Maternal mortality has increased over past decades. The majority of deaths are secondary to mental health and substance use disorders, with over 80% being preventable. Screening for mental health should be offered to all pregnant women and should be administered through all trimesters and postpartum. Barriers such as social and cultural determinants and maternity care deserts should be considered and addressed.
Key points
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The most common causes of maternal mortality are mental health disorders and substance use disorders.
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Majority of maternal mortality is preventable.
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Barriers to mental health diagnosis and treatment include:
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Patients’ social and cultural beliefs impact patients’ decision-making.
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Access to care including maternity care deserts.
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Introduction
Maternal death is defined by the Centers for Disease Control (CDC) as “the death of a woman during pregnancy, at delivery, or soon after delivery”. Other definitions are listed in Table 1 . A preventable death is one where an intervention by patient, family member, community, or health care system may have avoided the outcome. Maternal deaths are increasing over the past decades and are a grave tragedy for the pregnant person, their family, their community, and for society as a whole. The CDC have identified that mental health and substance use disorders (SUDs) are the leading contributors to maternal mortality, accounting for approximately 30% of these outcomes ( Table 2 ). The CDC and the American College of Obstetricians and Gynecologists (ACOG) have identified that over 80% of the maternal mortalities are preventable.
| Definition | |
|---|---|
| Maternal Death | Death of a woman during pregnancy, at or soon after delivery. |
| Maternal mortality rate | Annual number of female deaths from any cause related to or aggravated by pregnancy, or management during pregnancy, childbirth, or within 42 d of completion, regardless of duration and site. |
| Pregnancy associated death | Death during pregnancy or within 1 y postpartum, regardless of the cause |
| Pregnancy related death | Death during pregnancy or within 1 y postpartum, where the cause is related to or is aggravated by the pregnancy. |
| Condition | % |
|---|---|
| Depressive disorders | 72 |
| Postpartum depression | 15 |
| Anxiety | 48 |
| Substance use disorders | 22 |
| Other | 17 |
Screening and diagnosis
Gimbel LA and colleagues reviewed the impact of several initiatives, which exist to address screening, diagnosis, and reduction of these outcomes by identifying options for prevention and treatment and state that the leading contributors to mental health related deaths are perinatal mood and anxiety disorders, which include depression and anxiety. They explain that although many states have Maternal Mortality Review Committees (MMRCs), which are important surveillance systems for maternal mental health related deaths, unfortunately, reviews of suicide and overdose related deaths are not always included.
Self-harm
Trost and colleagues reported that although mental health disorders (including SUDs) were reported for individuals who died, there were not always linkages to evidence based treatments. Kountanis and colleagues reported that 70.9% of those included in a review, had mental health disease or SUD, but only 34.5% had received treatment for SUD. Although SUD-related deaths occurred in 71.1%, only 27.4% had received treatment. Of the prescriptions identified, 42.9% had opioid scripts, 44.3% were benzodiazepines, and 32.5% had both prescriptions. When reviewing post-mortem toxicology results, the most common substance identified was opioids. Of these, 45.9% had been prescribed by a physician. In another study, Metz and colleagues reported that although 50% of those who died by self-harm were taking psychotherapy medications at conception, 48% of them had stopped the medicines during pregnancy.
Smid and colleagues, in a cohort study of 136 persons, stated that drug use was the leading cause of pregnancy-associated death (35). Opioids accounted for 27 of these, prescription opioids accounted for 21 and polysubstance use was found in 29 of the 35.
According to the MMRC data, approximately 22% of deaths occur during pregnancy, 25% occur on the day of delivery or within 1 w, 23% from 7 to 42 d postpartum, and 30% occur 43 d to 1 y postpartum.
The prevalence of pregnancy-associated death after 42 d postpartum up to 1 y has increased between 2010 and 2019. Specific non-obstetric causes include drug use (11.4%), suicide (5.4%), and homicide (5.4%). Patients who have a current mental health issue, SUD, and/or intimate partner violence are at increased risk of pregnancy-associated suicide and homicide. A review by Mangla recognized depression, intimate partner violence (IPV), and SUD as 3 of the most common risk factors for pregnancy-associated suicide.
Depression and anxiety disorders account for the majority of pregnancy-related mental health deaths. Just like with SUD, these conditions are preventable, using evidence-based interventions. MMRCs have found that rigorous screening, followed by appropriate referrals and interventions, are the best interventions for prevention of these outcomes. Opportunities for these options exist at several touch points throughout pregnancy and post-partum, and can be applied regardless of the existence of prior disease or not. It is well-known that the post-partum period is the highest risk period for pregnancy related deaths due to mental health disorders (suicide) and SUD. Therefore, all post-partum persons should be evaluated to identify those at risk and the appropriate interventions should be initiated. Because up to 40% of postpartum women miss the postpartum visit, ACOG guidelines require screening for depression, anxiety, and SUD not only at the initial prenatal visit, but also during the pregnancy and post-partum. , Stene-Larsen and colleagues reported that just under 50% of those who died by suicide had contact with a primary care clinician within 1 mo before the event. Overall, the individuals are more likely to see a primary care or emergency medicine clinician versus a mental health clinician. Thus, the pregnancy and postpartum care provides an ideal opportunity to screen for mental health and SUD. After screening, a decision regarding referral for outpatient therapy versus inpatient admission can be made. A factor helping toward outpatient therapy for someone who screens positive is the presence of support systems such as family, friends, faith-based, and other community groups. During the postpartum period, a major confounding factor regarding mothers sharing concerns about depression, anxiety, suicidality, and so forth is her reluctance to be separated from her baby.
Approximately 5% to 20% of those screened for depression screen positive for self-harm. Concerns about self-harm are not easily communicated by patients, and can vary in different cultures and communities. Sleath and colleagues studied 73 multi-ethnic women, with 27% seeing a physician and 29% seeing a nurse. They found that 34% did not feel comfortable sharing concerns about anxiety and depression regardless of who they saw for prenatal care and 37% did not want to share with family members. Those with moderate to severe symptoms of depression were more likely to communicate their issues and of the ones who did not communicate, 13% wished that they had done so.
Suicide is less common during pregnancy, but it is more common in the immediate postpartum period. Although there are no reliable data regarding accuracy and likelihood of interventions to prevent maternal deaths by suicide, risk factors should be assessed. Less than 2% of these expressing suicide ideation will have attempted suicide. Other risk factors include lack of treatment, lack of social supports, and feelings of shame and stigma.
Vacheron and colleagues describe the findings of the French National Confidential Survey on Maternal Deaths, which state that from 2013 to 2015, suicide deaths accounted for 13.4% of the maternal deaths (35/262) with 33.3% having a prior psychiatric diagnosis. They also found that 30.3% had a history of psychiatric care that was unknown to the obstetric care team. Psychosocial vulnerability factors included history of violence, home insecurity, and financial difficulties. Of the suicides during this time period, only 1 occurred during pregnancy, 23% were within 42 d immediately post-partum, and 77% occurred between 42 d and 1 y after giving birth. The majority of the cases were violent deaths. Suboptimal care was found in 72% of cases, with 91% of the potentially preventable suicides resulting from lack of multidisciplinary treatment options and/or poor interactions between the patient and the health care system. Examples of the failures for the potentially preventable deaths were sub-optimal multidisciplinary treatment in spite of the patient’s psychiatric pathology being known; failure by the obstetric or emergency department team to screen for and detect psychiatric pathology.
Treatment
Although antidepressant therapy is a mainstay of treating depression, there is greater preference among pregnant and postpartum women for psychotherapy versus medications and many of them state that they would only consider antidepressant medications as a last resort. Munk-Olsen and colleagues reported higher rates of antidepressant discontinuation during pregnancy. They studied pregnant women and controls drawn from 25% of the entire Danish population to identify the prevalence of antidepressant medication use from 12 mo prior to childbirth to 12 mo postpartum. They found that 3.17% of the women (2733) had 1 or more prescriptions for antidepressants. Referrals to a psychiatrist occurred in 1.18% (935) and 1.76% (1399) were referrals to a psychologist. Women giving birth had a markedly lower rate of antidepressant use versus the controls, with the largest observed difference occurring during the 3rd trimester (0.6% vs 2.20%). They also reported that the number of filled prescriptions for antidepressants, and also contacts with psychiatrists or psychologists, all decreased during pregnancy but increased during the postpartum period.
Goodman and colleagues administered a questionnaire to pregnant women asking about treatment options that they would most likely accept regarding depression, and their attitudes toward psychopharmacology and any barriers. Of the 509 participants, 92% indicated that they would accept psychotherapy if it was available. Only 35% stated they would take recommended medications and 14% indicated they would accept group therapy. Barriers included lack of time (65%), stigma (43%), childcare, and other family obligations (33%). The majority preferred to receive the mental health care within the obstetrics clinic, regardless of whether the obstetrician or a mental healthcare clinician was providing the treatment. Battle and colleagues interviewed 61 pregnant women of who approximately half had clinical depression. They found that the women preferred non-pharmacologic treatments. They also found that a large number reported uncertainty regarding how to treat the depression symptoms ( Box 1 ). Thus, understanding and heeding such preferences would result in improved rates of treatment and resultant decrease in morbidity and mortality related to mental health disorders during pregnancy.
