Including women and healthcare professionals in conversations about perinatal suicide

By Kerry Hozhabrafkan.

I have a vivid memory of being at university during my midwifery training, listening to the lecturer describe a case study which had been chosen to support our learning. It was the tragic story of a woman who had recently become a mother for the first time and became rapidly unwell. The woman’s husband woke one morning to find her missing from their home. She was later found having taken her own life. It was a story that left us, as fresh faced students, completely shocked. This was to be our introduction to one of the (thankfully relatively rare) devastating outcomes associated with postpartum psychosis; and the take home message as student healthcare professionals (HCPs) was ‘be alert, know the signs’. As it was, this was the only time that perinatal suicide was discussed during the course or any of the associated practice placements. Would I, a newly qualified midwife, have known what to say, what to do if a woman disclosed suicidal feelings to me? The answer is a resounding no. I now see that this was such a missed opportunity for suicide prevention. And whilst I am confident that today’s midwifery education programmes maintain a greater focus on maternal mental health, I believe that there is more that can and should be done to educate and prepare those involved in the care of perinatal women to discuss suicidality specifically, in a compassionate and appropriate way. Suicidality is perhaps viewed as a ‘refer on’ issue and, of course, it is essential that referral pathways for specialist support be in place. Moreover, the role of midwives and health visitors encompasses the identification of risk factors for perinatal mental illness as well as routine screening for possible symptoms. Yet, it seems that currently no space exists to facilitate frank and open conversations about suicide between women and the HCPs providing their care.

Barriers to openness

Stigma sadly is a word that is too often mentioned in discussions about mental illness, particularly in relation to suicide [1]. So much valuable and ongoing work has been done in raising awareness of perinatal mental illness, but unfortunately, conversations around suicide remain taboo for many. For women, disclosure of suicidal feelings may be accompanied by fear of stigmatisation, negative judgment of fitness for motherhood, or even that a safeguarding referral will be made [2]. It could be argued that in addition, cultural and societal expectations of motherhood act to compound such feelings, making it more difficult still for women to talk about what is an already complex and distressing phenomenon.

Similarly, it seems that maternity HCPs do not feel they can fully embrace their role in suicide prevention. Studies have shown that midwives have low confidence and feel inadequately prepared to assess women’s mental health and suicide risk [3, 4, 5]. The reported reasons for this apprehension are manifold but include lack of training opportunities, time constraints, no clear understanding of the next step (i.e. referral processes) and the lack of continuous care models. These are not easily solved problems and such reasons affect not only suicide prevention but can also compromise many other aspects of the care that HCPs are able to offer.

What research says and what it has yet to say

In the UK, suicide is the leading cause of maternal death in the perinatal period [6]. Further to this, many women experience suicidal thoughts and urges during pregnancy [7] and within the year following birth [8]. For some it may be the first time they have experienced suicidal thoughts; others may have lived with suicidality for a much longer period. Suicide is influenced by numerous and complex factors [9]. However, in this population, having a past or current mental illness is associated with an increased risk of dying by suicide [10]. One large case series study found that perinatal women were more likely (than those who were not perinatal) to have had a depression diagnosis and no active treatment ongoing at the time of their death by suicide [11]. Current evidence is primarily focused on the epidemiology and correlates of perinatal suicide, but there is a dearth of empirical research in this area. This is why as part of my doctoral research I plan to investigate what are acceptable and appropriate ways to involve perinatal women in suicide focused research. Additionally I will explore the views of midwives and health visitors regarding their role in suicide prevention and suicide research. I hope that this work will contribute to the evidence base for conducting safe and ethical research in this population as well as have relevance for clinical care.

References

1. Carpiniello, B., & Pinna, F. (2017). The Reciprocal Relationship between Suicidality and Stigma. Frontiers in Psychiatry, 8, 35. https://doi.org/10.3389/fpsyt.2017.00035
2. Holland, C. (2018). The midwife’s role in suicide prevention. British Journal of Midwifery, 26(1), 44–50. https://doi.org/10.12968/bjom.2018.26.1.44
3. Coates, D., & Foureur, M. (2019). The role and competence of midwives in supporting women with mental health concerns during the perinatal period: A scoping review. Health & Social Care in the Community, 27(4). https://doi.org/10.1111/hsc.12740
4. Lau, R., McCauley, K., Barnfield, J., Moss, C., & Cross, W. (2015). Attitudes of midwives and maternal child health nurses towards suicide: A cross‐sectional study. 8.
5. McGlone, C., Hollins Martin, C. J., & Furber, C. (2016). Midwives’ experiences of asking the Whooley questions to assess current mental health: A qualitative interpretive study. Journal
6. Knight, M. (2019). The findings of the MBRRACE-UK confidential enquiry into Maternal Deaths and Morbidity. Obstetrics, Gynaecology & Reproductive Medicine, 29(1), 21–23. https://doi.org/10.1016/j.ogrm.2018.12.003
7. Gelaye, B., Kajeepeta, S., & Williams, M. A. (2016). Suicidal ideation in pregnancy: An epidemiologic review. Archives of Women’s Mental Health, 19(5), 741–751. https://doi.org/10.1007/s00737-016-0646-0
8. Pope, C. J., Xie, B., Sharma, V., & Campbell, M. K. (2013). A prospective study of thoughts of self-harm and suicidal ideation during the postpartum period in women with mood disorders. Archives of Women’s Mental Health, 16(6), 483–488. https://doi.org/10.1007/s00737-013-0370-y
9. Windfuhr, K., Steeg, S., Hunt, I. M., & Kapur, N. (2016). International Perspectives on the Epidemiology and Etiology of Suicide and Self-Harm. In The International Handbook of Suicide Prevention (pp. 36–60). John Wiley & Sons, Ltd. https://doi.org/10.1002/9781118903223.ch2
10. Orsolini, L., Valchera, A., Vecchiotti, R., Tomasetti, C., Iasevoli, F., Fornaro, M., De Berardis, D., Perna, G., Pompili, M., & Bellantuono, C. (2016). Suicide during Perinatal Period: Epidemiology, Risk Factors, and Clinical Correlates. Frontiers in Psychiatry, 7, 138. https://doi.org/10.3389/fpsyt.2016.00138
11. Khalifeh, H., Hunt, I. M., Appleby, L., & Howard, L. M. (2016). Suicide in perinatal and non-perinatal women in contact with psychiatric services: 15 year findings from a UK national inquiry. The Lancet Psychiatry, 3(3), 233–242. https://doi.org/10.1016/S2215-0366(16)00003-1

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