Volume 187 - Issue 8
Maternal mortality and psychiatric morbidity in the perinatal period
Authors: Phillip M Boyce and Jodi Barton
Med J Aust 2007; 187 (8): 474-476. || doi: 10.5694/j.1326-5377.2007.tb01367.x
Published online: 15 October 2007
Published online: 15 October 2007
To the Editor: Austin et al1 bring to our attention findings from the report on maternal deaths in Australia in which 26 suicides were reported, making it one of the leading causes of indirect maternal deaths in the perinatal period — a finding consistent with the Confidential Enquiries into Maternal Deaths report from the United Kingdom.2 These reports raise the issue of the importance and risk of maternal mental illness in the perinatal period.
While this high rate of suicide is unacceptable, it needs to seen in context: this is a rare event overall, representing a standardised mortality ratio of 1.14 per 100 000 women. This is considerably lower than the suicide rate for women in general, which ranges from 3.6 per 100 000 in the 15–19-year age group to 6.4 per 100 000 in the 25–29-year age group.2,3 This comparison verifies the observation made by Appleby that suicide rates are low during the perinatal period.4
Austin et al recommend that psychosocial screening, in conjunction with ongoing mental health monitoring and clear referral pathways, should be made available to women in a maternity setting as part of the solution to preventing the “relatively high” rate of early maternal suicide. But to date, antenatal screening programs have proven costly to implement, can produce large numbers of false positives, are often poorly accepted by antenatal care providers (as they add to the administrative burden), and do not result in greater uptake of services by at-risk women.5
Remarkably, 40% of the suicides reported by Austin et al occurred in the first trimester, predominantly before women had attended an antenatal clinic and before any psychosocial screening. A number of the suicide cases were already under the care of mental health services, and screening may not have prevented the tragic outcomes.
We believe the answer to this problem is for appropriately resourced, accessible and publicly funded specialised perinatal psychiatric services to be put in place (including dedicated mother and baby units) so that high-risk women can be appropriately treated. In providing such services, we would need to develop appropriate strategies to engage mothers who need support from psychiatric services. This concurs with the National Institute for Health and Clinical Excellence perinatal mental illness guidelines,6 which advocate for the identification of pertinent risk factors (such as personal and familial mental health history) and assessment of current distress (through targeted interviewing). Screening is recommended to monitor outcomes but not to dictate clinical decision making.
References
- Austin M-P, Kildea S, Sullivan E. Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Med J Aust 2007; 186: 364-367. 0_CBBCFAHB
- National Institute for Clinical Excellence; Scottish Executive Health Department; Department of Health, Social Services and Public Safety, Northern Ireland. Why mothers die 1997–1999. Fifth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: Royal College of Obstetricians and Gynaecologists, 2001. http://www.cemd.org.uk/reports/cemdrpt.pdf (accessed Sep 2007).
- Australian Bureau of Statistics. Suicides, Australia, 2005. Canberra: ABS, 2007. (ABS Cat. No. 3309.0.) 0_CBBFIHBJ
- Appleby L. Suicidal behaviour in childbearing women. Int Rev Psychiatry 1996; 8: 107-115. 0_pgfId-1430248
- Buist A, Bilszta J, Milgrom J, et al. The beyondblue National Postnatal Depression Program. Prevention and early intervention 2001–2005. Final report. Melbourne: beyondblue, 2006: 24-25. 0_CBBCBEIE
- National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinical management and service guidance. London: NICE, 2007. http://guidance.nice.org.uk/CG45/niceguidance/pdf/English (accessed Sep 2007).