What We Can Do to Prevent Maternal Suicide

Paying more attention to this serious subject can save lives

Editor's note: We know this may be a difficult subject for some readers, but we believe it is important to be open and honest about suicide and how we can prevent it.

Sasha Hettich's family knew she'd been suffering from postpartum depression (PPD) and anxiety. She first experienced symptoms three years earlier, after the birth of her daughter. She'd tried medication, joined a local support group, and spent 10 days at an inpatient treatment facility.

She recovered and was back to her old self for a while, says her husband Cody. Then Sasha got pregnant with the couple's second child in 2014. This time, her depression hit early and hard. "She struggled from May, through the birth of our son in July, all the way up until December," Cody says. "There were days when she was relatively back to normal, but much of the time she was cycling between severe anxiety and severe depression."

Cody fought hard for his wife, suggesting inpatient treatment again and researching other solutions. But even at the worst, he didn't expect Sasha to take her own life.

But on Christmas Day last year, when Sasha didn't return home with the kids, Cody reported her missing. The next morning, police found Sasha and her children, a 3-year-old and a 5-month-old. She'd driven to a field, left her car running, and taken her own life with a gun she'd purchased two weeks earlier. Physically, the children were unharmed. But their lives – and the lives of everyone around them – were changed forever.

Cody is sharing her story with other families in hopes that he can help them in a way he wasn't able to help her.

"I think there's an assumption that people who get PPD are weak, and I try to dispel that myth," he says. "Sasha was such a driven, accomplished, and loving person, and she took that spunk and energy into parenting. When she wasn't affected by depression and anxiety, she was an incredibly capable woman."

He also wants other women and their loved ones to understand how serious PPD symptoms can become. "When you see the signs, you can't hesitate," he says. "Because it can get really bad, really fast. This is a genuine medical condition, and you need to seek help for it, just like you would if someone you loved was having a heart attack. I don't think enough people think of it like that."

What we know about maternal suicide

Suicide is "the thing that we fear the most when we're taking care of a mother with a perinatal mood disorder," says Samantha Meltzer-Brody, MD, MPH, director of the perinatal psychiatry program at the University of North Carolina. "Thankfully it's very rare, but when it does happen, it is incredibly devastating."

Most new moms, even those with mood disorders, do not take their own lives. Studies have shown that the suicide rate among mothers in the first year after birth is actually lower than that of the general population. But because young women don't die from other conditions very often, suicide ranks as one of the top causes of maternal death.

The phrase "one of the top causes" is indicative of a problem here in the United States, says Katherine Stone, founder and CEO of the national nonprofit organization Postpartum Progress, Inc. Because suicides aren't always tracked the way other deaths are, the numbers are hard to pin down.

One National Institutes of Health study from 2005 found that suicide is the cause in up to 20 percent of postpartum deaths. When it comes to ranking that with other causes, however, research is sparse and results are mixed.

The Centers for Disease Control and Prevention (CDC) tracks pregnancy-related deaths for up to one year after birth, but suicide is not included in those rankings because it is considered an indirect cause of death (not related to pregnancy). Top causes include such conditions as noncardiovascular disease, cardiovascular disease, infection, and hemorrhage. 

The CDC does track suicides by age group and gender but does not differentiate between women who are mothers and those who are not. What those statistics do show, however, is that suicide is a leading cause of death among women of childbearing age. (It's the second most common cause for women ages 15 to 24, third for those ages 25 to 34, and fourth for women ages 35 to 44.) And suicide rates are up for women of all ages, adds Meltzer-Brody.

"If nothing else, this speaks to the fact that women in this country are clearly very stressed, and depression is quite common," she says. "As a society, we are not doing a good job delivering adequate mental health care."

According to data from other countries, that applies especially to mothers who may be struggling after the birth of a child. A 2015 British study found that suicide accounted for the cause of death 1 in 10 women who died up to a year after giving birth. And while maternity-related deaths in the United Kingdom have declined overall, there has been no such drop in "indirect" causes, such as those tied to a mental illness. Researchers in Denmark and Australia have come to similar conclusions in recent years. 

One recent study has shed some light on the problem in the United States: In 2014, Colorado's Maternal Mortality Prevention Program reviewed the deaths of all 211 women who died in the state during pregnancy and up to one year after giving birth, from 2004 to 2012. In this study, suicide was the third leading cause, after accidental drug overdose and automobile accident, and just before cardiovascular causes.

Who is most at risk?

Meltzer-Brody says a small percentage of women who take their own lives have postpartum psychosis, a condition with symptoms that can include delusions, hallucinations, and paranoia. But thankfully, she says, it's a very rare condition, occurring in only about 1 to 2 out of every 1,000 births. And even among women with postpartum psychosis, only an estimated 5 percent commit suicide. Many others never have violent thoughts or visions, and do not harm themselves or others.

Other perinatal mood and anxiety disorders, such as PPD and postpartum anxiety, are much more common. And according to a 2016 Danish study, women with these conditions are at increased risk of suicide within the first 12 months of giving birth, compared to women who don't have a diagnosed mood disorder.

Research from the United Kingdom suggests that women who commit suicide in the year after giving birth are more likely to have been diagnosed with depression (or with other psychiatric disorders, such as schizophrenia, bipolar disorder, or anxiety) than those who commit suicide outside of the perinatal period. They were also less likely to be receiving treatment at the time of their death.

The severity and timing of a woman's symptoms may also play a role. A 2016 study found that depression that starts during or before pregnancy (like Sasha Hettich's second experience) may be more severe because it is likely to go undiagnosed until after the baby is born. That's why doctors should screen for prenatal depression as well as postpartum depression, says study author Dorothy Sit, MD, and it should be considered a risk factor for more severe PPD. 

What we need to do

Maternal suicide needs to be taken seriously in the United States as a cause of death, says Stone. "As a country, we only seem to be concerned with the obstetric, physical causes, and that's not acceptable," she says. "I'm so frustrated by the number of maternal-child health programs out there – the conferences, the fundraising events – that focus on maternal mortality but give suicide either just a token mention or don't cover it at all."
Keeping better track of suicide deaths won't be easy, Stone acknowledges. In cases such as drug overdoses or car crashes, it's not always clear if someone's death was intentional or accidental.

But that's not a good enough excuse, she says. "We have to keep raising our voices, and I think we have to be a little more forceful," she says. "The squeaky wheel gets the grease, and I'm not sure we're being loud enough yet."

Barriers to treatment need to be overcome as well. People don't seek help for mental health disorders for many reasons, says Meltzer-Brody. For example, they may not be able to afford it, don't live near a provider, don't recognize their symptoms, or are afraid of being judged. A new mother may be worried that her baby will be taken away from her.

"We have to continue to destigmatize mental illness and get the word out that when people are really depressed and are having thoughts of ending their life, treatment can make a huge difference and change the way they view the world," she says. "We talk about all sorts of complications related to pregnancy that can lead to death, yet we want to tiptoe around this one."

"The numbers aren't huge," she says. "But whatever the numbers are, they matter. And we need to let mothers know that if they do find themselves in a position where they are thinking about suicide, they're not alone and there are things they should do."

What to do if you or a loved one is struggling

The first thing moms should do, Stone says, is talk to a healthcare provider and seek out additional help. "That might mean therapy, or it might mean medication," she says. "It might mean nothing because you really just had one bad moment. The point is to make the call, even if you have no specific plans to carry out those thoughts. Every mother is worthy of support."

Meltzer-Brody says people need to understand that suicide is a legitimate risk for women suffering from perinatal mood or anxiety disorders. "Anyone who experiences suicidal thoughts needs to take them extremely seriously and get help," she says, "and family members need to recognize that any time a woman is voicing these thoughts it is an emergency situation."

Although it can be difficult to broach the topic of suicide with someone you are concerned about, research findings and clinical experience both show that doing so actually reduces the risk that the person will follow through and take action to harm themselves, says Christiane Manzella, clinical director of the Seleni Institute.

Manzella stresses the importance of putting plans in place to support a pregnant woman who has had a perinatal mood or anxiety disorder (PMAD) in the past. "In a subsequent pregnancy, there's a risk for depression and anxiety. And therapy can be profoundly helpful because if depression or anxiety develops, she has a place to share her concerns and recognize that she is not alone.” Also, professional mental health support can reduce the likelihood that a woman will experience a PMAD again, lessen the severity of another episode, and lower the likelihood that she will develop lifelong anxiety or depression.

Regardless of whether a woman has been diagnosed with depression or anxiety, the warning signs are the same, says Meltzer-Brody. "The one thing any suicidal person would have in common is that they are beginning to feel hopeless, like they can't go on anymore," she says. "They start having thoughts of ending their life. At that point, it doesn't really matter what your other symptoms are. It needs to be a [signal] that they need treatment right away."

New government recommendations that all pregnant and postpartum women be screened for depression will hopefully identify more women at risk for suicide, says Meltzer-Brody. All depression questionnaires ask about suicidal ideation, she says, and any woman who checks that box should be referred for a comprehensive mental health evaluation.

Women with mild to moderate perinatal mood or anxiety disorders can often be treated successfully as outpatients, says Meltzer-Brody. This may include medication, talk therapy, or a combination of both. But for more serious cases, including those who are considering or have attempted suicide, an inpatient facility – like the Center for Women's Mood Disorders at UNC – may be a better option.

Regardless of the severity of a mother's symptoms, she should be encouraged to talk to her doctor at the first sign of mental health disorder, says Meltzer-Brody.

Stone agrees. "Maternal suicide means the loss of a life, which is bad enough, but then there's also a lifelong trauma for the children involved," she says. "In that sense, it's a tragedy times two, and a totally preventable one."