Near-Miss Suicide in Pregnancy

Key Points

  • Mental illness is a leading cause of maternal mortality in the UK.
  • The largest proportion of maternal deaths result from suicide.
  • Antenatal suicide attempts occur less frequently than postnatal attempts although they clearly increase risk of harm to the fetus.
  • There are currently no studies that have explored near miss suicides during pregnancy despite it becoming increasingly recognised that studying near miss events can provide important additional information to guide prevention strategies of rare events.

Surveillance Period

1st May 2018 – 30th April 2019

Background

Mental illness is estimated to affect one in ten pregnancies and, in the UK, has persistently been found to be a leading cause of maternal mortality1, 2. Although maternal deaths are rare (8.8 per 100,000 maternities)1, recent confidential enquiries into maternal mortality found that almost one in five women who died during birth had a mental illness and almost a quarter of those who died in the postnatal period died from mental health related causes3. Among this group of women the largest proportion of deaths resulted from suicide; In the UK and Ireland there was a rate of 2.3 deaths by suicide during or up to one year after the end of pregnancy per 100,000 maternities between 2009-133.

It is becoming increasingly recognised that studying near miss events (or life-threatening situations) can provide important additional information to guide prevention strategies of rare events4, however no previous studies have explored near miss suicides during pregnancy. Three quarters of maternal suicides occur during the postnatal period, making suicides during the antenatal period a rare event3. There is also evidence to suggest that suicide attempts may occur less frequently during pregnancy than following birth, although robust incident figures are not currently available.

Antenatal suicide attempts also increase the risk of potential harm to fetal development, particularly in the case of drug overdoses during pregnancy which can have teratogenic or fetotoxic effects5. However, no national data on near miss suicides during pregnancy exists, and very little is known about the epidemiology, neonatal outcomes, warning signs or clinical management proceeding and following a near miss suicide event during pregnancy within the UK. Finding ways to recognise and respond appropriately to women at particular risk signifies a key public health goal. Current insufficient research in this area is likely to limit efforts to effectively identify women at high risk of suicide and prevent further tragedies in the future.

Objective

To use the UK Obstetric Surveillance System to determine the incidence and management of near miss suicides (i.e. self-inflicted injury or poisoning, requiring admission to a general hospital for level 2 or 3 critical care or a liver unit) during pregnancy.

Research questions

  • What is the incidence of near miss suicides during pregnancy in the UK?
  • What are the circumstances of the near miss suicide events (e.g. methods, timing and nature) and individuals’ characteristics (.e. socio-demographic, diagnostic status, prescribed medication and prior contact with maternity and mental health services) during pregnancy in the UK?
  • What type of antenatal and mental healthcare do women with near miss suicides during pregnancy receive before and following the near miss event? (e.g. what assessments and treatments were offered, how many women were receiving input from specialist psychiatric teams prior to and following the event)
  • What are the maternal (i.e. level of injury, care plans, and pregnancy and birth outcomes) and neonatal outcomes (i.e. birth outcomes, post-birth care plans) for women with near miss suicides during pregnancy?
  • What are the circumstances and potential warning signs of women with a near miss suicide during pregnancy?

Case definition

Any women with self-inflicted injury or poisoning, during pregnancy, requiring an admission to a general hospital for:

EITHER:            Level 2 critical care (i.e. patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those 'stepping down' from higher levels of care)

OR:                  Level 3 critical care (i.e. patients requiring advanced respiratory support alone or monitoring and support for two or more organ systems. This level includes all complex patients requiring support for multi-organ failure)

OR:                  A liver unit

Funding

This study is funded as part of a King’s Improvement Science Fellowship (funded by King’s Health Partners).

Ethics committee approval

This study has been approved by London – Brent REC (ref. 10/H0717/20)

Investigators

Abigail Easter and Louise M Howard, Institute of Psychiatry, Psychology and Neuroscience London,

Jane Sandall, Department of Women and Children’s Health, King’s College London.

References

1.             Knight M, Nair M, Tuffnell D, Shakespeare J, Kenyon S, KurinczukJJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013–15. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2017.

2.             Oates, M., Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British medical bulletin, 2003. 67(1): p. 219-229.

3.             Knight, M., et al., Saving Lives, Improving Mothers’ Care—Surveillance of maternal deaths in the UK 2011–13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. National Perinatal Epidemiology Unit. University of Oxford, 2015.

4.             World Health Organization, Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health, in Geneva: World Health Organization. 2011. p. 29.

5.             Lindahl, V., J.L. Pearson, and L. Colpe, Prevalence of suicidality during pregnancy and the postpartum. Archives of Women’s Mental Health, 2005. 8(2): p. 77-87.