Suicide attempts during pregnancy

Article in review: Shigemi, D., Ishimaru, M., Matsui, H., Fushimi, K. & Yasunaga, H. (2021). Suicide attempts during pregnancy and perinatal outcomes, Journal of Psychiatric Research. https://doi.org/10.1016/j.jpsychires.2020.12.024

Summary: Suicide attempts by pregnant women are linked to a higher risk of miscarriage and other complications. Healthcare providers should pay attention to mental wellbeing among pregnant women, despite the problems of mental and behavioral disorders. The finding of the connection between violent strategies of suicide attempts and basic perinatal results may be a great help for healthcare providers.

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Maternal suicide in Japan has become an important public health issue. In 2017, the rate of maternal deaths by suicide was high when compared to other developed countries. A recent study has sought to examine individual factors that may have been contributors to these statistics. The study also sought to track perinatal outcomes for women admitted to a hospital following a suicide attempt.

Research to date

Our understanding of suicide and suicide attempts during pregnancy is somewhat limited. A 2006 American study found the incidence of suicide attempts was about 4 per 1000 pregnancies, and that overwhelmingly, in 96% of cases, the methods were drug or poison and firearms use. The reported frequency of perinatal suicide varies from 2 per 100,000 births in the UK to 3.7 per 100,000 births in Sweden. In Japan, this figure has risen to 8.7 suicides per 100,000 births.

A 2018 study found that women experiencing suicidality while pregnant are also at an increased risk for various adverse pregnancy outcomes, including miscarriage, preterm delivery, maternal hemorrhage, and stillbirth.

Cohort profile

In this Japanese study, researchers looked at data related to suicide attempts, which resulted in the hospitalisation of a pregnant woman. The study period was 27 months between January 2016 to March 2018.

During the study period, there were 319 eligible hospitalisations from 159 hospitals around Japan. These hospitals represent around 90% of the tertiary hospitals in that country. This relatively large sample size was drawn from national inpatient data. Of the study group, there were four maternal deaths by suicide, each at less than 28 weeks gestation.

Study fields

The study reviewed all data related to
• Maternal age
• Gestational age on admission
• Smoking habits
• If there was a disturbance of consciousness on admission
• If ICU admission occurred
• Mental and behavioural disorders on admission
• Method of suicide attempt

However, the study did not consider any social and cultural factors including relationship, family or economic factors. The study did not follow up on fetal outcomes either.

Key findings- methods of suicide attempt

Although wrist cutting was the most common method, women in the first trimester tended to choose drug overdose or jumping from heights while women later in pregnancy tended to attempt suicide by wrist cutting or hanging. The percentage of women attempting suicide by violent means increased with gestational age. Violent means are considered hanging, jumping from height, and stabbing while non-violent means are considered drug overdoses, poisons, and wrist cutting. Subsequent data analysis showed that where a suicide attempt by violent means had been made, there was a significant increase in the risk of critical perinatal outcomes such as spontaneous miscarriage, intrauterine feat death, or maternal death.

Key findings- Gestational age

The rate of suicides attempt by teens was greater in the first trimester. This reinforces the findings of other studies that have demonstrated that teen pregnancies are more likely to be mistimed, unwanted and that young women are more prone to be stigmatized about pregnancy, experience financial difficulties, loss of education and employment, or have less access to safe abortion. More than half (58%) of patients were in their third trimester when the suicide attempt was made.

Key findings- mental and behavioural illness

Depression, anxiety, and panic disorders have been said to increase the risk of suicide ideation during pregnancy. In this study, none of the sample groups had an intellectual disability and six were using substances. 39.5% had mental or behaviour disorders on admission (a total of 126 women), most commonly depression (15.4%), schizophrenia (13.2%), and personality disorders (9.7%). The fact that more than half of all women in the study had no diagnosis of mental illness before their suicide attempt suggests that healthcare providers need to pay attention to the mental health of all pregnant women, regardless of whether they have been diagnosed with mental illness.

Assessing the risk of suicidality in pregnant women

There is certainly room for more research on maternal suicide in Australia. One relevant Australian study found that three-quarters of suicides by women within 1 year postpartum were conducted by violent methods. By improving efforts to assess the suicidality of pregnant women, better supports can be provided to reduce the risk of suicide by women, at any stage of pregnancy.