By Camille Hoffman, MD, MSc
Associate Professor, Maternal Fetal Medicine, University of Colorado Departments of Obstetrics and Gynecology
and Psychiatry, Aurora, CO
Dr. Hoffman reports no financial relationships relevant to this field of study.
SYNOPSIS: In a recent study, investigators found that drug-related death and suicide were leading causes of postpartum death in California.
SOURCE: Goldman-Mellor S, Margerison CE. Maternal drug-related death and suicide are leading causes of post-partum death in California. Am J Obstet Gynecol 2019; June 4. pii: S0002-9378(19)30747-1. doi: 10.1016/j.ajog.2019.05.045. [Epub ahead of print].
Reduction in maternal mortality is relevant not only to prenatal care providers and our patients but also to society. Several states have added “mental health” to the list of common causes of maternal death as efforts to identify and mitigate risks have increased nationwide. These deaths are tracked, coded, and assessed by state Maternal Mortality Review Committees (MMRC), which are state-appointed committees convened to understand the nature of maternal mortality. MMRCs are tasked to track, code, and assess statewide maternal mortality annually, reach consensus on the root cause of each death and determine if each death was preventable. If a death was deemed preventable, then the committee specifies measures that might be taken to prevent similar types of deaths in the future. As more state MMRCs acknowledge suicide and drug overdose as a root cause of maternal death, it has come to light that this particular root cause is more common, and more ubiquitous, than previously understood.
More than 1 million women who delivered a live-born infant in California between 2010 and 2012 were included in this study. These women were followed for 12 months postpartum, as maternal mortality is now defined as a death that occurs during pregnancy or the first 12 months postpartum. During the two-year study, 300 women died at some point between delivery and the end of their 12-month postpartum period. The overall mortality rate was 28.33 deaths/100,000 person-years. Although obstetric-related problems (including hemorrhage, hypertension, infection, and venous thromboembolus) were the leading cause of death at 6.52/100,000 person-years, drug-related deaths were second at 3.68/100,000 person-years. Suicide was the seventh leading cause of death at 1.42/100,000 person-years. Two-thirds of the 300 women who died postpartum (of any cause) had at least one documented emergency department visit in the postpartum period. Of women who died of drug overdose or suicide, 74% had one or more emergency department visit(s) between delivery and death. Therefore, the authors noted postpartum emergency department visits as a potential opportunity to identify and mitigate risks.
COMMENTARY
Any maternal death is tragic. This event not only affects the newborn and family intimately, but maternal death also affects the healthcare community and society at large, as it often underscores a failure in the healthcare system and social safety nets. Appropriately, reduction in maternal mortality and consideration of mental health contributors to mortality are now major public health priorities. California joins other states, including Colorado and Illinois, that have recognized drug overdose and suicide as potential targets — via screening, assessment, and treatment efforts — in reducing maternal morbidity and mortality.1,2,3 The fact that the majority of women who died in the first year postpartum had at least one emergency department visit between delivery and death informs us of one potential opportunity to intervene. Along with other leading causes of maternal mortality that are assessed routinely and throughout the perinatal course (hypertension, hemorrhage risks, clotting risks), our patients deserve to have their mental health risks assessed, addressed, and treated as part of routine perinatal care. Based on these findings as well as previously published data and commentary,2,4 the following are encouraged.
At the individual patient-clinician level:
- Screening for and addressing perinatal substance use and perinatal mood and anxiety disorders as part of routine prenatal care. Screens such as the Edinburgh Postnatal Depression Scale and substance use questionnaires are free and available online.
- Minimize opioid and benzodiazepine prescribing as much as possible.
- Establish referral and treatment pathways.
At the systems level:
- Provider education and support regarding available mental health resources.
- Screening, identification, and referral pathway establishment.
- Use social workers and care coordinators when available.
At the community/state/federal level:
- Hotlines for women to call when in crisis and/or warm-lines pre-crisis.
- Use existing resources, including patient navigation and home visitation programs.
- Public education to reduce stigma.
- Support your state’s MMRC.
REFERENCES
- Goldman-Mellor S, Margerison CE. Maternal drug-related death and suicide are leading causes of post-partum death in California. Am J Obstet Gynecol 2019; June 4. pii: S0002-9378(19)30747-1. doi: 10.1016/j.ajog.2019.05.045. [Epub ahead of print].
- Metz TD, Rovner P, Hoffman MC, et al. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol 2016;128:1233-1240.
- Koch AR, Geller SE. Addressing maternal deaths due to violence: The Illinois experience. Am J Obstet Gynecol 2017;217:556.e.1-556.e6.
- Kendig S, Keats JP, Hoffman MC, et al. Consensus bundle on maternal mental health: Perinatal depression and anxiety. Obstet Gynecol 2017;129:422-430.
