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May 17, 2021 -- Death by suicide or overdose is a leading cause of death for women in the first year after they give birth, a new analysis shows.

Many of these deaths may be preventable, said Adrienne Griffen, who has a master’s degree in public policy and is executive director of the Maternal Mental Health Leadership Alliance.

Griffen discussed these findings and ways health care providers may be able to help at the 2021 virtual meeting of the American College of Obstetricians and Gynecologists.

Women “visit a health care provider an average of 25 times during a healthy pregnancy and first year of baby’s life,” she said. “Obstetric and primary care providers who serve pregnant and postpartum women are uniquely positioned to intervene effectively to screen and assess women for mental health disorders.”

To that end, doctors and other health care professionals should discuss mental health “early and often,” Griffen said.

“Asking about mental health issues and suicide will not cause women to think these thoughts,” she said.

“We cannot wait for women to raise their hand and ask for help because by the time they do that, they needed help many weeks ago.”

Obstetric providers can explain to patients that they will check on their mental health every visit, just as they do with their weight and blood pressure, Griffen said.

For example, a doctor might tell a patient: “Your mental health is just as important as your physical health, and anxiety and depression are the most common complications of pregnancy and childbirth,”

Griffen suggested. “Every time I see you, I’m going to ask you how you are doing, and we’ll do a formal screening assessment periodically over the course of the pregnancy. … Your job is to answer us honestly so that we can connect you with resources as soon as possible to minimize the impact on you and your baby.”

Although the OB-GYN should introduce this topic, a nurse, lactation consultant, or social worker may conduct screenings and help patients who are experiencing distress, she said.

During the past decade, several medical associations issued new guidance around screening new mothers for anxiety and depression. One recent ACOG committee opinion recommends screening for depression at least once during pregnancy and once after birth, and encourages doctors to initiate medical therapy if possible and provide resources and referrals.

Another committee opinion suggests that doctors should have contact with a patient between 2 and 3 weeks after birth, primarily to assess for mental health

Limited data

In discussing maternal suicide statistics, Griffen focused on data from Maternal Mortality Review

Committees, which are state-based and include experts from different fields who study all deaths among women within one year after they give birth.

Two other sources of data about maternal mortality – the National Vital Statistics System and the Pregnancy Mortality Surveillance System – do not include information about suicide, which may be a reason this cause of death is not discussed more often, Griffen noted.

Mortality review committees, on the other hand, include information about suicide and self-harm. About half of the states in the United States have these multidisciplinary committees. Members consider a range of clinical and nonclinical data, including reports from social services and police, to try to understand the circumstances of each death.

A 2019 report that examined pregnancy-related deaths using data from 14 U.S. states between 2008 and 2017 showed that mental health conditions were the leading cause of death for non-Hispanic white women. In all, 34% of pregnancy-related suicide deaths had a documented prior suicide attempt, and the majority of suicides happened in the late postpartum time frame (43-365 days after giving birth).

Some doctors point to a lack of education, time, reimbursement, or referral resources as barriers to maternal mental health screening and treatment, but there may be useful options available, Griffen said. Postpartum Support International provides resources for doctors , as well as mothers. The National Curriculum in Reproductive Psychiatry and the Seleni Institute also have educational resources.

Some states have mental health programs, where psychiatrists educate obstetricians, family doctors, and pediatricians about how to assess for and treat maternal mental health issues, Griffen said.

Self-care, social support, and talk therapy may help patients. “Sometimes medication is needed, but a combination of all of these things … can help women recover from maternal mental health conditions,” Griffen said.

Need to intervene

Although medical societies have emphasized the importance of maternal mental health screening and treatment in recent years, the risk of self-harm has been a concern for obstetricians and gynecologists long before then, said Marc Alan Landsberg, MD, a member of the meeting’s scientific committee who moderated the session.

“We have been talking about this at ACOG for a long time,” Landsberg said in an interview.

The presentation highlighted why obstetricians, gynecologists, and other doctors who deliver babies and care for women after birth “have got to screen these people,” he said. The finding that 34% of regnancy-related suicide deaths had a prior suicide attempt indicates that doctors may be able to identify these patients, Landsberg said. Suicide and overdose are leading causes of death in the first year after delivery and “probably 100% of these are preventable,” he said.

As a first step, screening may be relatively simple. The Edinburgh Postnatal Depression Scale, highlighted during the talk, is an easy and quick tool to use, Landsberg said. It contains 10 items and assesses for anxiety and depression. It also specifically asks about suicide.