Suicide as a cause of maternal mortality in the postpartum period in Spain

Abstract

Introduction

The postpartum period carries a high risk of suicide, one of the leading causes of maternal death in Europe. This study analyzes the incidence of suicide as a cause of maternal mortality within the first postpartum year in Spain.

Materials and methods

Data were obtained from the National Institute of Statistics. Suicide records in Spain (2016–2023) were linked to birth and birth-loss certificates. Suicides during pregnancy or after losses <22 weeks were excluded due to lack of national registration data. Variables included year of death, maternal age, and time from delivery to death. Analyses were descriptive. The study was approved by the Research Ethics Committee of Almería (June 26, 2024; SUICIDE_POSPARTO 37/2024).

Results

Thirty women died by suicide during the first postpartum year between 2016 and 2023. Eighty percent of cases involved women aged 30–40 years. Half of the suicides occurred within the first five months postpartum, with 83.3% classified as late maternal mortality (between day 43 postpartum and the end of the first year). The highest maternal mortality ratio due to suicide was recorded in 2017, at 0.76 per 100,000 live births (three cases), followed by 2022 with 0.61 (two cases). In contrast, late maternal mortality due to suicide was highest in 2016, with a ratio of 1.70 per 100,000 live births.

Conclusions

This is the first study to publish data on suicide in the first postpartum year in Spain, contributing to the national maternal mortality registry. Research on suicidal behavior and prevention strategies during pregnancy and postpartum remains a priority.

Introduction

Suicide is a significant public health issue. Globally, more than 700,000 people die by suicide each year.¹ In Spain, suicide was the leading cause of unnatural death in 2021, and according to data from National Institute of Statistics (INE), 4116 people died by suicide in 2023, including 1072 women.² In response, the Ministry of Health published the “Action Plan for Suicide Prevention 2025-2027”,³ according to the recommendations of World Health Organization (WHO) to prevent suicidal behavior.⁴ In this context, which is the relevance of suicide as a cause of maternal mortality?

A maternal death is defined as the death of a woman while pregnant or within 42 days of the termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, excluding accidental or incidental causes.^5,6 In public health, it is measured by the maternal mortality ratio (MMR) – the number of maternal deaths per 100,000 live births. The WHO also defines late maternal deaths as those occurring between 43 days and one year after the end of pregnancy, quantified using the late maternal mortality ratio (LMMR).^7,8

According to ICD guidelines, prenatal and postpartum suicides should be classified as direct maternal deaths under “Other”, even without a confirmed diagnosis (e.g. postpartum depression).⁹ The perinatal period – from pregnancy through the first postpartum year – is a time of major life changes and increased vulnerability to mental health disorders.¹⁰ The prevalence of suicidal ideation in pregnant women is estimated between 5% and 14%,^11–13 more common in urban populations, adolescents (OR 1.51, 95% CI: 1.21–1.88),¹⁴ and those with a history of psychiatric illness.^15,16 Pregnancy loss was also associated with an increased risk of perinatal suicide, especially stillbirth [adjusted odds ratio (OR 5.2; 95% CI 1.77–15.32), and spontaneous abortion (OR 3.81; 95% CI 2.81–5.15).⁷ Suicide is likely a major contributor to maternal deaths. However, its true prevalence is difficult to determine due to limited studies, population heterogeneity, and the exclusion of deaths within the first postpartum year.¹⁷

The MMR due to suicide (during pregnancy and up to the first 42 days) varies in European countries^18–20: Denmark (MMR 1), Finland (MMR 2.7), France (MMR 0.3), Italy (MMR 0.4), Netherlands (MMR 0.4), Slovakia (MMR 0.4), and UK (MMR 1.5). Furthermore, when data are analyzed for the first year postpartum, suicide is the leading cause of maternal death in European countries. Its contribution to total maternal mortality was 25% in France, 50% in the UK, and 10% in Italy.^19,20 The maternal mortality rate during pregnancy and up to one year postpartum (LMMR) was estimated at 3.84 per 100,000 live births in UK and Ireland (2020)¹⁸; 2.58 per 100,000 live births in Canada (1994–2008)²¹; and 3.7 per 100,000 live births in Switzerland (1980–2007).²² The highest incidence occurred between the sixth and ninth months postpartum, and affected women had a mean age of 30 years, with an increased incidence among adolescents.¹⁸

In Spain, there are no official data on suicide as a cause of maternal mortality, as death certificates do not record pregnancy status, despite WHO recommendations. Recognizing suicide as a cause of maternal death is a public health priority to highlight its magnitude and ensure appropriate perinatal biopsychosocial care.¹⁶ The aim of this study is to assess the incidence of suicide among maternal deaths during the postpartum period in Spain.

Materials and methods

This research study was approved by the Research Ethics Committee of Almería on June 26, 2024 (approval code: SUICIDE_POSPARTO 37/2024). This study was conducted as a pilot study with an 8-year sample due to the lack of prior data on suicide as a cause of maternal mortality in Spain. We requested data from the National Institute of Statistics (INE) on all women in Spain who died by suicide between January 1, 2016, and December 31, 2023, and who had, in the year prior to death, either a birth certificate or a statistical birth bulletin associated with their record. These documents certify the birth of a live infant or a late fetal death occurring in the second (≥22 weeks) or third trimester of pregnancy.²³

The following variables were analyzed: year of death, maternal age, and the time interval (in months) from delivery to death. Deaths were classified as early (≤42 days postpartum) or late (≥43 days postpartum), according to the WHO criteria.^7,8 Maternal deaths occurring during pregnancy and after pregnancy loss in first and early second trimester (<22 weeks) were excluded from the analysis. The INE did not provide information regarding suicide methods, psychiatric history, socioeconomic factors, or demographic details (excluding age). Furthermore, data on mental health history, interpersonal violence, and suicides during or after pregnancy loss (<22 weeks) were unavailable due to a lack of records, precluding their inclusion in this study. Additionally, we compiled birth data published by the INE between 2016 and 2023 to calculate the maternal mortality rate due to suicide during three distinct postpartum periods: within 42 days (standard maternal mortality ratio, maternal mortality ratio or MMR), between 43 days and one year (late maternal mortality ratio or LMMR), and the entire first postpartum year (global maternal mortality ratio). The MMR due to suicide was calculated by dividing the number of maternal deaths by suicide by the total number of registered live births each year, and multiplying the result by 100,000. We also reviewed the maternal mortality rate published by the INE (which includes pregnancy and postpartum ≤42 days) for the same period (2016–2023).²⁴ The INE data had been previously updated in collaboration with the Spanish Group for Obstetric Safety (GESO), which had suggested an underestimated incidence.²⁵

The data was collected in an anonymized database and the analyses were purely descriptive using frequency analysis. Descriptive data was presented as median (and range where applicable) for quantitative variables, and frequency and percentage for categorical variables. The software used was IBM SPSS Statistics (Version 26) for Windows.²⁶

Results

A total of 30 cases of women who died by suicide within the first postpartum year – following either a live birth or a pregnancy loss in the second (>22 weeks) or third trimester – were identified over an eight-year period from 2016 to 2023. The highest number of cases occurred in 2016, with 7 cases (23.3%), followed by 2019, 2020, and 2022, each with 5 cases. No cases were recorded in 2021 (Table 1). The average number of cases per year during the study period was 3.75.

Table 1.

Maternal mortality ratios due to suicide in Spain, 2016–2023.

Year	Births in Spain^a	Suicides in the first 42 days postpartum*	MMR^c due to suicide(first 42 days postpartum*)	Suicides from 43 days to the first postpartum year*	Late MMR^c due to suicide(from 43 days to the first postpartum year*)	Suicides in the first postpartum year*	Global MMR^c due to suicide (first postpartum year*)	MMR in Spain^b
2016	410,583	0	0.00	7	1.70	7	1.70	4.63
2017	393,181	3	0.76	0	0.00	3	0.76	3.31
2018	372,777	0	0.00	4	1.07	4	1.07	2.41
2019	360,617	0	0.00	5	1.38	5	1.38	2.22
2020	341,315	0	0.00	5	1.46	5	1.46	3.22
2021	337,380	0	0.00	0	0.00	0	0.00	5.34
2022	329,251	2	0.61	3	0.91	5	1.51	4.86
2023	320,656	0	0.00	1	0.31	1	0.31	3.43

a

Number of total births in Spain published by INE. Available at: https://www.ine.es.

b

Maternal mortality ratio published by INE during pregnancy and puerperium (≤42 days) due to all causes. Available at: https://www.ine.es.

c

Maternal mortality ratio (number of maternal deaths/100,000 live births).

*

After delivery of live infant or gestational loss occurring in the second (≥22 weeks) and third trimester of pregnancy.

During the first postpartum year in Spain, maternal age ranged between 30 and 40 years in 80% (24 cases), followed by 10% (3 cases) in the 20–30 age group. One case (3.3%) involved an adolescent under 20 years of age, and two cases (6.7%) involved women over 40 years of age.

Analysis of the timing of suicide showed a median occurrence in the fifth month, indicating that 50% of suicides took place within the first five months postpartum. Suicide occurred in 10% (3 cases) during the first month, with the highest frequency – 5 cases each (16.7%) – recorded in the fourth and fifth months (Table 2).

Table 2.

Time at which the suicide occurred from 2016 to 2023 in Spain.

Time of suicide^a	Frequency of suicide cases^b	Percentage (%)
During the 1st month	3	10.0
During the 2nd month	4	13.3
During the 3rd month	0	0.0
During the 4th month	5	16.7
During the 5th month	5	16.7
During the 6th month	0	0.0
During the 7th month	2	6.7
During the 8th month	0	0.0
During the 9th month	3	10.0
During the 10th month	4	13.3
During the 11th month	2	6.7
During the 12th month	2	6.7
Total	30	100.0

a

Month after delivery or gestational loss (>22 weeks).

b

Number of cases of suicide in women during the first postpartum year after birth or second or third trimester gestational loss (>22 weeks).

According to the standardized criteria of WHO, 5 cases (16.7%) were classified as early maternal deaths by suicide (within 42 days postpartum), while 25 cases (83.3%) were classified as late maternal deaths (from day 43 to one year postpartum) (Table 1).

When focusing specifically on suicides occurring within the first 42 days postpartum, the highest MMR due to suicide was recorded in 2017, at 0.76 per 100,000 live births (three cases), followed by 2022 with 0.61 (two cases). No early maternal suicides were recorded in the remaining years of the study period (Table 1).

In contrast, late maternal mortality by suicide (from day 43 to one year postpartum) reached an MMR of 1.70 per 100,000 live births in 2016, followed by 1.46 in 2020 and 1.38 in 2019. No late maternal deaths by suicide were recorded in 2017 and 2021 (Table 1).

The overall MMR due to suicide during the first year after a live birth or pregnancy loss in the second or third trimester was, on average, 1.02 per 100,000 live births. The highest extended MMR was observed in 2016 (1.70), followed by 2022 (1.51) (Table 1).

For comparison, the annual maternal mortality ratios published by the INE (which includes pregnancy and postpartum ≤42 days due to all causes) for the same period are also included (Table 1).

Discussion

The present study analyzed information regarding suicide during the first postpartum year in Spain.

The most relevant findings are: the overall MMR due to suicide during the first year after a live birth or pregnancy loss in the second or third trimester was, on average, 1.02 per 100,000 live births, the median occurrence of suicide was the fifth month postpartum, and most suicides (80%) involved women aged 30–40 years. In addition, this study identified five cases of maternal suicide occurring within the first 42 days postpartum, which represents a MMR of 0.76 per 100,000 live births (2017), followed by 0.61 per 100,000 live births (2022). These cases were not included in Spain's official maternal mortality registry, even though the WHO considers suicide a direct cause of maternal death,⁹ and would represent an increase of approximately 23% and 12.5% in the MMR in those years. These results are consistent with those published in European countries.^18–20 Therefore, we strongly recommend that suicide-related maternal deaths occurring within the first 42 days postpartum should be incorporated into the national registry, including pregnancy history in death reports.

Deaths occurring between 43 days and one year after the end of pregnancy are classified as late maternal deaths.^7,8 In European countries, suicide is the leading cause of maternal death in the first postpartum year. In our study, the global maternal mortality rate due to suicide in the first year after a live birth or miscarriage in the second–third trimester varied significantly over the eight years, with an overall mean of 1.02 per 100,000 live births, reaching a global maternal mortality rate of 1.70 per 100,000 live births in 2016, followed by 1.51 in 2022. Our results are likely underestimated by not accounting for suicide during pregnancy and first-trimester pregnancy losses, due to a lack of national registration. In fact, we did not detect any cases during the first postpartum year in 2021, and it could be explained in the context of the data source limitations.

During the first year after childbirth, women with a psychiatric disorder have the highest risk of hospitalization.²⁷ A recent meta-analysis identify other risk factors: previous attempted suicide, sleep disturbances, obstetric complications, negative attitude towards pregnancy, low social and economic status, history of child abuse, and gender-based violence.^7,15,17,28 These factors were not evaluated in our sample and should be considered in future studies, ideally using prospective data sources. Pregnancy loss was also associated with an increased risk of perinatal suicide. Our study, following WHO recommendations, included women who had suffered a miscarriage in the second and third trimesters.²⁸

The third relevant finding is that 80% of cases involved women aged 30–40 years, which is consistent with information published in the Maternal Mortality Register of the UK and Ireland. Of particular concern is the further increase in teenage suicides.^18,29 We also found a case of suicide was recorded in a young adult aged 20 years.

The major strength of this study is that it is the first to address the current incidence of suicide among women during postpartum in Spain.

However, we also encountered several limitations. Firstly, according to WHO recommendations,⁹ all suicides during pregnancy, regardless of the number of weeks of gestation, and up to 12 months postpartum, should be considered a direct cause of maternal mortality. Unfortunately, we could not include suicides during pregnancy or first and second-trimester pregnancy losses <22 weeks, due to the lack of national registration data. In addition, death certificates do not take into account the history of pregnancy in the previous year. This has been shown to reduce under-reporting of maternal deaths.⁹ Our study is also limited by the lack of information on psychosocial variables (history of child abuse, mental health diagnosis, etc.), which were not provided by the INE. Hence the importance of promoting research projects in this area.

Further research on perinatal suicidal behavior in Spain is a priority. It is urgent to improve the national registry of suicide cases during pregnancy and first year postpartum, including this item in death reports. This would allow for the recognition of this public health problem and provision of biopsychosocial care through specific prevention programs in perinatal period.

Authors’ contributions

All authors have read and agreed to the published version of the manuscript. The authors have reviewed and edited the output and take full responsibility for the content of this publication.

Institutional review board statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Almería, protocol code SUI-CIDIO_POSPARTO 37/2024, date of approval 26/6/2024).

Informed consent

Not applicable.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the authors used ChatGPT in order to improve the language. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Funding

This research received no external funding.