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.