Maternal Self-Harm Deaths: A Neglected Topic

This week we will be discussing a tremendously neglected topic; maternal self-harm deaths in the United States. The article, “Maternal self-harm deaths: an unrecognized and preventable outcome” was published in the American Journal of Obstetrics and Gynecology just last month. Authors Mongla, Hoffman, Trumpff, O’Grady, and Monk provide a concise review with the goal of filling the gap in the literature related to self-harm deaths during the pregnancy-postpartum period.

What did they do?

Using a collection of existing literature, the authors break down maternal suicide and opiate overdose as a major public health concern, highlighting ways in which we can improve outcomes and decrease overall maternal mortality. The authors highlight ways in which we can improve the prevention of maternal mortality, implement screening protocols, and use targeted interventions addressing maternal mental health.

Why did they do it?

While overall national rates of maternal mortality are decreasing, approaches aimed at maternal mental health typically do not include the deaths associated with behavioral health problems, such as suicide and overdose, which are two leading causes of death in the United States.

How did they do it?

The authors of this review used existing literature on maternal mortality to highlight four key areas of interest:

1. Challenges related to obtaining reliable epidemiological statistics on maternal mortality via self-harm (including suicide and overdose)
2. Rates of maternal self-harm deaths
3. Factors that may be rendering maternal mortality, focussing on self-harm as a “silenced public health issue”
4. Ways to improve prevention of self-harm related maternal mortality

What did they find?

The authors break down their findings into concise categories related to the areas of interest highlighted above. To parsimoniously relay the information provided by the authors, we will break down the findings in a similar way, highlighting key points:

1. Epidemiology
1. The authors found multiple studies indicating that the maternal mortality rate is severely underestimated.
2. The authors suggest, based on recent population based reports demonstrating that the peak time frame for maternal self harm deaths is around 9-12 months postpartum, that there should be resources allocated to extending the time period of statistics related to maternal deaths.
2. Rates of maternal self-harm deaths
1. Across regional “hot spots”, there has been a general rise in maternal self-harm deaths related to behavioral health.
2. A majority of maternal self-harm deaths occur in the postpartum period.
1. A specific case study in Virginia found that approximately 7% of maternal deaths from 1999-2005 were the result of suicide and accidental drug overdose, respectively.
3. Risk Factors
1. The most common risk factor for maternal self-harm death was found to be a diagnosis of major depression.
2. Opiate use is a particularly prevalent risk factor for maternal death, which the authors specifically highlight as being due to the increasing rate of opioid use in women of child bearing age.
1. Access to inpatient and/or outpatient treatment is particularly scarce in regards to specialized programs for pregnant and postpartum women.
2. According to a recent report from the Substance Abuse and Mental Health Services Administration’s, only 7% of inpatient treatment programs offer specialized programs for pregnant and postpartum women, with 44% of these programs offering nothing more than detox services.
4. Improving prevention of maternal self-harm deaths
1. The authors identified key characteristics of pregnant and postpartum women that may aid in the early prevention of maternal death; depression, discontinuation or lack of psychopharmacological medication, a prior hospitalization for a psychiatric illness, and disengagement from postpartum medical treatment.
2. Routine mental health screening during prenatal care was identified as a promising candidate for preventative care.

What does it all mean (our take)?

This article proved to be crucial in opening up our eyes to the reality that maternal self-harm death is a highly important area that will require ongoing study. However, the authors nicely identified places where providers can begin to potentially start making a difference. We appreciate the notion of regular mental health screening throughout the pregnancy period...a very simple and not overly laborious strategy that could have a significant impact on the health of these mothers. Additionally, the issue of appropriate and accessible substance abuse treatment options continues to be an ongoing problem we are facing in our country. Improvement in this area is essential.

But, how do we make a lasting difference? We feel that we must continue collecting data, learning from the data, and making changes to how we’re doing things clinically based on the data. Until these clinical changes occur, however, it will be difficult to expect significant patient improvement.