OBJECTIVE: To ascertain demographic and clinical characteristics of maternal deaths from self-harm (accidental overdose or suicide) to identify opportunities for prevention.
METHODS: We report a case series of pregnancy-associated deaths resulting from self-harm in the state of Colorado between 2004 and 2012. Self-harm deaths were identified from several sources, including death certificates. Birth and death certificates along with coroner, prenatal care, and delivery hospitalization records were abstracted. Descriptive analyses were performed. For context, we describe demographic characteristics of women with a maternal death from self-harm and all women with live births in Colorado.
RESULTS: Among the 211 total maternal deaths in Colorado over the study interval, 30% (n=63) resulted from self-harm. The pregnancy-associated death ratio from overdose was 5.0 (95% confidence interval [CI] 3.4–7.2) per 100,000 live births and from suicide 4.6 (95% CI 3.0–6.6) per 100,000 live births. Detailed records were obtained for 94% (n=59) of women with deaths from self-harm. Deaths were equally distributed throughout the first postpartum year (mean 6.21±3.3 months postpartum) with only six maternal deaths during pregnancy. Seventeen percent (n=10) had a known substance use disorder. Prior psychiatric diagnoses were documented in 54% (n=32) and prior suicide attempts in 10% (n=6). Although half (n=27) of the women with deaths from self-harm were noted to be taking psychopharmacotherapy at conception, 48% of them discontinued the medications during pregnancy. Fifty women had toxicology testing available; pharmaceutical opioids were the most common drug identified (n=21).
CONCLUSION: Self-harm was the most common cause of pregnancy-associated mortality, with most deaths occurring in the postpartum period. A four-pronged educational and program building effort to include women, health care providers, health care systems, and both governments and organizations at the community and national levels may allow for a reduction in maternal deaths.
Self-harm (suicide and accidental overdose) is the leading cause of pregnancy-associated mortality in Colorado, with the majority of decedents having identifiable risk factors for self-harm.
University of Colorado School of Medicine, Aurora, and Denver Health Medical Center, Department of Obstetrics and Gynecology, the Colorado School of Public Health at the University of Colorado Denver, the Department of Biostatistics and Informatics, the Colorado Department of Public Health and Environment, and the Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado.
Corresponding author: Torri D. Metz, MD, MS, Denver Health Medical Center, Department of Obstetrics and Gynecology, 777 Bannock Street, MC 0660, Denver, CO 80204; e-mail: Torri.Metz@dhha.org.
Supported by the Agency for Health care Research and Quality Grant number R24 HS022143-01 and National Institutes of Health/National Center for Research Resources Colorado CTSI Grant No. UL1 TR001082. I. A. Binswanger was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R34DA035952. T. D. Metz was supported by the National Institute on Child Health and Human Development under Award Number 2K12HD001271-16.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the National Institutes of Health. In addition, the Colorado Maternal Mortality Review Committee received funding from the Association of Maternal and Child Health Programs (AMCHP) and Merck for Mothers to assist with the expansion of the committee and to allow for further exploration of suicide as a cause of maternal death in Colorado to identify possible points of intervention.
Financial Disclosure The authors did not report any potential conflicts of interest.
Presented as a poster at the Society for Maternal-Fetal Medicine 36th Annual Meeting, February 1–6, 2015, Atlanta, Georgia.
The authors thank Kirk Bol and Lauren Bardin at the Colorado Department of Public Health and Environment for their assistance with obtaining birth certificate data for all live births over the study period as well as for identification of the cases of maternal death.