Maternal Deaths From Suicide and Overdose in Colorado, 2004–2012

Abstract

Objective To ascertain demographic and clinical characteristics of maternal deaths from self-harm (accidental overdose or suicide) in order to identify opportunities for prevention. Methods We report a case series of pregnancy-associated deaths due to self-harm in the state of Colorado between 2004 and 2012. Self-harm deaths were identified from several sources, including death certificates. Birth and death certificates along with coroner, prenatal care and delivery hospitalization records were abstracted. Descriptive analyses were performed. For context, we describe demographic characteristics of women with a maternal death from self-harm and all women with live births in Colorado. Results Among the 211 total maternal deaths in Colorado over the study interval, 30% (n=63) resulted from self-harm. The pregnancy-associated death ratio from overdose was 5.0 (95% CI 3.4, 7.2) per 100,000 live births and from suicide 4.6 (95% CI 3.0, 6.6) per 100,000 live births. Detailed records were obtained for 94% (n=59) of women with deaths from self-harm. Deaths were equally distributed throughout the first postpartum year (mean 6.21 ± 3.3 months postpartum) with only 6 maternal deaths during pregnancy. Seventeen percent (n=10) had a known substance use disorder. Prior psychiatric diagnoses were documented in 54% (n=32) and prior suicide attempts in 10% (n=6). While half (n=27) of the women with deaths from self-harm were noted to be taking psycho-pharmacotherapy at conception, 48% of them discontinued the medications during pregnancy. Fifty women had toxicology testing available; pharmaceutical opioids were the most common drug identified (n=21). Conclusion Self-harm was the most common cause of pregnancy-associated mortality with most deaths occurring in the postpartum period. A four-pronged educational and program building effort to include women, providers, health care systems, and both governments and organizations at the community and national level may allow for a reduction in maternal deaths.

Medicaid Coverage of Methadone Maintenance and the Use of Opioid Agonist Therapy Among Pregnant Women in Specialty Treatment

“…Moreover, the postpartum period is a high-risk time for overdose death; however, Medicaid coverage through the pregnancy eligibility pathway ends 60 days postpartum. (5,46,47) Changes in coverage status postpartum may disrupt access to OAT, particularly in states where Medicaid expansion did not occur. Further research is needed to assess the impact of OAT coverage policies on a broad range of outcomes in pregnant women.…”

Recent advances in understanding maternal perinatal mood disorders

“…More importantly, they pale in comparison to the effects of maternal mental illness, which are still being articulated fully but include poorer fetal outcomes 25 , long-term effects on child behavior 26 and cognition 27 , and maternal self-harm, the last of which recently was again shown to be the most common cause of death in a population of perinatal women 28 . Less information is available on perinatal use of other classes of psychotropics, including mood stabilizers and antipsychotics.…”

Maternal and infant characteristics associated with maternal opioid overdose in the year following delivery

“…In the United States, opioid‐related overdose events are increasingly implicated in pregnancy‐associated deaths, defined as deaths occurring during or within a year of the end of pregnancy, contributing to 11–25% of deaths in several states . The majority of the reported deaths occur later in the postpartum period; in Massachusetts, more than 90% of substance use‐related pregnancy‐associated deaths occurred after 6 weeks postpartum, compared with 60% of all other pregnancy‐associated deaths . In Massachusetts, the 7–12 months following delivery were found to be a period of increased risk of both fatal and non‐fatal opioid overdose events (12.3 of 10 000 person‐days) compared with the trimester just prior to delivery (3.3 of 10 000 person‐days) .…”