Unbearable trauma and irreparable damage: maternal death by suicide raises seri-ous perplexities

Introduction: Maternal death by suicide raises serious perplexities. The ICD-10 classifies maternal suicide as an indirect form of maternal death. Due to this current mis-classification, a classificatory consensus of maternal suicide as a direct form of maternal death is urgent. Objective: Analyze the psychological that permeate the phenomenon of maternal suicide, to define the profile of mothers in the postpartum period and pregnant women who commit suicide, with the purpose of elucidating ways of preventing maternal sui-cide. Method: A systematic review was made following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). Results: Twenty-one studies reported the urgent need to implement interventions in order to prevent or reduce mental health problems caused by mothers and pregnant wom-en who commit suicide. Twenty studies demonstrate the need for interventions to organi-zational adjustments, especially related to the emotional conflicts involved suicide and maternity. Conclusion: Maternal suicide is mainly caused by severe psychiatric disorders, however, higher suicide rates are seen due to psychosocial factors, such as poor familial support and domestic violence, illegal substance abuse and alcoholism, history of sexual or physical violence, racial oppression, economic instability, unwanted pregnancy, diffi-culty in accessing intentional abortion, and trauma related to past maternity experiences. Modesto Leite Rolim Neto School of Medicine Universidade Federal do Cariri – UFCA, Barbalha, Brazil. Phone: (+55 88) 999042979 Email: modesto.neto@ufca.edu.br Edited by Juliana Ramos Andrade


Introduction
T he death of a mother, in of itself, leaves unbearable trauma and irreparable damage not only for the children but for the entire family and social context surrounding the mother. Hence, the struggle for the survival of pregnant women and mothers in the postpartum period has raised great scientific and social efforts, resulting in the global decline of annu-al rates of maternal death by 46% between the years of 1990 and 2010. 1 Most causes of maternal death, such as hemorrhage, eclampsia, malnutrition, infection, and venous thromboembolism, have been combated and mitigated. 2,3 However, little focus has been placed on maternal suicide, which is now characterized as the primary cause of maternal death in developed countries as well as among the leading causes in developing coun-tries. 4 Maternal death is defined by the tenth edition of the International Classification of Diseases (ICD-10) as the death by any means of a pregnant woman up to one year af-ter the end of her pregnancy, whether directly, i.e. pregnancy-related obstetric causes, childbirth, and puerperium, or indirectly, due to non-obstetric or pre--existing conditions, aggravated by the effects of pregnancy. 5 In this context, maternal death by suicide raises serious perplexities. The ICD-10 classifies maternal suicide as an indirect form of maternal death, making these cases even more difficult to classify, analyze, and prevent. 6 Due to this current misclassification, a classificatory consensus of maternal suicide as a direct form of maternal death is urgent. 7 Because of this, the discussion for the eleventh edition of the International Classification of Diseases (ICD-11) has proposed to include suicide as a direct form of maternal death in order to facilitate its epidemiological analysis, screening and prevention. 4,6,7 Nevertheless, even with ICD-10 applied the notification and computation of maternal suicides are extremely impaired because there is still no defini-tive, standard classification; many countries, especially the least developed, still do not classify maternal suicides as direct maternal deaths, leading to an important gap in the knowledge of maternal deaths due to suicide worldwide. 4 In the midst of this situation, maternal suicide continues to reach terrifying rates. There are 2 suicides per 100,000 live births in the USA 8 and Canada 9 , while there are 3.7 suicides for every 100,000 in Sweden 10 , and 2.3 per 100,000 in Italy 11 , with similar rates worldwide. This paper aims to understand the phenomenon of maternal suicide by quali-tatively analyzing the relationship between suicide and maternity, characterizing causes, issues, and cofactors involved in the process of maternal suicide, as well as proposing pre-ventative measures. Above all, this paper aims to identify who are the mothers and preg-nant women who commit suicide.

Method
A systematic revision was made, following the PRISMA protocol (Preferred Re-porting Items for Systematic Reviews and Meta-Analysis).

Inclusion criteria
To search for studies, the following databases were used: Pubmed Scopus and Embase. We identified categorized references for the "Maternal death"; "Suicide"; "Mental disor-ders"; "Pregnancy"; "Postpartum period". Besides, we identified references by searching (title/abstract) in the database, using the keywords: suicide *, psych *, stress *, ans *, depr *, mental *. We selected all references identified specifically for the inclusion criteria for this systematic review.

Data extraction and methodological quality assessment
We have developed a data extraction form to collect data on participants and exposure intervention, if relevant, results related to relationship between suicide and maternity, characterizing causes, issues, and cofactors involved in the process of maternal suicide. We extracted data on mental health problems, as well as related ones (that is, risk/resilience factors); strategies implemented or accessed by with the objective to identi-fy who are the mothers and pregnant women who commit suicide.
Three researcher (MLRN, SNAO and NNRL) extracted data and another verified the extraction. Three researchers (KRDA, FC and MMMB) independently assessed the methodological quality of systematic reviews using the AMSTAR tool 12 and qualitative studies using the CASP checklist (Critical Appraisal Skills Program -CASP). 13 A re-searcher (MLRN) assessed the quality of cross-sectional studies using the JBI Prevalence or the JBI Cross-sectional analytical checklist and longitudinal studies using the JBI Co-hort checklist (Johanna Briggs Institute ). 14

Data presentation and analysis
We summarized the results narratively. We described interventions and outcomes based on the information provided in the studies. We decided not to perform a quantitative analysis of summaries of the associations between the various correlates and health fac-tors, due to a combination of heterogeneity in the measures and lack of control groups, and an embraced lack of descriptions necessary to confirm sufficient homogeneity. We rated the certainty of the evidence using the GRADE approach -(Grading of Recom-mendations Assessment, Development and Evaluations. 15

Results
The search strategy yielded 229 results in Pubmed Scopus and Embase. Titles and/or abstracts of these records were screened and 156 did not meet the eligibility criteria. Out of the remaining 73 full-text articles, 32 were excluded for various reasons, such as lack of relevancy to the proposed topic. Thus, our systematic review includes 41 publications ( Figure 1 and Table 1).
Almeida KRD, Oliveira SNA, Rolim Neto ML ASAA Tabela 1. Porcentagem de resistência aos antibióticos de uso oral de acordo com o total de amostras de cada microrganismo isolado. History of hospitalization due to a psychiatric disorder was associated with the highest odds ratio and the highest attributable risk for suicide. Cohabiting or single marital status, unemployment, low income, retirement, disability, sicknessrelated absence from work, and a family history of suicide and/or psychiatric disorders were also significant risk factors for suicide.
Having a young child with lower suicide risk in female subjects.

2013
The Scientific World Journal Literature review. Narrative description of the evolution of female suicidal rates during a lifetime.
There is an idea that the birth of a child is a protective factor against fatal and non-fatal self-harm, especially in the first year after delivery. However, pregnant and postpartum women who experience depressive disorders are more likely to complete suicide. Suicidal behavior may be increased after abortion, miscarriage, or other factors, such as single marital status, low income, unemployment, poor social support. Cross-sectional analysis of women surveyed during 20 to 30 weeks of pregnancy using Self-Report Questionnaire-20.
The prevalence of suicidal ideation was 6.3%. Factors associated with suicidal ideation were common mental disorders, single partner status, past psychiatric history, and smoking tobacco. All cases of suicidal ideation were associated with common mental disorders. Suicidality seems to run in families, independent of depression and other psychopathology.

Evaluation of the methodological quality of the included studies
The most common methodological weaknesses in all the studies arose from insuf-ficient reporting: samples, scenarios, and recruitment procedures were often not fully de-scribed.

Interventions in mental health
Twenty-one studies reported the urgent need to implement interventions in order to prevent or reduce mental health problems caused by mothers and pregnant women who commit suicide. Twenty studies demonstrate the need for interventions to organizational adjustments, especially related to the emotional conflicts involved suicide and maternity.

Changes in mental health
Fifteen of the studies that implemented mental health interventions reported the ef-fects of interventions on emotional conflicts involved suicide and maternity.
The only data available to connect the impact of the suicide came from three longitudinal research studies, that report changes over time, both of low-quality methodological value.
The summary of the results table below shows the studies that contribute to each mental health result. We evaluate that the certainty of the reported results of levels of anxiety, depression, distress, and sleep problems in pregnant women who commit suicide, using the GRADE approach, is moderate. 3.9.

Discussion
Studies report that motherhood can work as a protective factor for mental health, reducing the risk of suicide, especially in pregnant women and women who have recently given birth. 16,17 However, maternal suicide is a major cause of maternal death around the world, primarily in developed countries. 4,18 Pregnancy and the arrival of a child represent, for many women, a unique experience of hope and joy, but for some women, this period may become overlapped by serious psychiatric disorders, which destabilize and lead to life-threatening situations for many mothers and pregnant women. 18,19 In this context, motherhood seems to intensify the prevalence of mental illnesses in vulnerable women 3 , with a history of suicidal thoughts, i.e. a set of suicidal behaviors that include intentional self-harm (with or without the intention to die), suicide ideation and suicide attempts. 20 Major depressive disorders during pregnancy and the postpartum period, which is consid-ered a main risk factor for maternal suicide, is heavily prevalent, affecting around 20% of women worldwide, from mild forms to more severe ones and, more rarely, psychosis. 4,21 Indeed, perinatal depression is a unique subtype of major depressive disorder, where women rapidly experience severe forms of depressive episodes with high levels of comor-bidities such as anxiety, obsessive-compulsive disorders, and ideations of inflicting self-harm and harm to the child. 18,22 Women in mental distress are more likely to commit suicide 18 , mainly in the first months postpartum 17,23 and during the pregnancy. 8,23 Studies confirm this notion, stating that the vast majority of pregnant women and mothers who commit suicide are afflicted with severe mental illnesses 3 , such as major depressive disorders and schizophrenia 19,24 , and account for nearly 75% of all maternal suicides. 2,10,24 Furthermore, high rates of suicidal behavior are also seen in women with a history of illegal substance abuse [23][24][25] , alco-holism 23,26,27 , and even tobacco consumption. 3 A study performed in Sri Lanka links the high prevalence of depression in pregnant women, with 27.1% of the pregnant women having a depressive episode prior to the pregnancy and 16.2% having postpartum depres-sion, with the high rate of maternal suicides, which represents almost 18% of all of the causes of maternal deaths in the country. 28 Suicide is also one of the main causes of ma-ternal deaths in other developing countries, but nonetheless, maternal suicide has re-mained under-investigated and under-diagnosed and consequently under-treated. 29 The social stigma surrounding taking one's life, as well as inadequate health systems and clas-sificatory obstacles still prevail, which all contribute to the serious problem of underre-porting. 4,29 In any case, maternal suicide, as with any other psychological phenomenon, does not have one single cause. Pregnant women and mothers in postpartum in such a diverse world could not have the same sufferings nor could they suffer equally in any of their afflictions. However, family support has been shown to be a significant protective factor against maternal suicide 29,30 , while mothers without adequate family support have higher rates of suicide. 3,29 Guasia et al. 31 claim that in Bangladesh, unhelpful and unsupportive husbands and mother-in-laws were significant risk factors for suicide, especially for wom-en who have suicidal ideation during pregnancy, which makes up 14% of all pregnant women in the country. In addition, unmarried or divorced marital statuses, as well as pregnancies outside of marriage are also presented as risk factors for maternal suicide, as these situations could be associated with a lack of familial ties and support. 25,32 On the other hand, marital satisfaction was revealed as a protective factor, due to the emotional support provided. 33 Not surprisingly, teenage mothers may be three times more likely to commit suicide than other age group of women. 3,17 Almeida KRD, Oliveira SNA, Rolim Neto ML ASAA Likewise, domestic violence has been demonstrated to aggravate the risk of ma-ternal suicide. 27,34,35 In the USA, 54.3% of women who have committed maternal suicide have experienced some type of domestic abuse. 8 In India, Supraja et al. 36 also indicated that domestic violence and inadequate familial and social support had a strong correlation with suicidal ideation in early pregnancy. Furthermore, other types of abuse, whether physical or psychological, are also identified as determining factors for maternal sui-cide 20,25 , such as sexual violence, where studies indicate that mothers who were victims of sexual abuse in the antenatal period have 2 to 4 times more symptoms of depression. 3 Social contexts of oppression, such as being an ethnic minority, also proves to be of high significance when examining the suicide of mothers and pregnant women world-wide. 29 In Canada, where approximately 1 in 5 maternal deaths occurs due to suicide or drug toxicity 9 , self-harm ideation rates are alarmingly higher in Aboriginal women, who experience different forms of social disparities, than in other groups of Canadian women. 37 Similarly, in the USA, Native American women have been reported to have higher rates of maternal suicide than any other ethnic group. 8 In Sweden, women who have emigrated from developing countries had 3 times more psychiatric morbidities dur-ing postpartum than Swedish immigrants from more developed countries. 10 This situation-al framework is further intensified in women refugees and asylum seekers, where Collins et al. 38 report that such groups reach three times higher prevalence of post-natal depression due to serious stressful and traumatic life events in the past.
A range of various social settings has been demonstrated to have significant im-pacts on maternal mental health and, therefore, a direct effect on maternal suicide. Fur-thermore, unemployment and low wages are already well understood to be related to sui-cide in the general population. 16,29 Supraja et al. 36 also reported that, in India, the highest prevalence of maternal suicide occurs in middle-class women, potentially due to the un-stable and still growing Indian economy, where even the middle class finds themselves lacking financial stability. There is also evidence that lower levels of education, which may be related to low income and unemployment, is a risk factor for suicide, particularly in the first postpartum year. 21,34,39 Unplanned or unwanted pregnancies are also described as a risk factor for mater-nal suicide. 3,20 Thus, difficult access to abortion services, as well as the illegality of abor-tion in certain countries, also tends to corroborate maternal suffering and possibly sui-cide. 25 A study conducted in Brazil by Alves et al. 40 associated unwanted pregnancy, the illegality of intentional abortion, and less privileged social condition with maternal sui-cide, where suicide could present itself as the only resource in the face of the despair of women without adequate familial support. Intentional abortion is also associated with higher rates of maternal suicide in some studies. 11,17 However, the evidence establishes a higher suicide rate after intentional abortion because it stems from traumas experienced during the procedure, and not from the abortion decision or from the act itself. 41 Miscar-riage and the loss of a child in the first year of life are described as very strong risk factors for suicidal behavior 33,42 , as well as the sorrow of having a stillborn child. 21 It is important to highlight that the general population of women is less likely to commit violent suicide 10 , however, in the case of maternal suicides, the vast majority of women end up committing suicide violently 43 , mainly by hanging or jumping. 44 Thornton et al. 45 refers that, in Australia, 73% of maternal suicide cases were conducted by violent means, some cases including gunshot and lying in front of a moving object. Maternal dis-tress and suicidal ideation during pregnancy are even associated with gestational and childbirth complications, as well as impairments in the newborn child's physiology, such as reduced dopamine levels and increased cortisol levels. 25 Revealing the singularity of the phenomenon of maternal suicide, the violent way in which pregnant or in-postpartum women seek to take their own lives opens up the complexity of the theme and the severity of the despair suffered by those who do so. Countless reasons can lead women, both in the pregnancy period and in the postpartum period, to attempt violence against their own lives. Many studies are in consensus that maternal suicide presents itself as a serious and unique psychiatric phenomenon despite the social factors strongly associated with suicidal behavior mentioned above. 11,18,20,22 Thus, a history of mental illness such as depression, anxiety, bipolarity, post-traumatic stress disorder, suicide ideation, substance abuse, or any other effect of psychotic disor-der, in addition to a family history of psychiatric diseases and suicide is a primary risk factor for maternal suicide. 16,18,19,25,32 The death of a pregnant or a puerperal woman by suicide is a tragedy of incalcula-ble damage, which carries immeasurable psychological damage for the entirety of their life. 46 The descendants of mothers who come to commit suicide are at an increased risk of also committing suicide 47 , in addition to being prone to numerous other psycho-emotional disorders. 46,48,49 Lieb et al. 49 still indicate that suicidal behavior may have genetic factors involved as well, as though suicide could run in Almeida KRD, Oliveira SNA, Rolim Neto ML ASAA families. Therefore, antenatal treatment of depression can prevent higher rates of suicide in the offspring. 39

Conclusion
Women who commit maternal suicide are, above all, women with serious mental illnesses 18,19,22 , and with suicide aggravated by serious situations of psychosocial vulnera--bilities, those of which include poor familial support 30,33 ,domestic abuse 34,35 , a history of sexual abuse 3 , illegal substance abuse and alcoholism 24,26,27 , specific racial oppression 10,37 , economic instability 21,36 , and unwanted pregnancy combined with difficulty or illegality to perform intentional abortion 40 , in addition to severe trauma related to motherhood, such as miscarriage and loss of child during the delivery or within the first year of life. 42 Considering that pre-existing mental illness is strongly associated with most sui-cide cases, maternal suicides must be considered preventable with adequate medical care, especially with primary health care. 6 With the universal and systematic screening of men-tal illness in the earlier stages of pregnancy 23,48 , about a quarter of all maternal suicides could be prevented 44 , with adequate pharmacological therapy and comprehensive psycho--logical assistance. 42 Regarding the profile of pregnant women and mothers in the postpar-tum period who have committed suicide, it is imperative to develop multidisciplinary monitoring standards for the preventative care for suicide in women defined as most vul-nerable 2,48 in all levels of care. 29 Special treatments must be focused mainly on pregnant women who have related a past of psychiatric disorders or addictions 23,27 , or even a histo--ry of suicide in the family 16 , with great attention given to unmarried women, unemployed women, women in the course of unwanted pregnancy, those who have suffered from traumatic experiences, such as physical or sexual violence, those who lack adequate sup-port from family and those belonging to marginalized social groups. 24,25,38 Furthermore, there is an urgent need for a consensus on the classification of maternal suicide 4 , in order to avoid misclassification bias and enable better analysis of the theme. 6,7,19