Suicide, Overdose Are Significant Contributors to Pregnancy-Related Maternal Deaths
Abstract
Preventable maternal deaths associated with psychiatric illness occur predominantly in the postpartum period and often in the period after the standard six-week postpartum obstetric visit.
Suicide, drug overdose, and mental illness are significant and preventable contributors to maternal pregnancy–related deaths, said psychiatrists at a workshop on perinatal maternal mortality during the virtual annual meeting of the Academy of Consultation-Liaison Psychiatry.
“The United States is the only high-income nation in the world with an increasing maternal mortality rate,” said James Levenson, M.D., a professor of psychiatry at the Virginia Commonwealth University. “The most recent data found that mental health causes, including suicide and drug overdoses, accounted for nearly 9% of maternal mortality. Overall, mental health conditions are on a par with hypertensive crisis and postpartum hemorrhage as causes of maternal mortality. And that doesn’t even account for the indirect effects of mental disorders increasing the risk of many medical causes of death.”
MMRCs Need the Expertise of Psychiatrists
Maternal Mortality Review Committees need the expertise of psychiatrists and mental health professionals.
That’s what Christina Wichman, D.O., a professor of psychiatry and behavioral medicine and obstetrics and gynecology at the Medical College of Wisconsin, said during a workshop on perinatal mortality and mental health at the virtual annual meeting of the American Academy of Consultation-Liaison Psychiatry.
An MMRC is a multidisciplinary committee convened at the state level to review deaths of mothers during or one year after pregnancy. “We reflect on and recognize the maternal lives that were lost, review all the factors that contributed to mortality, and identify public health and clinical interventions at the family or individual level, the community level, or in the health care system.”
MMRCs investigate each death brought before it, asking the following questions:
Was the death pregnancy related?
What was the cause of death? (Not uncommonly, the cause as determined by the MMRC is different from the cause listed on the death certificate.) Was it preventable?
What are the factors contributing to that death?
What recommendations can be made to address those factors?
What is the anticipated impact if those recommendations are applied?
She said that a wide variety of professionals are included in MMRCs, but until recently mental health has not been well represented. Many deaths stemming from mental illness or substance use disorders may not be tagged as “preventable” unless there are knowledgeable professionals on the committee.
“It is really important to have a robust [diversity of disciplines] to understand how prevention can happen at multiple points of care. We know that the perinatal period is often associated with the first onset of mental illness, and psychiatric illness is under- or misdiagnosed in this period. Involvement of mental health professionals on these committees is really important.”
Perinatal psychiatrists presented data from the Centers for Disease Control and Prevention (CDC) on the contribution of mental illness and substance use disorders to maternal mortality and state-level data from Maternal Mortality Review Committees (MMRCs) in Massachusetts and Washington. MMRCs are multidisciplinary committees charged with looking at cases of maternal death, determining causes and contributing factors, and developing recommendations to prevent deaths (see box).
Speakers agreed that pregnancy-related deaths stemming from mental illness or substance use disorders are almost always preventable. And the speakers especially emphasized that MMRCs need the participation of psychiatrists and that mothers’ mental health should be a factor in determining optimal perinatal care.
Levenson said, “Maternal mortality conversations are evolving to consider physical and mental causes of maternal death, leading to widespread recommendations that mental health professionals be integrated into obstetric care.”
Mental Health–Related Pregnancy Deaths Are Preventable
Overall, the CDC estimates that 700 mothers die every year from complications related to pregnancy or delivery. Nancy Byatt, D.O., M.S., an associate professor of psychiatry and obstetrics-gynecology at the University of Massachusetts Medical School, presented preliminary findings from the CDC’s Maternal Mortality Team, which aggregated data from 14 state MMRCs on 1,259 cases of maternal death between 2008 and 2017; of those, 453 were determined to be “pregnancy related” (occurring within one year of pregnancy from a pregnancy complication, a chain of events initiated by the pregnancy, or aggravation of an unrelated condition by the physiologic effects of the pregnancy).
Nancy Byatt, D.O., M.S., says all of the maternal deaths related to psychiatric illness between 2008 and 2017 were deemed preventable. “We absolutely cannot address maternal and child health or decrease maternal mortality unless we address mental health.”
In an analysis looking at the contribution of mental illness and substance use disorders, the team looked at data on divorce, domestic violence reports, history of incarceration, involvement of child protective services, unintended pregnancy, miscarriage, and medication instability (defined as inconsistent or terminated use of prescribed medications).
Among the 453 pregnancy-related deaths, 46 were deemed to be mental health related, including deaths by suicide (63%), nonsuicidal overdoses (24%), or other mental health–related causes or injury of unknown intent (13%).
Timing of deaths appears to be crucial: 20% of deaths occurred during pregnancy, while 15% occurred within 42 days of pregnancy and 65% occurred between 42 days and one-year postpartum. “This finding speaks to the importance of a fourth trimester approach to perinatal care and following women longer after pregnancy,” Byatt said. “It also speaks to the importance of screening in pediatric settings.”
In 2018, the American College of Obstetrics and Gynecology called for a “new paradigm” of postpartum care as an ongoing process, rather than the standard single encounter at six weeks. Likewise, the American Academy of Pediatrics (AAP) recommends that primary care pediatricians screen mothers for depression at children’s one- , two- , four- , and six-month well visits.
Integrating C-L Psychiatry Into Perinatal Care
In Massachusetts, Leena Mittal, M.D., director of women’s mental health at Brigham and Women’s Hospital in Boston, reported similar patterns in maternal deaths associated with mental illness. There, the state MMRC found that the pregnancy-associated mortality rate increased 33% from 2012 to 2014, from 30.4 deaths per 100,000 to 40.4 per 100,000.
Sixty-nine deaths associated with pregnancy occurred during that period, 35 of which occurred in women with a documented mental health diagnosis. In the majority of those (91.4%), the diagnosis was documented prior to pregnancy, indicating opportunities for prevention by prenatal and primary care physicians.
Diagnoses included depressive, anxiety, bipolar, and posttraumatic stress disorders as well as a history of postpartum depression.
Mittal highlighted in particular the sharp increase in substance abuse–related deaths among mothers in the perinatal period. The proportion of pregnancy-associated deaths related to substance use rose dramatically from 8.7% in 2005 to 41.4% in 2014.
“Treatment for opioid use disorder can really save lives, driving down mortality and a preventable cause of maternal mortality,” she said.
Mittal also echoed other speakers in noting the need for wider prenatal screening for mental illness and substance use disorders of women who are minority members to address racial and ethnic disparities in perinatal care. She said attention to those disparities has been a core focus of the Massachusetts MMRC.
This attention has helped the MMRC develop broad population and public health recommendations for change, as well as recommendations at the clinical level to reduce racial disparities in perinatal and mental health care.
In Washington state, Amritha Bhat, M.D., M.P.H., an assistant professor in the Department of Psychiatry and Behavioral Science at the University of Washington, said the MMRC used data reflecting similar trends and problems in perinatal care to derive broad recommendations for preventing perinatal maternal death and deaths associated with mental illness and substance use disorders.
These were broken down further into specific recommendations for perinatal professionals and health systems—such as developing policies and practices for a phone call to all patients a day or two after delivery, seeing patients throughout the year following delivery, and ensuring a “warm hand-off” to primary care at the end of the perinatal period.
“We know maternal mortality is just the tip of the iceberg [as an indicator of the quality of maternal health care],” she said. “If we try to understand the issues surrounding these deaths, we won’t just be preventing maternal mortality but improving maternal care overall.” ■
