Research in context
Evidence before this study
We aimed to inform suicide prevention strategies in the perinatal period (during pregnancy and in the first postnatal year) by comparing the characteristics of women who died by suicide within and outside the perinatal period for women who had been in recent contact with UK psychiatric services. We searched MEDLINE for reviews and peer-reviewed articles published between Jan 1, 1990, and Oct 25, 2015, with evidence of the extent or risk factors for perinatal suicide in the general population and in psychiatric patients. Our search terms were (suicide or Suicide/) and (pregnancy or antenatal or postnatal or perinatal or maternal or Pregnancy/ or Perinatal Death/ or Perinatal Mortality/ or Maternal Mortality/). We also reviewed all available publications from the UK Confidential Enquiries into Maternal Deaths. Most studies used general population data and reported that suicide rates during pregnancy and the postnatal period were about two to three times lower than age-adjusted rates in non-perinatal women, in both high-income countries and low-income and middle-income settings. The proportion of maternal deaths attributable to suicide in most studies ranged from roughly less than 1% to 5% in low-income and middle-income countries (Fuhr DC, et al, 2014) and from 3% to 13% in high-income countries (as reported in studies from Europe, North America, and Australia). Few studies examined risk factors for maternal suicides. Reported risk factors included mental illness (present in 30–70% of maternal suicides), substance misuse, intimate partner violence, neonatal complications (particularly perinatal death), and medical comorbidity. Associations with age and socioeconomic status differed by setting and timing of suicide, with teenagers reported to have a higher risk of pregnancy suicide than women of other ages, especially in low-income and middle-income countries.
We identified one study of psychiatric patients, which investigated suicide rates in women admitted to a psychiatric hospital in the first postnatal year in Denmark over a 21 year period. This study reported that 0·9% of the women died by suicide in the first postnatal year (a 70 times higher risk than women in the general population) and 3·3% died by suicide over the whole study period (a 17 times higher risk). These findings suggest that the post-partum period, which is protective against suicide in the general population, is a high-risk period for women with severe post-partum mental illness. Qualitative evidence from maternal death inquiries suggest that mental illness is often undetected in perinatal women who die by suicide and, when detected, is often suboptimally managed, but these findings have not been investigated quantitatively. We did not find other evidence of the characteristics or risk profile of psychiatric patients who die by suicide in the perinatal period.
Added value of this study
This study is one of the largest case series of perinatal suicides among women in contact with psychiatric services, and uniquely compares sociodemographic and clinical characteristic of patients who died by suicide within and outside the perinatal period. We reported that women in contact with psychiatric services who died by suicide in the perinatal period were more likely to be young and married, and to have shorter mental illness duration and no history of alcohol misuse, than were those who died outside that period. Almost half of perinatal women had a diagnosis of depression (compared with a third of non-perinatal women) and a fifth had a diagnosis of schizophrenia or personality disorder; a quarter had a history of self-harm. A substantial minority were not receiving any active treatment or follow-up at the time of death. About three-quarters of women who died by suicide in the perinatal period used a violent suicide method (possibly indicating severe illness and serious intent).
Implications of all the available evidence
In the general population, suicide in the perinatal period is less common than at other times in a woman's life, but this protective effect might not apply to women in contact with psychiatric services (ie, those with severe mental illness), who might have a particularly high suicide risk in the first postnatal year. Women who die by suicide in the perinatal period are more likely to have a brief illness and depression diagnosis, and are less likely to be receiving active treatment, than are women who die by suicide outside this period. Clinicians should be aware that women with severe perinatal depression in particular are a group at risk of suicide who need careful monitoring and treatment.