Friday, November 26, 2004

Maternal Health: Suicide is a Major Risk

As we, in the USA, reflect on our good fortune, and our preoccupation with family values, it is good to pause for a moment and think of the global perspective:

Iraq has one of the highest maternal mortality rates in the world - 53 per 1,000 live births, compared to the UK's six per 1,000.

Given the fact quoted above, plus the fact that the United States of America has assumed responsibility for the well-being of Iraqi citizens, plus the fact that the current administration has proclaimed life-affirming values, one naturally would expect that the US government would be doing something about the dreadful maternal mortality rate in Iraq.

Naturally, that would be wrong.  The UK is doing something: they have started a program (see link, above) to train midwives to perform low-tech deliveries as safely as possible, with limited resources.  Well, I suppose that makes sense: each of us is doing what we are good at.  The USA is good at blowing things up; the rest of the world is good at humanistic endeavors.

We are interested in health care, but only if there is money to be made.  Midwifery does not count. 

Of course, there is a place for technological advances is perinatal care, as illustrated in the recent BMJ article:
Depression and obesity are major causes of maternal death in Britain
BMJ  2004;329:1205 (20 November)
Madeleine Brettingham

[...] The Confidential Enquiry into Maternal Death assessed 391 deaths over a period of three years, from 2000 to 2002, to arrive at its findings. "There has been a vast reduction in the number of direct obstetric complications, and that shows a great improvement in medical science," said Richard Congdon, the enquiry’s chief executive. "But there are a number of areas where the situation has not improved and there is evidence that in some cases it has got worse."

Forty per cent of maternal deaths are now attributed to indirect causes. Depression and suicide were singled out as areas of particular concern. Psychological factors are now the leading cause of death among young mothers or expectant women, and the report emphasised the need for patients to be assessed and counselled effectively before the birth.

"Half of those women who committed suicide due to serious mental illness had a history of mental problems," said Margaret Oates, consultant perinatal psychiatrist at Nottingham University Hospital. "It is important for professionals to have clear and relevant information about the patient to enable them to give appropriate care."

The report suggests several improvements, among them the development of a standard national checklist to ascertain the social and inherited risk factors that may affect a woman and the establishment of a specialist perinatal psychiatric team in every locality. [...]

These are good ideas: screen all pregnant women for risk factors for suicide, and establish specialized perinatal psychiatric teams.  Yes, it would cost money, but when you consider the cost to society, when a woman dies shortly after giving birth, it would be a pretty good investment. 

So how does the USA do with respect to maternal mortality?  We probably get a B+.  There are 20 countries that have lower maternal mortality rates that the USA.  We did manage to reduce the rate during the period from 1940 to 1982.  Then the progress stopped.  Although the reason for the change is not known, I cannot help but notice that the cessation of progress corresponds to the time when social services in the USA started to get cut back.

Perhaps we should take a look at the impact of declining social services on maternal mortality.  There are plenty of reasons to think that we could have an impact, although I was not able to find any articles that prove this.  I did find some indirect evidence, which I present a little further on in the post.  Even those with private insurance are not getting adequate service.  "Managed care" needs to loosen up a little bit.  Most plans allow for 20 sessions for mental health care.  Most human pregnancies last 40 weeks.  It is pretty easy to see that the (completely arbitrary) limitation of 20 sessions is not enough, especially since many pregnant women chose to not take antidepressant medication. 

A study done in the Netherlands showed that women who expressed a desire for counseling turned out to have a much higher risk for postpartum depression.  This would seem to indicate that pregnant women are pretty good at knowing what they need, so it would make sense to give them what they ask for. 

Another interesting study, this one done in the USA, indicates that the risk of suicide is inversely related to social integration.  That is, the more integrated a person is to his or her community, the lower the risk of suicide. 

Poor social integration and suicide: fact or artifact? A case-control study

Center for the Study and Prevention of Suicide, University of Rochester Medical Center, 300 Crittenden Boulevard, Rochester, NY 14642, USA


Background. Sociological studies have shown that poor social integration confers suicide risk. It is not known whether poor integration amplifies risk after adjusting statistically for the effects of mental disorders and employment status.

Method. A case-control design was used to compare 86 suicides and 86 living controls 50 years of age and older, matched on age, gender, race, and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls. Social integration was defined in reference to two broad levels of analysis: family (e.g. sibship status, childrearing status) and social/community (e.g. social interaction, religious participation, community involvement).

Results. Bivariate analyses showed that suicides were less likely to be married, have children, or live with family. They were less likely to engage in religious practice or community activities and they had lower levels of social interaction. A trimmed logistic regression model showed that marital status, social interaction and religious involvement were all associated with suicide even after statistical adjusting for the effects of affective disorder and employment status. Adding substance abuse to the model eliminated the effects of religious involvement.

Conclusions. The association between family and social/community indicators of poor social integration and suicide is robust and largely independent of the presence of mental disorders. Findings could be used to enhance screening instruments and identify problem behaviors, such as low levels of social interaction, which could be targeted for intervention.

Although the study did not look specifically at postpartum depression, prior studies did establish a link between a lack of adequate social support and an increased risk for postpartum depression.  I was not able to find a single study that tied all of these things together; that is, I could not find a study that links poor social support, postpartum depression, and suicide.  It would be hard to do such a study, though, because you would need to enlist a very large study population in order to find a statistically-significant correlation. 

The Rochester study looked at quantifiable aspects of social integration.  I would be interested to see someone try to study things that are harder to quantify, although this -- not surprisingly -- would be harder to do.  What is the effect of the attitudes in society, and in the family, toward situations such as unmarried women who are pregnant, marriages in which the in-laws do not like the spouse, interracial marriage, etc.?  Could it be that a high degree of harmony and tolerance would lower the rate of maternal mortality?

What all of this shows is that, not only are we failing to meet our responsibilities in Iraq, we are not doing a very good job here in the USA.  Some of the recommended interventions would cost money, but some would not.  Even the ones that cost money would be well worth the investment. 

And maybe we could learn to be nice to each other.  That probably would help.

(Note: The Rest of the Story/Corpus Callosum has moved. Visit the new site here.)
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