The Committee notes that … suicide has become one of the leading causes of maternal death in Australia. – The Obstetrics Clinical Committee, report to the Medicare Benefits Schedule Review, August 2016.
The federal government’s Medicare Benefits Schedule review is well underway. Teams of clinicians are looking at more than 5,700 items on the Medicare Benefits Schedule (MBS) to see if health services are up to date and in line with the latest clinical evidence.
In its report for the review, the Obstetrics Clinical Committee called for changes aimed at ensuring more women were screened for perinatal (meaning the period just before and after birth) anxiety and depression by suitably qualified health professionals.
The committee said suicide has become one of the leading causes of maternal death in Australia.
Is that right?
Checking the source
Obstetrics is the branch of medicine and surgery that specialises in the care of women before, during and after childbirth. The Obstetrics Clinical Committee is a group of 11 experts commissioned by the federal government to review the obstetrics items on the MBS and report on their findings.
When asked for data to support the assertion, the committee’s chair Professor Michael Permezel referred The Conversation to the Australian Institute of Health and Welfare report Maternal deaths in Australia 2008-2012.
Is suicide a leading cause of maternal death?
Yes. The Australian Institute of Health and Welfare (AIHW) produces the best data on this question.
Its latest report on the issue, which was the one the committee cited, was released in 2015 and covers the years 2008 to 2012. It shows that suicide is one of the leading causes of maternal death in Australia. If late maternal deaths are included, it is the leading cause.
When we’re talking about this issue, it’s important to distinguish between “maternal death” and “late maternal death”:
- Maternal death is when a woman dies in pregnancy or within 42 days after the end of any pregnancy
- Late maternal death is when a woman dies within 12 months of the end of any pregnancy.
In Queensland, suicide is the leading cause of death for women during pregnancy and within 12 months of the end of a pregnancy. Suicide was the leading cause of maternal death in New Zealand between 2006 and 2013, and remains a leading cause today.
Suicide is uncommon during pregnancy – it occurs more frequently when a pregnancy is over. Recent investigations have revealed a high proportion of late maternal deaths are linked to preexisting mental health disorders and what clinicians call “psychosocial distress”. Psychosocial distress is a broad term that covers depression, stress and dissatisfaction with life.
There are standard definitions used worldwide to describe the type, or category, of maternal death:
- Direct deaths – those directly attributable to the pregnancy, for example, post-partum bleeding
- Indirect deaths – when preexisting conditions, such as heart disease, are exacerbated by pregnancy
- Incidental deaths – are not usually related to pregnancy, for example, accidents.
Suicide, homicide and deaths related to mental health, such as accidental overdose, are described as being due to “psychosocial causes”.
The World Health Organizationrecently recommended that deaths from psychosocial causes be categorised as “direct deaths” – directly attributable to the pregnancy. This recommendation has not yet been widely adopted.
In Australia, death by suicide is usually categorised as an “indirect” death if there is evidence the mother had a preexisting mental health condition.
Some international reports continue to class deaths by suicide and other psychosocial causes as “incidental” – not related to pregnancy. This means they don’t count towards the maternal mortality ratio, which is the international measure of the number of women dying during pregnancy or within 42 days of a pregnancy ending.
How many deaths are we talking about?
The latest AIHW report on the issue notes:
Maternal death in Australia is a rare event in the context of worldwide maternal deaths. In 2008–2012, there were 105 maternal deaths in Australia that occurred within 42 days of the end of pregnancy, representing a maternal mortality ratio (MMR) of 7.1 deaths per 100,000 women who gave birth.
The AIHW data show there were 16 deaths in the psychosocial causes category, of which 12 were due to suicide. Death by psychosocial causes ranked equal first with heart disease. Death by suicide ranked equal second with sepsis, obstetric haemorrhage and non-obstetric haemorrhage.
Australian state and territory data also show suicide to be a prominent feature in maternal death. The latest report by the Queensland Maternal and Perinatal Quality Council reported on 40 maternal deaths – including late maternal deaths – over 2013 and 2014.
Out of these 40 deaths, 12 (28%) were due to psychosocial causes – making it the largest category. Overall, suicide was the leading cause of maternal death in Queensland in 2013-14.
The most recent report from New Zealand shows a similar picture. Between 2006 and 2013, 24% of maternal deaths were due to suicide. That’s 22 women out of 90 who died by suicide during pregnancy or within 42 days of their pregnancy ending.
What don’t we know?
What is unknown is the nature of the relationship between pregnancy and suicide. Not all pregnancies are diagnosed or recorded, especially if a woman is early on in her pregnancy when she dies by suicide.
Despite efforts to capture all deaths in pregnancy and in the postpartum period, experts still don’t know yet the full story. To gain a full understanding of the impact of pregnancy on suicide risk, we would need to compare the suicide rates for women who were or had recently been pregnant, and those who had not.
The Obstetrics Clinical Committee was correct to say suicide is one of the leading causes of maternal death in Australia. If late maternal deaths are included in the analysis, it is the leading cause. – David Ellwood.
I have reviewed this article and the author presents a fair and accurate view of the data.
A paper my colleagues and I published in 2013 showed that of the women who died by suicide and trauma in Australia between 2000 and 2006, 67% had a mental health condition, and/or a condition related to substance abuse.
We reported a notable peak in deaths from suicide and trauma from nine to 12 months after the end of pregnancy when compared to deaths in the first three months after the end of a pregnancy. The World Health Organization wants to see more emphasis placed on this issue and clearer identification of deaths by suicide up to one year after the pregnancy ends.
We may be underestimating the numbers of late maternal deaths by suicide. If Australia follows the WHO recommendation to classify more deaths by suicide as directly attributable to pregnancy, we would likely see the numbers rise. – Hannah Dahlen
If this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 44.
David Ellwood is Chair of the Queensland Maternal and Perinatal Quality Council, and a member of the National Maternal and Mortality Advisory Group. He is Deputy Head of School (Research) at Griffith University School of Medicine and Director of Maternal-Fetal Medicine at Gold Coast University Hospital.
Hannah Dahlen has received funding from the NHMRC and the ARC. She is the national spokesperson for the Australian College of Midwives.
Authors: David Ellwood, Professor of Obstetrics & Gynaecology, Griffith University