in the perinatal period (pregnancy and 1 year postpartum). We review recent findings on prevalence, risk factors, outcomes, and prevention and intervention for suicide during pregnancy and the first year postpartum.

RECENT FINDINGS

Standardization of definitions and ascertainment of maternal deaths have improved identification of perinatal deaths by suicide and risk factors for perinatal suicide. Reports of a protective effect of pregnancy and postpartum on suicide risk may be inflated. Clinicians must be vigilant for risk of suicide among their perinatal patients, especially those with mental health diagnoses or prior suicide attempts. Pregnancy and the year postpartum are a time of increased access to healthcare for many, offering many opportunities to identify and intervene for suicide risk. Universal screening for suicide as part of assessment of depression and anxiety along with improved access to mental health treatments can reduce risk of perinatal suicide.

Premature mortality after pregnancy loss: Trends at 1, 5, 10 years, and beyond

OBJECTIVE

Little is known on the long-term risk of mortality following pregnancy loss. We assessed risks of premature mortality up to three decades after miscarriage, induced abortion, ectopic or molar pregnancy, and stillbirth relative to live birth.

STUDY DESIGN

We carried out a longitudinal cohort study of 1,293,640 pregnant women with 18,896,737 person-years of follow-up in Quebec, Canada, from 1989 to 2018. We followed the women up to 29 years after their last pregnancy event to determine the time and cause of future in-hospital deaths before age 75 years. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of miscarriage, induced abortion, ectopic pregnancy, molar pregnancy, and stillbirth with premature mortality, compared with live birth.

RESULTS

Premature mortality rates were higher for most types of pregnancy loss than live birth. Compared with live birth, pregnancy loss was associated with an elevated risk of premature mortality (HR_miscarriage 1.48, 95% CI 1.33, 1.65; HR_{induced abortion} 1.50, 95% CI 1.39, 1.62; HR_ectopic 1.55, 95% CI 1.35, 1.79; and HR_stillbirth 1.68, 95%. CI 1.17, 2.41). Molar pregnancy was not associated with premature mortality (HR 0.87, 95% CI 0.33, 2.32). Miscarriage and induced abortion were associated with most causes of death, whereas ectopic pregnancy was associated with cardiovascular (HR 2.18, 95 % CI 1.39, 3.42), cancer (HR 1.38, 95 % CI 1.11, 1.73), and suicide-related mortality (HR 4.94, 95 % CI 2.29, 10.68). Stillbirth was associated with cardiovascular mortality (HR 4.91, 95 % CI 2.33, 10.36).

CONCLUSION

Pregnancy loss is associated with an elevated risk of premature mortality up to three decades later, particularly cardiovascular, cancer, and suicide-related deaths.

[Maternal deaths due to suicide in France 2013-2015]

Pregnancy represents a period of significant psychological vulnerability for women. During the perinatal period, twenty percent of them would present with mental disorders ranging from anxiety to depression. In those with pre-existing mental illness, the risk of acute decompensation is significant. For this reason, the World Health Organization recommends classifying suicides occurring during pregnancy and up to one-year post-partum as maternal deaths. Thus, between 2013 and 2015, 35 maternal suicides occurred in France, representing a maternal mortality ratio of 1:4 per 100,000 live births (95% CI: 1.0-2.0). By constituting 13.4% of all maternal deaths for the period, this group is the one of the 2 leading causes of maternal mortality. A total of 23% occurred in the first 42 days post-partum, and 77% between 43 days and one year after birth. 33.3% of the suicidal mothers had a known psychiatric history and 30.3% had a history of psychiatric care, unknown to obstetrical teams. Non-optimal care was present in 72% of cases with 91 % of suicides were potentially preventable, preventability factors beinga lack of multidisciplinary care and inadequate interaction between the patient and the care system. Strong messages were drawn from the analysis of these cases to optimize care: improve knowledge of the psychiatric history from the time of enrolment in maternity units, improve the identification of warning symptoms and the use of the psychologist and/or psychiatrist, set up a specific care pathway and multidisciplinary collaboration in case of known psychiatric disease.

[Maternal Mortality, Frequency, causes, women's profile and preventability of deaths in France, 2013-2015]

OBJECTIVE

To describe, for the 2013-2015 period, the frequency, causes, risk factors, adequacy of care and preventability of maternal deaths in France.

METHOD

Data from the National Confidential Enquiry into Maternal Deaths for 2013-2015.

RESULTS

For the period 2013-2015, 262 maternal deaths occurred in France, one every four days, i.e a maternal mortality ratio of 10.8 per 100,000 live births (95 % CI 9.5-12.1), stable compared to 2010-2012. Compared to women aged 25-29, the risk is multiplied by 1.9 for women aged 30-34, by 3 for women aged 35-39 and by 4 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (24 %) than in the general population of parturients (11 %). There are territorial disparities - the maternal mortality ratio in the French overseas departments is 4 times higher than in metropolitan France -, and social disparities - the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 2.5 times higher than that native women. A striking result of the 2013-2015 period is the preponderance of suicides and cardiovascular diseases, the two leading causes of maternal mortality, each responsible for approximately one death per month. These two etiologies are not only the most frequent, but also among those with the highest proportion of preventable deaths, 91.3 % and 65.7 % respectively. Another important result is the continued decrease in mortality from obstetric haemorrhage, halved in 15 years, particularly the decrease n hemorrhages due to uterine atony. Overall, 57.8 % of maternal deaths are considered probably or possibly preventable and in 66 % of cases, the care provided was not optimal.

CONCLUSION

While the overall maternal mortality ratio remains stable overall, and territorial and social inequalities unchanged, the profile of the causes of maternal mortality is changing. Some developments are a success, such as the continued decrease in maternal mortality due to haemorrhage, the result of the general mobilisation of health actors on this issue. Others point to new priorities for mobilisation, in particular on the mental and cardiovascular health of women during pregnancy or in the year following childbirth. In order to go further in understanding the mechanisms involved, and to identify precise avenues for prevention, it is necessary to analyse in detail the stories of each maternal death in order to identify the opportunities for improvement repeatedly found in the series of deaths. This is what the following articles in this issue propose, with an analysis by cause of death.