What Is the Leading Cause of Mortality During the Postpartum Period?
Answer: Suicide resulting from postpartum mood disorders.
Depression during the postpartum period is not uncommon, with prevalence rates as high as 20% (and perhaps even more prevalent in low-income countries). Recent years have called for increased recognition of postpartum depression, reduction of associated stigma, and support for new mothers in need of treatment. Several organizations, including the US Prevention Task Force Services and the American College of Obstetrics and Gynecologists have recommended that all women be screened for symptoms of depression at least once during the prenatal and postnatal period. Unfortunately, following childbirth many new mothers have no regular interaction with any healthcare professional aside from their child's pediatrician; thus identifying women at risk of postpartum depression can be tricky. Fortunately, there is currently a call to action for more collaborative care in terms of postpartum mental health, with suggestions that all new mothers are screened for depression by pediatricians during well-baby visits at 1-, 2- and 4-months postpartum.
Although it may be commendable when a clinician recognizes postpartum depression, there is some concern over initiating appropriate treatment. The latest data indicate that many cases of postpartum depressive symptoms may actually be bipolar in nature, especially in patients who have never had a depressive episode outside of the postpartum period. It is therefore essential that all new mothers who screen positive for symptoms of postpartum depression (using a screening tool such as the Edinburgh Postnatal Depression Scale) also be screened for any symptoms of (hypo)mania and family history of bipolar disorder. New mothers who become suicidal, or worse infanticidal, are virtually always suffering from postpartum psychosis, which is a very severe manifestation of bipolar disorder that is all-too-often misdiagnosed as unipolar depression and treated with antidepressant monotherapy (a potentially tragic treatment strategy that can actually make symptoms of (hypo)mania, suicidality, and psychosis worse).
References
Gelaye B, Rondon M, Araya R, et al. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016;3(10):973-82.
O'Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol 2013;9:379-407.
Sharma V, Doobay M, Baczynski C. Bipolar postpartum depression: an update and recommendations. J Affect Disord 2017;219:105-11.
Thomson M, Sharma V. Therapeutics of postpartum depression. Exp Rev Neurotherapeutics 2017;17(5):495-507.
Epidemiology of Maternal Depression, Risk Factors, and Child Outcomes in Low-Income and Middle-Income Countries
In a recent meta-analysis, review studies were selected that focused on the epidemiology of perinatal depression among women residing in low-income and middle-income countries (Gelaye et al., 2016). The relationship between perinatal depression and infant/child outcomes was also explored. The meta-analysis included 51 articles that focused on antepartum depression, and 53 articles that centered on postpartum depression in women living in low-and middle-income countries (LAMICs). About one in four women were identified as having antepartum depression and one in five women having postpartum depression. Approximately 25% of girls and more than 10% boys in LAMICs report experiencing childhood violence. Recent findings have been reported that a history of sexual and physical child abuse is associated with a 2.47-fold increased odds of antepartum depression (OR=2.74, 95% CI: 1.79-3.40) among Peruvian women (Barrios et al., 2015). In a multi-study of nine LAMICs, intimate partner violence (IPV) was reported to range from 10% to 52% (Krug et al., 2002). A study from Peru found that pregnant women who were victims of IPV had a 4.1-fold (95% CI 2.79-5.97) and 5.8-fold (95% CI 3.33-10.08) risk for moderately severe and severe depression, respectively (Gomez-Beloz et al., 2009). Other risk factors pregnant women in LAMICs included maternal low educational attainment, low socioeconomical status at the time of pregnancy, lack of social support, and history of mental illness (Gelaye et al., 2016). The effect of perinatal depression on infant and childhood outcomes was examined from a total of 21 studies on women in LAMICs. Women with antepartum depression were nearly twice as likely to deliver low birth weight infants (OR=1.90; 95% CI: 130-2.90) as compared to non-depressed women (Rahman et al., 2007). Perinatal depression was also associated with childhood obesity (McConley et al., 2011) and delayed language processing in offspring (Quevedo et al., 2012). The results of this meta-analysis demonstrate that antepartum and postpartum depression in LAMICs are highly prevalent.
References
Barrios YV, Gelaye B, Zhong Q, et al. Association of childhood physical and sexual abuse and risk of prenatal and postpartum depression or depressive symptoms among pregnant women. PLoS One 2015; 10(1):e0116609.
Gelaye B, Rondon M, Araya R, et al. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016;3(10):973-82.
Gomez-Beloz A, Williams MA, Sanchez SE et al. Intimate partner violence and risk for depression among postpartum women in Lima, Peru. Violence 2009; 24(3): 380-08.
Krug EG, Mercy JA, Dahlberg LL, et al. The world report on violence and health. Lancet 2002; 360(9339):1083-8.
McConley RL, Mrug S, Gilliland MJ, et al. Mediators of maternal depression and family structure on child BMI: parenting quality and risk factors for child overweight. Obesity 2011; 19(2): 345-52.
Quevedo LA, Silva RA, Godoy R, et al. The impact of maternal post-partum depression on the language development of children at 12 months. Child Care Health Dev 2012; 38(3): 420-4.