Suicidal ideation and intentional self-harm in pregnancy as a neglected agenda in maternal health; an experience from rural Sri Lanka

Abstract

BackgroundSuicide only present the tip of the iceberg of maternal mental health issues. Only a fraction of pregnant women with suicidal ideation proceeds to intentional self-harm (ISH) and even a smaller proportion are fatal. The purpose of the present study was to determine the prevalence of depression, suicidal ideation (present and past) and history of ISH among pregnant mothers in rural Sri Lanka.MethodsWe have conducted a hospital based cross sectional study in the third largest hospital in Sri Lanka and an another tertiary care center. Pregnant women admitted to hospital at term were included as study participants. The Edinburgh Postpartum Depression Scale (EPDS), a self-administered questionnaire for demographic and clinical data and a data extraction sheet to get pregnancy related data from the pregnancy record was used.ResultsThe study sample consisted of 475 pregnant women in their third trimester. For the tenth question of EPDS “the thought of harming myself has occurred to me during last seven days” was answered as “yes quite a lot” by four (0.8%), “yes sometimes” by eleven (2.3%) and hardly ever by 13 (2.7%). Two additional pregnant women reported that they had suicidal ideation during the early part of the current pregnancy period though they are not having it now. Four (0.8%) pregnant women reported having a history of ISH during the current pregnancy. History of ISH prior to this pregnancy was reported by eight women and five of them were reported to hospitals, while others were managed at home. Of the 475 pregnant females included in the study, 126 (26.5%) had an EPDS score more than nine, showing probable anxiety and depression. Pregnant women who had primary/post-primary or tertiary education compared to those who were in-between those two categories were at higher risk of high EPDS score with a OR of 1.94 (95% CI 1.1–3.3). Reported suicidal ideation prior to pregnancy was also associated with high EPDS with a OR of 6.4 (95% CI 2.3–17.5).ConclusionsBased on our data, we conservatively estimate around 500 pregnant women each year having suicidal ideation and, 130 ISH annually in Anuradhapura, which should be considered as a high priority for an urgent intervention.

Addressing Psychosocial Vulnerabilities Through Antenatal Care—Depression, Suicidal Ideation, and Behavior: A Study Among Urban Sri Lankan Women

“…Despite this possible pregnancy protective effect, nearly 12% of the sample required urgent referral based in part on current risk from self-harming ideations and/or behaviors. Finally, lifetime SIB was strongly associated with both depressive and current pregnancy SIB outcomes as seen in other LMIC settings (3,13). This supports global evidence that a history of suicidal ideation and particularly behavior is a critical factor identifying those most at risk of later suicide (9), and indicates women's experience during pregnancy and beyond may be influenced by pre-pregnancy difficulties.…”

“…Maternal health programs continue to focus on obstetric causes of mortality and morbidity. However, more recent evidence suggests common perinatal mental disorders (CPMDs) such as depression and anxiety are the commonest morbidities experienced by perinatal women ( 3 ). As a result, programs have missed large subsets of women experiencing CPMDs and—although rarer—symptoms of psychosis, self-harm, and suicide ( 4 ).…”

“…As obstetric causes of maternal death have fallen, deaths due to suicide have emerged as significant if not leading contributors to preventable deaths in perinatal women, including during pregnancy ( 3 , 6 ). With the postnatal period too late for intervention, there is an urgent need to identify antenatal women at risk of SIB.…”

“…Further, they commonly embed questions on self-harm into tools for depression (e.g., EPDS, Patient Health Questionnaire, Beck Depression Inventory, and Hamilton Depression Rating Scale), preventing exploration of SIB in the absence of CPMDs ( 14 ). These embedded questions can inappropriately assume suicidal intent or are improperly interpreted as such by scholars with regularity, including those applying the EPDS which cannot deduce intent ( 3 ). Others conflate suicidal and non-suicidal self-harming ideation (e.g., Patient Health Questionnaire) or use vague and/or stigmatizing language (e.g., Hamilton Depression Rating Scale queries “gestures of suicide”).…”

“…The Government of Sri Lanka recognizes perinatal suicides as an important public health challenge, but rigorous evidence on SIB in perinatal women is unavailable. Previous research on CPMDs in Sri Lanka has almost wholly prioritized postnatal women and excluded minority and low literacy subpopulations ( 3 , 19 , 20 ). As such, this research aimed to answer four research questions about the mental health of a perinatal population in Sri Lanka: What is the prevalence of antenatal depressive symptomology indicative of depression?…”