Maternal Mortality May Be Even Higher Than We Thought
Recent studies have documented steep increases in maternal deaths, opioid overdoses, and postpartum depression in the United States, but according to a new report from Columbia University researchers, these trends are closely connected.
Maternal mortality has more than doubled in the United States since 1990, to an estimated 18 per 100,000 births, and the United States has the highest rate among wealthier nations.
But the rate may be even higher if deaths from suicide and accidental overdoses are counted, according to a new report from Columbia University, where researchers say that rising rates of opioid use, depression, and maternal mortality are closely connected.
“Most estimates of maternal mortality only report deaths caused by complications of childbirth, such as stroke, preeclampsia, or hemorrhage,” says Kimberly Mangla, MD, a reproductive psychiatrist at Columbia University Vagelos College of Physicians and Surgeons, who wrote the review with Columbia medical psychologist Catherine Monk, PhD. “Yet pregnancy does not protect against depression and substance abuse, and the postpartum period has been identified as a particularly vulnerable time. Some studies in other countries suggest maternal suicide is much more common than previously thought and even a leading cause of death.”
Mangla recently spoke with the CUIMC Newsroom about why self-harm as a cause of maternal death has been largely ignored—and what physicians can do to prevent it.
How many maternal deaths are due to suicide or drug use?
We don’t really know. One of the reasons we don’t have good estimates is because there’s no national registry or database of suicide and overdose deaths that records pregnancy status. It wasn’t until 2003 that CDC first recommended that states add a pregnancy status checkbox to death certificates, but inclusion of the checkbox is voluntary, so we don’t have data from all states.
A few recent studies at the state and city level have tried to estimate the rate using data from multiple sources—police reports, treatment records for substance abuse or mood disorders, and information about the survival of the fetus. These studies estimate rates between 14% and 30% of reported maternal deaths, depending on the location.
We desperately need better, more reliable data. This would require accurate reporting of pregnancy status on death certificates and consideration of autopsy findings or other diagnostic tests to determine cause of death in this population.
Why have suicide and accidental overdose among new mothers gone under the radar?
There’s a lot of pressure in our society for mothers to be perfect and happy. They are reluctant to share their difficulties, particularly when they are struggling with an already stigmatized illness such as depression.
And as a society, I think we are disinclined to accept that during pregnancy and the postpartum period women can experience despair with a force that propels them towards suicide or accidental overdose. But we know that up to 15% of pregnant and postpartum women experience depression. In fact, going through a major life transition like pregnancy or childbirth, mixed with a lack of sleep, is a huge risk factor for the onset or exacerbation of mental illness.
Society also tends to make a distinction between physical and mental illnesses. This is reflected in the CDC’s definition of maternal mortality, which excludes suicide and overdose and treats them as "incidental." This distinction implies that self-harm deaths are inherently different, a reflection of character or moral failure and therefore less worthy of public health attention and resources.
What impact have opioids had on maternal deaths?
A study published just this year concluded that maternal mortality involving opiates doubled between 2007 and 2016, at least in the 22 states that used the pregnancy checkbox during that time period. By 2016, 70% of maternal deaths involving opioids occurred during pregnancy or up to 42 days postpartum.
Although most of the deaths are caused by heroin and synthetic opioids, we were surprised to learn how commonly opioids are prescribed after a C-section and even during pregnancy. In some states, up to 20% of pregnant women receive a prescription for opioids.
Opiates are particularly dangerous for women. Women are more likely to have chronic pain conditions and are at greater risk of addiction due to higher rates of sexual and physical abuse and mood disorders. So we think providers need more information about alternatives to opioids for pain management during pregnancy.
What can doctors do to prevent suicide and overdoses in new mothers?
There’s an increased risk of mood disorder exacerbation shortly before and after delivery and of depression onset within the first year postpartum. Extended surveillance through obstetric clinics, collaboration of obstetricians and mental health providers and adherence to screening guidelines can increase recognition of these disorders in women.
A single checkup six weeks after delivery—which was the guideline issued by the American College of Obstetrics and Gynecology (ACOG)—may not be enough to identify those at risk and prevent self-harm. Now, ACOG recommends another checkup at three months postpartum, which they call the fourth trimester, although there is no standard guideline. Just a few decades ago we believed a woman returned to “normal physiology” 42 days after giving birth, though new studies show that nine to 12 months postpartum is particularly high risk for suicide.
It’s important to embed psychologists and psychiatrists in obstetrics clinics, as it is cumbersome and time-consuming for pregnant women and new mothers to go to another clinic.
We also need to increase providers’ comfort level with handling mental health issues during pregnancy and postpartum, particularly when it comes to giving advice about how to manage mood and prescribing antidepressants. There is a standard screening tool for depression, which is typically given once during pregnancy and again postpartum, but not all providers do this.
Finally, there is a lot of data showing that the use of opioid addiction medications such as suboxone and methadone are safe when used during pregnancy and postpartum. But most women aren’t aware of these options, and many obstetric providers don’t know where to refer women to get these treatments.
Kimberly Mangla, MD, is an instructor in psychiatry at Columbia University Vagelos College of Physicians and Surgeons.
Catherine Monk, PhD, is a professor of medical psychology at Columbia University Vagelos College of Physicians and Surgeons. She is also director of the Women’s Mental Health Program in Columbia’s Department of Obstetrics & Gynecology, which addresses the mental health needs of women before, during, and after pregnancy.
The paper, titled "Maternal self-harm deaths: an unrecognized and preventable outcome," was published online in the American Journal of Obstetrics and Gynecology.
The other authors are M. Camille Hoffman (University of Colorado School of Medicine, Denver, CO), Caroline Trumpff (Columbia University Irving Medical Center), and Sinclaire O’Grady (CUIMC).