Commentary Maternity and Birthing

In the Conversation About Pregnancy-Related Deaths, Don’t Forget to Talk About Suicide

Katherine L. Wisner

There's more awareness of how many U.S. women die during or after pregnancy, but it's time to include self-harm in both public and private discussions.

When Alexis Joy D’Achille went to a physician to talk about depression after and during her pregnancy, the doctor evaluated her and remarked to her husband that “she is too pretty to kill herself.”

Soon after—and six weeks after giving birth to a daughter—Alexis took her own life in 2013. It’s a story that her husband, Steven D’Achille, told during his keynote address at November’s annual conference of the Perinatal Mental Health Society—and a story that underscores just how much work health-care providers need to do to understand postpartum depression and suicide. After all, you can’t tell how depressed someone is by looking any more than you can check blood pressure by sight.

The pregnancy-related death rate in the United States has steadily increased in the past three decades. And a survey of 2003-2007 statistics from the National Violent Death Reporting System found 94 cases of pregnancy-associated suicide, with most deaths occurring in the first year after birth. But even as there is growing awareness of maternal mortality in the United States, there’s little discussion about these fatalities.

I’ve cared for pregnant women with depression and other mental health conditions across the decades as a professor of psychiatry at Northwestern University. It’s agonizing to witness the impact of these preventable deaths on families and communities.

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Biology and a culture that does not adequately support mothering play a role in postpartum depression and suicide. After giving birth, the mother’s hormone concentrations plunge within a matter of days. This massive drop, initiation of breastfeeding, and the often-challenging adjustment to parenting contribute to the risk for developing depression.

In fact, the most common time for a woman to develop depression in her lifetime is after the birth of a child. One of every seven experiences depression in the first four to six weeks after delivery. This number is staggering—and runs radically counter to the societal perception of maternal bliss.

The American College of Obstetricians and Gynecologists recommends depression screening for all women at least once during the perinatal period, but the majority of childbearing women with depression are neither identified nor treated. Stigma associated with mental illness deters women from accessing care, as does the shortage of both mental health care professionals and perinatal specialists. Limited financial and personal resources to support travel to appointments, co-payments, and lack of insurance also only further exacerbate the problem.

Screening for high blood pressure and diabetes during pregnancy is routine, and so should be the case for depression. Mental health screening and treatment located within obstetrical practices as collaborative care normalizes the process as part of routine pregnancy management. It also conserves resources, is effective (particularly for low-income mothers), and is a model for progress in this field.

Education for health-care professionals is another necessary step. Unfortunately, the education of mental health and obstetrical professionals has lagged behind advances in research, public policy, and innovative models of perinatal mental health care, to the detriment of new mothers and their families.

We must develop new tools like one a Massachusetts hospital recently began offering new mothers: a free iPhone app that aims to help screen for postpartum depression. Whether such an app works as it claims and will be used more widely remains to be seen, but development of this digital tool points to the seriousness and urgency around treating postpartum depression.

Beyond screening, conversation helps. When you congratulate the next new mother you meet, recognize that she has been through a major physical and emotional challenge. When you ask her how she is doing, listen carefully for the emotion behind the response. Remember that one of every seven women has depression that causes difficulty with simply functioning. To be sure, talking with her about being overwhelmed, sad, or anxious can be awkward. But you can validate how difficult physical and emotional recovery from birth can be and how common postpartum depression is.

Tell her that she is not alone, and that she is not to blame. You may save a life.

Women and their loved ones can get support by calling Postpartum Support International at 1-800-944-4773. It is critical for partners, relatives, friends, and health-care professionals to have these conversations with new mothers and, as Steven D’Achille would emphasize, their partners as well.

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