The contribution of suicide to maternal mortality: A nationwide population-based cohort study

Objective: To identify the incidence and characteristics of maternal suicide. Design: Nationwide population-based cohort study. Setting: The Netherlands, 2006-2020. Population: Women who died during pregnancy or within 1 year postpartum, and a reference population of women aged 25-45 years. Methods: The Cause of Death Register and Medical Birth Register were linked to identify women who died within 1 year postpartum. Data were combined with deaths reported to the Audit Committee for Maternal Mortality and Morbidity (ACMMM), which performs confidential enquiries. Maternal suicides were compared with a previous period (1996-2005). Risk factors were obtained by combining vital statistics databases. Main outcome measures: Comparison of incidence and proportion of maternal suicides among all maternal deaths over time, sociodemographic and patient-related risk factors and underreporting of postpartum suicides. Results: The maternal suicide rate remained stable with 68 deaths: 2.6 per 100 000 live births in 2006-2020 versus 2.5 per 100 000 in 1996-2005. The proportion of suicides among all maternal deaths increased from 18% to 28%. Most suicides occurred throughout the first year postpartum (64/68); 34 (53%) of the women who died by suicide postpartum were primiparous. Compared with mid-level, low educational level was a risk factor (odds ratio 4.2, 95% confidence interval 2.3-7.9). Of 20 women reported to the ACMMM, 11 (55%) had a psychiatric history and 13 (65%) were in psychiatric treatment at the time of death. Underreporting to ACMMM was 78%. Conclusions: Although the overall maternal mortality ratio declined, maternal suicides did not and are now the leading cause of maternal mortality if late deaths up to 1 year postpartum are included. Data collection and analysis of suicides must improve.