Suicide is a leading cause of pregnancy-related deaths in the United States, and new research shows that people with suicidal thoughts after giving birth dramatically increased between 2006 and 2017, with the biggest spikes amongst people who are Black, lower income, or younger.
The study, published Wednesday in the journal JAMA Psychiatry, looked at just under 600,000 privately-insured people. Researchers analyzed the data to track cases of suicidality — suicidal ideation and deliberate self-harm — within a year either before or after giving birth.
From 2006 to 2017, suicidality diagnoses increased from .2 percent per 100 people to .6 percent per 100. In the same period, cases of deliberate self-harm went up from .1 percent per 100 in 2006 to .2 percent per 100 in 2017. When applied to the approximately 4 million births that take place each year, that means an increase in tens of thousands of suicidal cases and intentional self-harm.
“Suicidality is something we don’t think about or talk about as much, and it’s a lot more common than I had realized,” said Kara Zivin, a professor at the University of Michigan and the paper’s senior author.
Zivin pursued the research based on her own experience — 10 years ago, after giving birth to her son, her postpartum depression made her suicidal. Now, she said, she wants to shine light on an under-discussed topic in public health that has profound consequences.
Already, the United States’ rate of pregnancy-related deaths is higher than any other wealthy nation. And suicide is a major concern. According to a 2017 report by the federal Centers for Disease Control and Prevention, it accounted for about 6.5 percent of all pregnancy-related deaths.
“I was certainly aware of the risks of things like postpartum depression. I never expected the level of illness I had,” Zivin said. “I don’t fully understand it, still.”
It’s not clear what is behind the trend, though the researchers argued that it’s likely a combination of doctors more often catching cases of suicidality — which is typically under-diagnosed — and the problem itself growing more common. But it’s hard to know what is driving the increase.
Zivin said the study makes a strong case for policy interventions that ensure people can access mental health care during and after pregnancy. For instance, people who have Medicaid as their insurance when pregnant will lose that eligibility after 60 days post-birth in most states — even though suicide a year after giving birth is still considered pregnancy-related. That’s something states or the federal government could address, she said, by extending Medicaid to guarantee insurance for a year postpartum, and making sure people can see mental health specialists.
The study found that Black people experienced the largest increase in perinatal suicidality of any single racial group — increasing from .2 percent per 100 in 2006 to .9 percent in 2017. In some ways, that reflects a bigger reality: The nation’s pregnancy-related death rate is far higher for Black people than for White people.
That’s still likely an undercount of the gap, said Katy Kozhimannil, an associate professor at the University of Minnesota and director of its rural health research center. Black women are disproportionately covered through Medicaid, not private insurance. (Kozhimannil was not involved in the study.)
The study authors said it’s not clear why Black people experienced such a dramatic increase in diagnoses. But experiences of racism have been linked to physical stress and mental illness symptoms, Kozhimannil noted. And big picture, she added, the data emphasizes why health policy-makers need to emphasize the impact of systemic racism when crafting pregnancy-related health interventions.
“It’s not about race, it’s about racism,” she said. “Thinking about it in that way would point to the common root, and might get us in policy discussions further toward valuing the health of Black people in pregnancy.”
The authors believe that the paper is even more pressing now. If pregnancy-related suicide was already a problem, experts say it’s one that is likely to only grow, especially in the wake of the COVID-19 pandemic, which has added new strains to perinatal mental health.
As the pandemic worsens this winter, experts are sounding the alarm about a potential spike in suicides. That’s especially a concern for people who have access to firearms, Kozhimannil said; the vast majority of gun deaths each year are suicides, and people who attempt suicide with a gun are more likely to suicide. And right now, more women are buying firearms for the first time.
“This is more important than ever in the COVID-19 era,” said Lindsay Admon, an OB-GYN at the University of Michigan and the study’s lead author. “The postpartum isolation people feel will have been compounded by this epidemic.”
It’s likely that the study data underestimates the extent of the problem.
The study looks only at people with private insurance, who tend to be wealthier. It does not include the almost half of all American births that are insured through Medicaid, which covers lower-income people. People on Medicaid are already more likely to experience the kinds of external stressors that can trigger symptoms of depression and anxiety, and more likely not to have a doctor diagnose or help them access treatment.
The study also only tracked official diagnoses, even though self-harm and suicidal thought are typically underreported and under-diagnosed.
“It shows a big problem and probably undercounts the magnitude of the problem, and the magnitude of the potential disparity,” Kozhimannil said.
If you or a loved one are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 74174.