Maternal suicide - Register based study of all suicides occurring after delivery in Sweden 1974-2009

The impact of severe mental disorders on mother-infant interaction: a systematic review

PURPOSE

Mother-Infant Interaction (MII) is the first dynamic relationship that focuses on both mother-infant involvement and dyadic coordination and is associated with infant development. The main objective of this review is to summarize the evidence on the quality of MII in mothers with Severe Mental Illness (SMI).

METHOD

A systematic search for cross sectional, cohort or case control studies has been carried out in PubMed, Web of Science, PsycINFO and Scopus to extract studies addressing the relationship between the quality of MII and SMI.

RESULTS

A total of 15 studies with a sample of 992 women were included. Studies showed worst outcomes for MII in mothers with psychotic disorder and bipolar disorder. The impairments were more pronounced in psychotic disorders.

CONCLUSIONS

There is evidence of impaired MII in SMI. Social cognition (SC) is essential for understanding and responding to infant cues, so it could partially explain the associations between SMI and interaction outcomes. The current evidence is limited due to substantial heterogeneity and methodological limitations in the studies. Therefore, such findings should be interpreted with caution.

Factors associated with suicide mortality among reproductive age women: a case-control study

OBJECTIVE

Examine demographic, psychosocial, pregnancy-related, and healthcare utilisation factors associated with suicide mortality among reproductive age women.

METHODS

Data from nine health care systems in the Mental Health Research Network were included. A case-control study design was used in which 290 reproductive age women who died by suicide (cases) from 2000 to 2015 were matched with 2,900 reproductive age women from the same healthcare system who did not die by suicide (controls). Conditional logistic regression was used to analyse associations between patient characteristics and suicide.

RESULTS

Women of reproductive age who died by suicide were more likely to have mental health (aOR = 7.08, 95% CI: 5.17, 9.71) or substance use disorders (aOR = 3.16, 95% CI: 2.19, 4.56) and to have visited the emergency department in the year prior to index date (aOR = 3.47, 95% CI: 2.50, 4.80). Non-Hispanic White women (aOR = 0.70, 95% CI: 0.51, 0.97) and perinatal (pregnant or postpartum) women were less likely to have died by suicide (aOR = 0.27, 95% CI: 0.13, 0.58).

CONCLUSIONS

Reproductive age women with mental health and/or substance use disorders, prior emergency department encounters, or who are of racial or ethnic minority status were at increased risk of suicide mortality and may benefit from routine screening and monitoring. Future research should further examine the relationship between pregnancy-related factors and suicide mortality.

"She Was Feeling Overwhelmed at Home Caring for Her Children": Expectations of "Intensive Motherhood" as a Risk Factor for Young Women's Suicide

Suicide is a leading cause of death among young women and perinatal mothers. This paper explores how expectations of motherhood played a role in young women's deaths by suicide. I question the notion that motherhood is a "protective" factor against suicide. Using the concept of "intensive motherhood," I interrogate how expectations of mothers became fatal. Through analysis of 31 young Australian mothers who died by suicide, three key themes are explored, centered upon the theme of "failing motherhood": mothering without a father, mothering with mental illness, and the loss of care of children.

Investigating the association between metabolic syndrome conditions and perinatal mental illness: a national administrative claims study

BACKGROUND

Although the association between mental disorder and metabolic syndrome as a bidirectional relationship has been demonstrated, there is little knowledge of the cumulative and individual effect of these conditions on peripartum mental health. This study aims to investigate the association between metabolic syndrome conditions (MetS-C) and maternal mental illness in the perinatal period, while exploring time to incident mental disorder diagnosis in postpartum women.

METHODS

This observational study identified perinatal women continuously enrolled 1 year prior to and 1 year post-delivery using Optum's de-identified Clinformatics® Data Mart Database (CDM) from 2014 to 2019 with MetS-C i.e. obesity, diabetes, high blood pressure, high triglycerides, or low HDL (1-year prior to delivery); perinatal comorbidities (9-months prior to and 4-month postpartum); and mental disorder (1-year prior to and 1-year post-delivery). Additionally, demographics and the number of days until mental disorder diagnosis were evaluated in this cohort. The analysis included descriptive statistics and multivariable logistic regression. MetS-C, perinatal comorbidities, and mental disorder were assessed using the International Classification of Diseases, Ninth, and Tenth Revision diagnosis codes.

RESULTS

372,895 deliveries met inclusion/exclusion criteria. The prevalence of MetS-C was 13.43%. Multivariable logistic regression revealed prenatal prevalence (1.64, CI = 1.59-1.70) and postpartum incident (1.30, CI = 1.25-1.34) diagnosis of mental health disorder were significantly higher in those with at least one MetS-C. Further, the adjusted odds of having postpartum incident mental illness were 1.51 times higher (CI = 1.39-1.66) in those with 2 MetS-C and 2.12 times higher (CI = 1.21-4.01) in those with 3 or more MetS-C. Young women (under the age of 18 years) were more likely to have an incident mental health diagnosis as opposed to other age groups. Lastly, time from hospital discharge to incident mental disorder diagnosis revealed an average of 157 days (SD = 103 days).

CONCLUSION

The risk of mental disorder (both prenatal and incident) has a significant association with MetS-C. An incremental relationship between incident mental illness diagnosis and the number of MetS-C, a significant association with younger mothers along with a relatively long period of diagnosis mental illness highlights the need for more screening and treatment during pregnancy and postpartum.

Health care utilization, mental disorders and behavioural disorders among perpetrators of intimate partner homicide in 2000-2016: A registry-based case-control study from Sweden

Little is known about intimate partner homicide (IPH) perpetrator´s healthcare contacts and mental health problems before the killing. The aim was to compare male and female IPH perpetrators with matched controls from the general population by analysing differences in healthcare utilization and mental and behavioural disorders. This study includes 48 males and 10 females who perpetrated IPH between 2000 and 2016 in the Västra Götaland Region of Sweden. Controls (n = 458) were randomly selected from the general population and matched for sex, birth year and residential area. Data were retrieved from the Swedish National Patient Register and the Western Swedish Healthcare Register. Mental and behavioural disorders were classified according to ICD-10 (F00-F99). The Mann-Whitney U test was used to test for differences in health care utilization and mental and behavioural disorders. Compared to their controls, male perpetrators had more registered contacts with primary care ≤ 30 (p = < .001) and ≤ 365 days (p = .019), respectively, before the homicide; with specialist outpatient care ≤ 30 (p = < .001) and ≤ 365 days (p = < .001), respectively, before the homicide: and with inpatient care ≤ 30 (p = < .001) and ≤ 365 days (p = .024), respectively, before the homicide. Female perpetrators had more specialized outpatient care (p = .040) and inpatient care (p = .003) contacts ≤ 365 days before the homicide, compared to controls. Male perpetrators had at least one mental or behavioral disorder diagnosed in any studied healthcare setting except in inpatient care ≤ 30 days before homicide. Female perpetrators had more mental health disorders diagnosed in specialized outpatient care ≤ 365 days before the homicide (p < .001). Perpetrators had more healthcare contacts and mental disorders one year and one month prior to the homicide compared to their controls. Health care professionals should obtain necessary skills in routinely enquiring about intimate partner violence perpetration.

The most painful estrangement: Death at birth

More than two million babies a year die during or before birth around the world, evoking grief that is traumatic. Because the psychological, physical, social, and emotional ramifications of grief following a baby's death are so enduring and intense, social support is essential to helping families cope. In particular, emotional acts of caring and judicious use of language are crucial, avoiding the use of the terms that belittle the value of the baby's life and the importance of the baby as part of a family history. Traumatic grief informed continuing education can aid providers in increasing sensitivity to the needs of grieving families and minimize additional trauma and suffering in the aftermath of such loss.

Perinatal Depression and Risk of Suicidal Behavior

Importance

Suicidal ideation is common among women with perinatal depression (PND). However, prospective data are limited on the risk, particularly long-term risk, of suicidal behavior (suicide attempt and completed suicide) among women with perinatal depression.

Objective

To examine the association between PND and risk of short- and long-term suicidal behavior.

Design, Setting, and Participants

A nationwide population-matched cohort study was conducted in Sweden including 86 551 women with PND from 2001 to 2017 and 865 510 unaffected women individually matched on age and calendar year at delivery. Sibling comparison was used to account for familial confounding. Data were analyzed from January 2022 to November 2023.

Exposure

PND was identified through depression diagnosis or filled prescriptions of antidepressants from pregnancy to 1 year post partum in registers.

Main Outcomes and Measures

All women were followed up for the first event of suicidal behavior recorded in registers. Hazard ratios (HR) of suicidal behavior were estimated using time-to-event analysis.

Results

Women with PND (86 551 participants) received a diagnosis at a mean (SD) age of 30.67 (5.23) years. During a median (IQR) follow-up of 6.91 (3.62-10.88) years, 3604 events of suicidal behavior (incidence rate [IR], 5.62 per 1000 person-years) were identified among women with PND and 6445 (IR, 1.01 per 1000 person-years) among population-unaffected women. Women with PND had an elevated risk of suicidal behavior when compared with matched unaffected women (HR, 3.15; 95% CI, 2.97-3.35). Comparable, albeit somewhat attenuated, associations were yielded when comparing PND women with their PND-free sisters (HR, 2.75; 95% CI, 2.10-3.61). In the population-matched cohort, the association was greater for postnatal depression and among women without a history of psychiatric disorders. The excess risk was pronounced during the first year after diagnosis (HR, 7.20; 95% CI, 6.07-8.54), yet remained statistically significant during 5 to 18 years of follow-up (HR, 2.34; 95% CI, 2.12-2.57).

Conclusions and Relevance

In this nationwide cohort study, women with PND were at an increased risk of suicidal behavior, particularly within the first year after diagnosis with persistent risk elevations throughout the 18 years of follow-up, highlighting the need for vigilant clinical monitoring of this vulnerable group.

Postpartum Psychosis: A Review of Risk Factors, Clinical Picture, Management, Prevention, and Psychosocial Determinants

Postpartum psychosis is rare, but is a serious clinical and social problem. On its own, it is not included in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) or ICD-10 (International Statistical Classification of Diseases and Related Health Problems) as a disease entity, and current diagnostic criteria equate it with other psychoses. This poses a serious legal problem and makes it difficult to classify. The disorder is caused by a complex combination of biological, environmental, and cultural factors. The exact pathophysiological mechanisms of postpartum psychosis remain very poorly understood. There is a need for further research and increased knowledge of the medical sector in the prevention and early detection of psychosis to prevent stigmatization of female patients during a psychiatric episode. It is necessary to regulate its position in the DSM5 and ICD-10. Attention should be paid to the social education of expectant mothers and their families. This article aims to review the current status of risk factors, prevention, and management of postpartum psychosis.

Maternal suicide attempts and deaths in the first year after cesarean delivery

BACKGROUND

Cesarean delivery (CD) has been associated with postpartum psychiatric disorders, but less is known about the risk of suicidal behaviors. We estimated the incidence and risk of suicide attempts and deaths during the first postpartum year in mothers who delivered via CD v. vaginally.

METHOD

All deliveries in Sweden between 1973 and 2012 were identified. The mothers were followed since delivery for 12 months or until the date of one of the outcomes (i.e. suicide attempt or death by suicide), death by other causes or emigration. Associations were estimated using Cox proportional hazards regression models.

RESULTS

Of 4 016 789 identified deliveries, 514 113 (12.8%) were CDs and 3 502 676 (87.2%) were vaginal deliveries. During the 12-month follow-up, 504 (0.098%) suicide attempts were observed in the CD group and 2240 (0.064%) in the vaginal delivery group (risk difference: 0.034%), while 11 (0.0037%) deaths by suicide were registered in the CD group and 109 (0.0029%) in the vaginal delivery group (risk difference: 0.008%). Compared to vaginal delivery, CD was associated with an increased risk of suicide attempts [hazard ratio (HR) 1.46; 95% CI 1.32-1.60], but not of deaths by suicide (HR 1.44; 95% CI 0.88-2.36).

CONCLUSIONS

Maternal suicidal behaviors during the first postpartum year were uncommon in Sweden. Compared to vaginal delivery, CD was associated with a small increased risk of suicide attempts, but not death by suicide. Improved understanding of the association between CD and maternal suicidal behaviors may promote more appropriate measures to improve maternal mental well-being and further reduce suicidal risks.

Postpartum Psychosis

PURPOSE OF REVIEW

Postpartum psychosis is a psychiatric emergency that can affect the health and life of mothers, infants, and families. Postpartum psychosis (PPP) is distinct from non-postpartum psychosis in many ways, and it is crucial to study and understand PPP to identify, treat, and possibly prevent this condition. We therefore sought to review the latest research findings about PPP with the intention of updating readers about the latest evidence base.

RECENT FINDINGS

Multiple physiologic pathways have been implicated in the development of PPP, and further understanding these pathways may allow for early detection and treatment. Risk assessment and treatment should include consideration of the woman patient but also the mother-infant dyad and the larger family. It is our hope that this review of research updates in postpartum psychosis may inform clinical practice and promote specialized, evidence-based diagnosis, risk assessment, and treatment.

Review of suicidal ideation during pregnancy: risk factors, prevalence, assessment instruments and consequences

Background

Pregnancy is a period when women are particularly vulnerable to suicidal ideation and a great opportunity for suicide risk prevention.

Aims

This study aimed to establish a comprehensive understanding of suicidal ideation prevalence, risk factors, screening tools, consequences and management during pregnancy.

Method

A literature search was performed in MEDLINE and PsycInfo databases from 2016 to 2021. A narrative synthesis of the literature and a critical overview of the current issues/questions to be addressed within the topic of suicidal ideation during pregnancy was performed.

Results

The prevalence of suicidal ideation during pregnancy was between 2.73 and 18% internationally. The risk factors identified were major depressive disorder, anxiety disorder, difficulties with sleep, previous suicide attempts, high rumination, low incomes, being black, being young, low educational level, partner violence, having poor support, food insecurity, history of child abuse, high obstetric risk, multiparity, previous induced abortion and exposure to tobacco or human immunodeficiency virus diagnosis. The screening tools used for suicidal ideation during pregnancy were item 10 of the Edinburgh Postpartum Depression Scale and item 9 of the Patient Health Questionnaire. Results showed that suicidal ideation during pregnancy is associated with poor cognitive development in children and low birth weight. No case management studies on suicidal ideation were found.

Limitations

The main limitation of the available studies was the lack of articles with a high degree of methodological rigour on this subject.

Conclusions

This narrative review is a state-of-the-art paper about suicidal ideation during pregnancy. Further research is needed, and researchers should carry out systematic reviews and meta-analyses, leading to Clinical Practice Guidelines in this area. This effort would improve our evidence-based practice in Perinatal Psychology and prevent associated suicidal behaviour.

Initiation of Opioid Prescription and Risk of Suicidal Behavior Among Youth and Young Adults

BACKGROUND AND OBJECTIVES

Opioids are involved in an increasing proportion of suicide deaths. This study examined the association between opioid analgesic prescription initiation and suicidal behavior among young people.

METHODS

We analyzed Swedish population-register data on 1 895 984 individuals ages 9 to 29 years without prior recorded opioid prescriptions. We identified prescriptions dispensed from January 2007 onward and diagnosed self-injurious behavior and death by suicide through December 2013. We first compared initiators with demographically matched noninitiators. To account for confounding, we applied an active comparator design, which examined suicidal behavior among opioid initiators relative to prescription nonsteroidal antiinflammatory drug (NSAID) initiators while inverse-probability-of-treatment weighting with individual and familial covariates.

RESULTS

Among the cohort, 201 433 individuals initiated opioid prescription. Relative to demographically matched noninitiators, initiators (N = 180 808) had more than doubled risk of incident suicidal behavior (hazard ratio = 2.64; 95% confidence interval [CI], 2.47-2.81). However, in the active comparator design, opioid initiators (N = 86 635) had only 19% relatively greater risk of suicidal behavior compared with NSAID initiators (N = 255 096; hazard ratio = 1.19; 95% CI,: 1.11-1.28), corresponding to a weighted 5-year cumulative incidence of 2.2% (95% CI, 2.1-2.4) for opioid and 1.9% (95% CI, 1.9-2.0) for NSAID initiators. Most sensitivity analyses produced comparable results.

CONCLUSIONS

Opioid initiation may make only a small contribution to the elevated risk of suicidal behavior among young people receiving pharmacologic pain management. In weighing benefits and harms of opioid initiation, our results suggest that increased risk of suicidal behavior may not be a major concern.

Fertility, pregnancy and post partum management after bariatric surgery: a narrative review

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Of the women who gave birth in Australia in 2018, 47% had overweight or obesity, with obesity being associated with both maternal and fetal complications.

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Bariatric surgery improves fertility and some pregnancy‐related outcomes.

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Following bariatric surgery, pregnancy should be delayed by at least 12–18 months due to adverse pregnancy outcomes associated with rapid weight loss.

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Contraception should be prescribed after bariatric surgery, although the effectiveness of the oral contraceptive pill may be reduced due to malabsorption and contraceptive devices such as intrauterine devices should be considered as first line therapy.

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After bariatric surgery, women should undergo close monitoring for nutritional insufficiencies before, during and after pregnancy. Expert opinion recommends these women undergo dietary assessment and supplementation to prevent micronutrient deficiencies.

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Bariatric surgeons, bariatric medical practitioners, bariatric dieticians, the patient’s usual general practitioner, obstetricians, and maternity specialists should be involved to assist in the multidisciplinary management of these complex patients.

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.

Women's Suicide in the First-Year Postpartum: A Population-based Study

BACKGROUND

In dominant suicidology there is a long traditionof theorizing that women are protected from suicide, particularly when mothers and during the postpartum. Studies have mostly confirmed the postpartum suicide-protection theory, with low suicide mortality generally observed among postpartum women. A limitation of these studies is that most were conducted in majority European-descent-population countries. A challenge to the more general maternal suicide-protection theory is that in East-Asia women of childbearing age exhibit substantial suicidality, nonfatal and fatal. This study evaluated whether suicide is less likely in first-year postpartum women as compared to women past the first-year postpartum.

METHODS

This population-based, nested case-control study focused on women whose live birth was between 2001 and 2016 in East-Asian Taiwan. To ascertain suicide outcomes, the women were followed until 2017. For each suicide case, four control cases were randomly selected from the Birth Certificate Application dataset, with a 1:4 matching ratio based on age of last live-delivery and parity (one delivery record vs. two or more records) (cases N = 1571; controls N = 6284). Conditional logistic regression analyses were conducted to assess whether suicide was less likely in women in the first-year postpartum relative to women past the first-year postpartum.

RESULTS

The odds ratios of suicide were elevated at 42 days postpartum [Odds Ratio (OR) = 2.06; 95% Confidence Interval (CI) = (1.04, 4.16)], six-months postpartum [OR = 2.28; 95% CI = (1.60, 3.29)] and one-year postpartum [OR = 2.26; 95% CI = (1.76, 2.96)], when controlling for sociodemographic and mental-disorder variables. Suicide was more likely in women who were single at index birth, had lower socioeconomic status, or had a mental disorder history.

CONCLUSION

Our findings suggest that the postpartum stage is not suicide-protective per se. Whether the postpartum stage is associated with suicide protection or suiciderisk appears to depend on context and culture.

Suicidal behaviours in the peripartum period: a systematic scoping review of data linkage studies

The purpose of this scoping review was to summarize research that uses linked data to examine peripartum suicidal behaviours and critically appraise studies to identify evidence gaps and future research priorities. A systematic search of PubMed, Scopus, and grey literature was undertaken to identify data linkage studies that examined suicidal behaviours among women in the peripartum period. All articles available through PubMed and Scopus up until the search date of 26 September 2019 were deemed eligible for inclusion. A grey literature search was also undertaken, through the Google search engine, on 11 November 2019. Studies were analysed descriptively and synthesized qualitatively. Eighteen studies were identified that met inclusion criteria. All studies examined the incidence of suicidal behaviours. Twelve studies examined sociodemographic correlates, associations, or risk factors, and nine studies examined mental health. There was a high degree of variability regarding how both peripartum status and suicidal behaviours were defined. Few studies used data linkage to examine suicidal behaviours from a health services or social services perspective. The evidence base could benefit from conceptual clarity and standardization of constructs regarding suicidal behaviours in the peripartum period, to enable meaningful synthesis of results across studies. Data linkage can be used to improve understandings of risk factors and pathways. It can also be harnessed to examine both health and social services utilization, to inform coordinated multi-sectoral interventions and care pathways for women and their children.

Acute psychiatric illness and drug addiction during pregnancy and the puerperium

Pregnancy and the puerperium do not protect against acute psychiatric illness. During puerperium, the chance of acute psychiatric illness, such as a psychotic episode or relapse of bipolar disorder, is greatly increased. Suicide is a leading cause of maternal death. Both psychiatric disease and ongoing drug addiction impact not only the pregnant woman's somatic and mental health but also impact short-term and long-term health of the child. Indeed, prompt recognition and expeditious treatment of acute psychiatric illness during pregnancy and the puerperium optimize health outcomes for two patients. Pregnancy and puerperium represent a stage of life of great physiologic adaptations, as well as emotional and social changes. This conjunction of changes in somatic, emotional health and social health may mitigate the occurrence, clinical presentation, and clinical course of acute psychiatric illness and call for a multidisciplinary approach, taking into account both the medical and social domains. This chapter describes acute psychiatric illnesses during pregnancy and the puerperium and illicit substance abuse, from a clinical perspective, while also describing general principles of diagnosis and clinical management during this stage of life, which is an important window of opportunity for both the pregnant woman and the child.

Suicide Risk and Mood Disorders in Women in the Postpartum Period: a Longitudinal Study

Suicide associated with severe psychiatric illnesses is considered the leading cause of maternal deaths. We aimed to assess the suicide risk in women who experienced depressive or mixed episodes of mood change during the postpartum period and to determine which disorder is more related to suicide risk in the same period. We conducted a longitudinal study with 706 women whose children were born from April 2007 to May 2008 in a southern city in Brazil, and received prenatal care by the Brazilian National System of Public Health. The first assessment occurred during the prenatal period and the second within 30 to 60 days postpartum. The incidence of suicide risk was 10.9%. The odds of postpartum suicide risk were 6.50 (95% CI: 2.73; 15.48) higher in mothers with postpartum depression and 41.50 (95% CI: 12.11; 142.16) higher in those with mixed episodes than those who did not suffer from any mood disorder. Women with chronic episodes (who had depressive or mixed episodes during pregnancy and postpartum) were at increased odds of 4.94 (95% CI: 1.46; 16.69) of a postpartum suicide risk. The postpartum seems to be a critical period in the women's mental health. The impact of mental disorders in this period, especially mixed episodes, can increase the odds of a suicide risk onset. A good psychiatric evaluation and support during the prenatal and postpartum care may prevent the subsequent risk of suicide.

Mental disorder in pregnancy and the early postpartum

Perinatal mental illness is common, affecting up to 20% of women, but remains under-recognised and under-diagnosed. It may have adverse effects on pregnancy and neonatal outcomes, and mental disorder remains one of the leading causes of maternal death in the UK. Women with mental ill health face difficult decisions in balancing risks and benefits of treatment. Stigma related to mental disorder may lead to non-engagement with maternity care. Some disorders bring specific challenges for anaesthetists working in maternity settings and it is vital that anaesthetists have knowledge of these disorders so they may offer care which is sensitive and appropriate.

[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.

Recovery from postpartum psychosis: a systematic review and metasynthesis of women's and families' experiences

Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women's experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria. Four main themes incorporating 13 subthemes were identified following synthesis: (1) Experiencing the unspeakable, (2) Loss and disruption, (3) Realigning old self and new self and the integrative theme of (4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrate that recovery does not follow a linear path. To improve clinical outcomes, a more integrative and individualised approach is needed which incorporates long-term psychological and psychosocial support, and considers the needs of the family. Further areas for staff training, service development and future research are highlighted.

Self-harm in women with postpartum mental disorders

BACKGROUND

Women suffering from first onset postpartum mental disorders (PPMD) have a highly elevated risk of suicide. The current study aimed to: (1) describe the risk of self-harm among women with PPMD and (2) investigate the extent to which self-harm is associated with later suicide.

METHODS

We conducted a register-based cohort study linking national Danish registers. This identified women with any recorded first inpatient or outpatient contact to a psychiatric facility within 90 days after giving birth to their first child. The main outcome of interest was defined as the first hospital-registered episode of self-harm. Our cohort consisted of 1 202 292 women representing 24 053 543 person-years at risk.

RESULTS

Among 1554 women with severe first onset PPMD, 64 had a first-ever hospital record of self-harm. Women with PPMD had a hazard ratio (HR) for self-harm of 6.2 (95% CI 4.9-8.0), compared to mothers without mental disorders; but self-harm risk was lower in PPMD women compared to mothers with non-PPMD [HR: 10.1, (95% CI 9.6-10.5)] and childless women with mental disorders [HR: 9.3 (95% CI 8.9-9.7)]. Women with PPMD and records of self-harm had a significantly greater risk for later suicide compared with all other groups of women in the cohort.

CONCLUSIONS

Women with PPMD had a high risk of self-harm, although lower than risks observed in other psychiatric patients. However, PPMD women who had self-harmed constituted a vulnerable group at significantly increased risk of later suicide.

The Rajarata Pregnancy Cohort (RaPCo): study protocol

Background

Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes.

Methods

The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio-demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses.

Discussion

This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi-cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda.

The Risk Factors Predicting Suicidal Ideation Among Perinatal Women in Japan

INTRODUCTION

The aim of the present study was to elucidate the foreseeable risk factors for suicidal ideation among Japanese perinatal women.

METHODS

This cohort study was conducted in Nagoya, Japan, from July 2012 to March 2018. The Edinburgh Postnatal Depression Scale (EPDS) questionnaire was conducted at four time points: early pregnancy, late pregnancy, 5 days postpartum, and 1 month postpartum. A total of 430 women completed the questionnaires. A logistic regression analysis was performed using the presence of suicidal ideation on the EPDS as an objective variable. The explanatory variables were age, presence of physical or mental disease, smoking and drinking habits, education, hospital types, EPDS total score in early pregnancy, bonding, and quality and amount of social support, as well as the history of major depressive disorder (MDD).

RESULTS

The rate of participants who were suspected of having suicidal ideation at any of the four time points was 11.6% (n=52), with the highest (n=25, 5.8%) at late pregnancy. For suicidal ideation, education level (OR: 1.19; 95% CI: 1.00-1.41; p=0.047), EPDS total points in the pregnancy period (OR: 1.25; 95% CI: 1.16-1.34; p < 0.000), a history of MDD (OR: 2.16; 95% CI: 1.00-4.79; p=0.049), and presence of mental disease (OR: 2.39; 95% CI: 1.00-5.70; p=0.049) were found to be risk factors for suicidal ideation. Age [odds ratio (OR): 0.88; 95% confidence interval (CI): 0.80-0.95; p=.002] and quality of social support (OR: 0.77; 95% CI: 0.60-0.99; p=.041) were found to be protective factors.

CONCLUSION

Based on these results, effective preventive interventions, such as increasing the quality of social support and confirming the history of depression, should be carried out in pregnant depressive women at the early stage of the perinatal period.

Maternal suicide in Italy

Suicide has been identified as one of the most common causes of death among women within 1 year after the end of pregnancy in several high-income countries. The aim of this study was to provide the first estimate of the maternal suicide ratio and a description of the characteristics of women who died by suicide during pregnancy or within 1 year after giving birth, induced abortion or miscarriage (i.e., maternal suicide) in 10 Italian regions, covering 77% of total national births. Maternal suicides were identified through the linkage between regional death registries and hospital discharge databases. Background population data was collected from the national hospital discharge, abortion and mortality databases. The previous psychiatric history of the women who died by maternal suicide was retrieved from the regionally available data sources. A total of 67 cases of maternal suicide were identified, corresponding to a maternal suicide ratio of 2.30 per 100,000 live births in 2006-2012. The suicide rate was 1.18 per 100,000 after giving birth (n = 2,876,193), 2.77 after an induced abortion (n = 650,549) and 2.90 after a miscarriage (n = 379,583). The majority of the women who died by maternal suicide (34/57) had a previous psychiatric history; 15/18 previously diagnosed mental disorders were not registered along with the index pregnancy obstetric records. Suicide is a relevant cause of maternal death in Italy. The continuity of care between primary, mental health and maternity care were found to be critical. Clinicians should be aware of the issue, as they may play an important role in preventing suicide in their patients.

Suicidal ideation and intentional self-harm in pregnancy as a neglected agenda in maternal health; an experience from rural Sri Lanka

Background

Suicide only present the tip of the iceberg of maternal mental health issues. Only a fraction of pregnant women with suicidal ideation proceeds to intentional self-harm (ISH) and even a smaller proportion are fatal. The purpose of the present study was to determine the prevalence of depression, suicidal ideation (present and past) and history of ISH among pregnant mothers in rural Sri Lanka.

Methods

We have conducted a hospital based cross sectional study in the third largest hospital in Sri Lanka and an another tertiary care center. Pregnant women admitted to hospital at term were included as study participants. The Edinburgh Postpartum Depression Scale (EPDS), a self-administered questionnaire for demographic and clinical data and a data extraction sheet to get pregnancy related data from the pregnancy record was used.

Results

The study sample consisted of 475 pregnant women in their third trimester. For the tenth question of EPDS “the thought of harming myself has occurred to me during last seven days” was answered as “yes quite a lot” by four (0.8%), “yes sometimes” by eleven (2.3%) and hardly ever by 13 (2.7%). Two additional pregnant women reported that they had suicidal ideation during the early part of the current pregnancy period though they are not having it now. Four (0.8%) pregnant women reported having a history of ISH during the current pregnancy. History of ISH prior to this pregnancy was reported by eight women and five of them were reported to hospitals, while others were managed at home. Of the 475 pregnant females included in the study, 126 (26.5%) had an EPDS score more than nine, showing probable anxiety and depression. Pregnant women who had primary/post-primary or tertiary education compared to those who were in-between those two categories were at higher risk of high EPDS score with a OR of 1.94 (95% CI 1.1–3.3). Reported suicidal ideation prior to pregnancy was also associated with high EPDS with a OR of 6.4 (95% CI 2.3–17.5).

Conclusions

Based on our data, we conservatively estimate around 500 pregnant women each year having suicidal ideation and, 130 ISH annually in Anuradhapura, which should be considered as a high priority for an urgent intervention.

Interpersonal trauma and suicide attempts in low-income depressed mothers in home visiting

BACKGROUND

Risk of suicide is a major concern for depressed mothers in the perinatal period. The strongest predictor of completing suicide is having made a previous attempt. Little is known about the clinical features of low-income, depressed mothers who have attempted suicide in contrast to those who have not.

OBJECTIVE

This study examined clinical and psychosocial features of 170 low-income, young, depressed mothers with and without previous suicide attempts who were enrolled in an early childhood home visiting program.

METHOD

Mothers were identified via screening at three months postpartum and diagnosed with major depressive disorder (MDD) using a semi-structured interview. Psychiatric history and presentation, child maltreatment history, intimate partner violence, and social functioning were measured.

RESULTS

31.8% of mothers had previous suicide attempts. Mean age of first attempt was 14.38 years (SD = 2.55) and the median number of lifetime attempts was 2. In contrast to no attempts, those who had attempted suicide had more MDD symptoms, earlier age of first MDD episode, and more episodes. A previous attempt was associated with greater childhood trauma, more current MDD symptoms and PTSD diagnosis. No differences were found on intimate partner violence. Mothers who made an attempt reported lower levels of tangible social support and smaller social networks.

CONCLUSIONS

History of suicide attempts is associated with childhood trauma history and later psychosocial impairments in low income, depressed mothers in home visiting. Implications for addressing the needs of depressed mothers with suicide attempt histories in the context of early childhood programs are discussed.

A Case of Fetal Tachycardia after Electroconvulsive Therapy: A Possible Effect of Maternal Hypoxia and Uterine Contractions

Electroconvulsive therapy (ECT) is considered to be an effective and safe treatment for depression in pregnant women in that it avoids the risk of psychotropic pharmacotherapy. However, clinicians should be cautious about the adverse effects in the fetus, such as fetal cardiac arrhythmia. Most of the previous studies have demonstrated a reduction in fetal heart rate associated with ECT. However, we encountered a case of fetal tachycardia after maternal ECT-induced convulsions. The patient was a woman who was 30 weeks' pregnant and had severe depression; fetal tachycardia (180–200 bpm) occurred immediately after the electrical stimulation and lasted for more than 30 minutes. The fetal tachycardia might have been caused by maternal hypoxia and uterine contractions. To our knowledge, this is the first report of fetal tachycardia as an adverse effect of ECT. Prolonged fetal tachycardia may cause fetal heart failure. Therefore, oxygenation during convulsions and careful fetal cardiac monitoring are essential when administering ECT in pregnancy.

Mental Disorders and Suicide Attempts in the Pregnancy and Postpartum Periods Compared with Non-Pregnancy: A Population-Based Study

OBJECTIVE

To compare the rate of mental disorders (i.e., mood and anxiety, substance use, psychotic disorders) and suicide attempts within the same group of women across the pre-pregnancy, pregnancy, and postpartum periods, and between this perinatal cohort and a non-perinatal reference group.

METHOD

Data were from an administrative repository of residents in Manitoba, Canada. The perinatal cohort consisted of women aged 18 to 45 years who experienced >1 live birth pregnancy between 2011 and 2014 (n = 45,362). Pre-pregnancy, pregnancy, and postpartum periods were defined over consecutive 40-week intervals. The non-perinatal cohort consisted of age-matched women with no pregnancies during the same period (n = 139,705). A reference 40-week interval was defined from the individual's birthdate in the year they entered the cohort. Rate ratios of diagnosed mental disorders were adjusted (aRR) for demographic factors, parity, and mental health history.

RESULTS

Within the perinatal cohort, pregnancy was associated with a lower rate of diagnosed mood or anxiety disorder, substance use disorder, and suicide attempt relative to pre-pregnancy (aRR range, 0.22-0.82). Pregnancy also had lower rates of all outcomes compared with the postpartum period (aRR, 0.44-0.87). Postpartum had a higher rate of psychotic disorder compared with pre-pregnancy (aRR, 1.61; 95% CI, 1.17-2.21), but a lower rate of mood or anxiety disorder and suicide attempt. Compared with non-perinatal women, pregnancy was associated with lower rates of all outcomes (aRR range, 0.25-0.87).

CONCLUSIONS

Compared with a non-perinatal period, the rate of a diagnosed mental disorder is lower during pregnancy but begins to rise in the postpartum period, highlighting an important period for early identification and rapid access to intervention.

Combined effect of adverse childhood experiences and young age on self-harm ideation among postpartum women in Japan

BACKGROUND

Suicide among postpartum women is a new and emerging issue in developed countries. However, little is known about the combined effect of risk factors on self-harm ideation, although various risk factors have been found. The aim of this study is to examine the combined effect of maternal adverse childhood experiences and maternal age on self-harm ideation among postpartum women.

METHODS

The study comprised a cross-sectional study of 8074 mothers participating in a 3-month health checkup between September 2013 and August 2014 in City A, Prefecture A, Japan. Main outcome was self-harm ideation assessed using the Edinburgh Postnatal Depression Scale (EPDS), item 10. Possible risk factors were maternal adverse childhood experiences (ACEs), maternal characteristics, relationship with husband/partner (e.g., feelings when pregnancy was confirmed), household characteristics, child characteristics (e.g., age, sex, birth weight), and postpartum characteristics, and postpartum depression status other than self-harm ideation.

RESULTS

Postpartum women with 3 or more ACEs and younger age (<25 years old) were 10.3 times more likely than those with no ACEs and older age to have self-harm ideation (95%CI = 5.3-20.2). This combined effect was also found in first-time mothers (OR = 7.6, 95%CI = 3.2-17.9).

LIMITATIONS

Study limitations are excluding an item on sexual abuse which is one of the ACEs, recall bias and information bias.

CONCLUSIONS

Postpartum women with 3 or more ACEs and who were younger than 25 years old were at a high risk for self-harm ideation. Providing prevention strategies aimed at mothers with multiple risk factors, especially younger age and ACEs, is warranted.

Postpartum psychiatric disorders

Pregnancy is a complex and vulnerable period that presents a number of challenges to women, including the development of postpartum psychiatric disorders (PPDs). These disorders can include postpartum depression and anxiety, which are relatively common, and the rare but more severe postpartum psychosis. In addition, other PPDs can include obsessive-compulsive disorder, post-traumatic stress disorder and eating disorders. The aetiology of PPDs is a complex interaction of psychological, social and biological factors, in addition to genetic and environmental factors. The goals of treating postpartum mental illness are reducing maternal symptoms and supporting maternal-child and family functioning. Women and their families should receive psychoeducation about the illness, including evidence-based discussions about the risks and benefits of each treatment option. Developing effective strategies in global settings that allow the delivery of targeted therapies to women with different clinical phenotypes and severities of PPDs is essential.