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Suicide & Maternal Depression: Uncovering the Prevalence of Maternal
Depression Resulting in Self-HarmApril 4th, 2018
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3
Presenter
M. Camille Hoffman, MD, MSCS
• Associate Professor of Maternal Fetal Medicine in the University of Colorado School of Medicine departments of Obstetrics & Gynecology and Psychiatry
Suicide and Maternal Depression: Uncovering the Prevalence of
Maternal Depression Resulting in Self-Harm
Camille Hoffman, MD, MSCSDivision of Maternal Fetal Medicine
Department of Obstetrics & Gynecology and PsychiatrySCL Health & University of Colorado School of Medicine
4
Disclosures
• I have no relevant financial disclosures or conflicts of interest
• I represented the Society for Maternal Fetal Medicine (SMFM) on the Council on Patient Safety in Women’s Health bundle on Maternal Mental Health
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Objectives
• Broadly review U.S. and Colorado Maternal Mortality statistics
• Highlight recent data regarding self-harm as a leading cause of maternal mortality
• Discuss ongoing national efforts and resources to reduce maternal mortality
6
Please indicate whether you are a:
• Researcher
• Suicide prevention/treatment practitioner
• Injury prevention practitioner
• Physician – Mental Health
• Physician – Obstetrics/Perinatal
• Midwife/Advanced practice nurse
• Other
POLL 1
7
Please answer the poll
Media
8
• United States:-Highest Maternal Mortality rate of any high resource country
-only country outside of Afghanistan and Sudan where the rate is rising.
9July 17, 2015
21.5/100,0009.8/100,000 births
Maternal Mortality in the US 1999-2014
10
All of the following are leading causes of Maternal Mortality except:
• Hemorrhage (excessive bleeding)
• Self-harm (suicide and drug overdose)
• Cardiovascular diseases
• Cancer
• Hypertension (high blood pressure)
POLL 2
11
Please answer the poll
Amniotic fluid embolism- 4.2% Unintentional injury- 2.8%Homicide- 3.3% Anesthesia complications- 2.3%Cerebrovascular accidents- 2.8% Autoimmune disease- 2.3%
Leading Underlying Causes of Pregnancy-Related Deaths
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Pregnancy Related Deaths: Timing
http://reviewtoaction.org 13
Timing & Leading Underlying Cause
http://reviewtoaction.org 14
Pregnancy Mortality Surveillance System (PMSS)
Pregnancy-related Mortality by Race & Hispanic Ethnicity
2006-2013
15 15
Pregnancy-related Mortality
Non-Hispanic Black & White
http://reviewtoaction.org 16
Preventability & Timing
http://reviewtoaction.org 17
Contributing Factors
http://reviewtoaction.org 18
11.1
7.7
10.0
14.6
11.8 11.7
14.0
7.4
7.3
10.9
9.7
11.6
9.2
6.2
16.9
8.9
15.1
13.1
12.19.9
9.9
9.8
13.3
12.7
15.516.9
16.6
19.3
19.9
22.0
0.0
3.0
6.0
9.0
12.0
15.0
18.0
21.0
24.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
California Rate
United States Rate
Maternal Mortality Rate,
California and United States; 1999-2013
Mate
rnal D
eath
s p
er
100,0
00 L
ive B
irth
s
HP 2020 Objective – 11.4 Deaths per 100,000 Live Births
California: ~500,000 annual births, 1/8 of all US births
19
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42
days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same
codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-
2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health,
Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015.
*CMQCC QI Taskforces and Toolkit supported by CDPH, thru Title V Grant support 19
11.1
7.7
10.0
14.6
11.8 11.7
14.0
7.4
7.3
10.9
9.7
11.6
9.2
6.2
16.9
8.9
15.1
13.1
12.19.9
9.9
9.8
13.3
12.7
15.516.9
16.6
19.3
19.9
22.0
0.0
3.0
6.0
9.0
12.0
15.0
18.0
21.0
24.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
California Rate
United States Rate
Maternal Mortality Rate,
California and United States; 1999-2013
Mate
rnal D
eath
s p
er
100,0
00 L
ive B
irth
s
HP 2020 Objective – 11.4 Deaths per 100,000 Live BirthsOB Hemorrhage
QI Toolkit*, Collaboratives
Preeclampsia QI Toolkit*,
Collaboratives
20
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42
days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same
codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-
2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health,
Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015.
*CMQCC QI Taskforces and Toolkit supported by CDPH, thru Title V Grant support 20
AIMAlliance for Innovation in Maternal Health
Cooperative Agreement between the
Council on Patient Safety in Women’s Health Care and
the Maternal and Child Health Bureau
2121
22
23
• American Hospital Association (AHA)• Association of Maternal Child Health Programs (AMCHP)• Association of State and Territorial Health Officers (ASTHO)• Center for Medicaid and CHIP Services (CMCS-CMS)
– Focus on postpartum and inter-conception care (improving care for women with chronic disease and improving the health of women prior to conception)
• Center for Medicare and Medicaid Innovation (CMMI-CMS)– Partnership for Patients: Hospital Engagement Networks (HENs):
focus on Hemorrhage and Preeclampsia
• Centers for Disease Control (CDC)– Promoting Perinatal Quality Collaboratives (PQC’s)– Enhancing state maternal mortality review committees
• The Joint Commission (TJC)• The March of Dimes
Key National Partners for AIM: Stitching them all together (in alpha order…)
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Obstetric Hemorrhage
Severe Hypertensionin Pregnancy
Maternal VTE Prevention
Patient, Family and Staff Support after Severe Maternal
Event
Safe Reduction of Primary
Cesarean Births
Safety Bundles
Safety Tools
Maternal Early Warning Criteria
Severe Maternal Morbidity Case Review Forms
“Wrap-around bundles
Reducing Disparities in
Maternity Care
Postpartum Visit / Inter-
Conception Care
24safehealthcareforeverywoman.org
Implementation Toolkit
Developed by AIM Workgroups
AIM supported Patient Safety Bundles http://safehealthcareforeverywoman.org/
Maternal Mental Health
Developed by “Council”Workgroups
Surgical Site Infections
24
Obstetric Hemorrhage
Severe Hypertensionin Pregnancy
Maternal VTE Prevention
Patient, Family and Staff Support after Severe Maternal
Event
Safe Reduction of Primary
Cesarean Births
Safety Bundles
Safety Tools
Maternal Early Warning Criteria
Severe Maternal Morbidity Case Review Forms
“Wrap-around bundles
Reducing Disparities in
Maternity Care
Postpartum Visit / Inter-
Conception Care
25safehealthcareforeverywoman.org
Implementation Toolkit
Developed by AIM Workgroups
AIM supported Patient Safety Bundles http://safehealthcareforeverywoman.org/
Maternal Mental Health
Developed by “Council”Workgroups
Surgical Site Infections
25
What is a Patient Safety Bundle?
Bundle theory in clinical care improvement: Individual elements based on solid science.
Endpoint is the improvement of clinical outcomes.
Emphasis on improving process reliability.
Reser R, Pronovost P, Haraden C, et aUsing a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Safe. 2005 May;31(5):243-8.
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Why was a “Safety Bundle” on Maternal Mental Health created?
• Perinatal mood and anxiety disorders are the most common pregnancy complication
• Self-harm is a leading cause of Maternal Mortality
• Opioid use disorders are becoming more common among women of childbearing age
• All of the above
POLL 3
27
Please answer the poll
Why Do We Need a Patient Safety Bundle for Maternal Mental Health?
Untreated maternal depression can have a devastating effect on women, their infants and their families.
In extreme form, depressive psychosis can lead to maternal suicide and/or infanticide.
Maternal suicide within a year of birth is emerging as a significant cause of maternal mortality, and is probably underreported.
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© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. Published by Lippincott Williams & Wilkins, Inc.
Koch A, Rosenberg D, Geller S. Higher Risk of Homicide Among Pregnant and Postpartum Females Aged 10-29 Years in Illinois, 2002-2011. Obstetrics & Gynecology. 2016; 128(3):440-446. DOI: 10.1097/AOG.00000000000015590
Mortality Risk Illinois: Homicide, Suicide
• Ten-year pregnancy-associated mortality rates for deaths by violence and injury compared with the leading obstetric causes in Illinois, 2002-2011.
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Colorado Maternal Mortality Review Committee
• Established 1993• Prior outreach focused on
medical conditions such as hypertensive disease
• Recognition of high proportion of drug overdoses & suicides
• Every Mother Initiative Action Learning Collaborative (AMCHP/Merck)
www.wikipedia.org
30
Colorado: Detailed Data Extraction (by Obstetrics & Gynecology resident)
211 maternal deaths in Colorado between 2004-2012(614,154 live births during this time period)
Data collected from:• Birth certificate• Death certificate• Labor & Delivery records • Prenatal and postpartum records • Autopsy
– Toxicology results
• Coroner’s report• Law enforcement report
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Original Research
Maternal DeathsFrom Suicide and Overdosein Colorado, 2004–2012
Torri D. Metz, MD, MS, Polina Rovner, MD, M. CamilleHoffman, MD, MSc, Amanda A. Allshouse, MS,Krista M. Beckwith, MSPH, and Ingrid A. Binswanger, MD, MPH, MS
OBJECTIVE: To ascertain demographic and clinical char-
acterist ics of maternal deaths from self-harm (accidental
overdose or suicide) to identify opportunit ies for pre-
vention.
METHODS: We report a case series of pregnancy-
associated deaths resulting from self-harm in the state of
Colorado between 2004 and 2012. Self-harm deaths were
identified from several sources, including death certifi-
cates. 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% (n5 63) resulted
from self-harm. The pregnancy-associated death ratio
from overdose was 5.0 (95% confidence interval [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 re-
cords were obtained for 94% (n5 59) of women with
deaths from self-harm. Deaths were equally distributed
throughout the first postpartum year (mean 6.216 3.3
months postpartum) with only six maternal deaths dur-
ing pregnancy. Seventeen percent (n5 10) had a known
substance use disorder. Prior psychiatric diagnoses were
documented in 54% (n5 32) and prior suicide attempts
in 10% (n5 6). Although half (n5 27) of the women with
deaths from self-harm were noted to be taking psycho-
pharmacotherapy at conception, 48% of them discon-
tinued the medications during pregnancy. Fifty women
had toxicology testing available; pharmaceutical opioids
were the most common drug identified (n5 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, health care providers, health care systems,
and both governments and organizations at the com-
munity and national levels may allow for a reduction in
maternal deaths.
(Obstet Gynecol 2016;128:1–9)
DOI: 10.1097/AOG.0000000000001695
Reduction of maternal mortality has become a pri-
ority in the United States and other nations.1,2 As
a consequence of collaborative efforts among the
American College of Obstetricians and Gynecolo-
gists, the Centers for Disease Control and Prevention
(CDC), the Society for Maternal-Fetal Medicine, and
others, common causes of pregnancy-related mortal-
From theUniversity of Colorado School of Medicine, Aurora, and Denver Health
Medical Center, Department of Obstetrics and Gynecology, theColorado School
of Public Health at the University of Colorado Denver, the Department of
Biostatistics and Informatics, the Colorado Department of Public Health and
Environment, and the Institute for Health Research, Kaiser Permanente
Colorado, Denver, Colorado.
Supported by the Agency for Health care Research and Quality Grant number
R24 HS022143-01 and National Institutes of Health/National Center
for Research Resources Colorado CTSI Grant No. UL1 TR001082. I. A.
Binswanger was supported by the National Institute on Drug Abuse of the
National Institutes of Health under Award Number R34DA035952. T. D.
Metz was supported by the National Institute on Child Health and Human
Development under Award Number 2K12HD001271-16.
The content is solely the responsibi lity of the authors and does not necessarily
represent theofficial viewsof theAgency for HealthcareResearch and Quality or
theNational Institutes of Health. In addition, theColorado Maternal Mortality
Review Committeereceived funding from theAssociation of Maternal and Child
Health Programs(AMCHP) and Merck for Mothers to assist with theexpansion
of the committee and to allow for further exploration of suicide as a cause of
maternal death in Colorado to identify possible points of intervention.
Presented as a poster at the Society for Maternal-Fetal Medicine 36th Annual
Meeting, February 1–6, 2015, Atlanta, Georgia.
Theauthors thank Kirk Bol and Lauren Bardin at theColorado Department of
Public Health and Environment for their assistance with obtaining birth certif-
icatedata for all livebirths over thestudy period aswell as for identification of
the cases of maternal death.
Corresponding author: Torri D. Metz, MD, MS, Denver Health Medical Center,
Department of Obstetrics and Gynecology, 777 Bannock Street, MC 0660,
Denver, CO 80204; e-mail: [email protected].
Financi al Disclosure
Theauthors did not report any potential conflicts of interest.
© 2016 by TheAmerican Collegeof Obstetriciansand Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/16
MS NO: ONG-16-939
Copyright Ó by The American College of Obstetriciansand Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
VOL. 128, NO. 5, NOVEMBER 2016 OBSTETRICS & GYNECOLOGY 1
Torri D. Metz, MD, MS, Polina Rovner, MD, M. Camille Hoffman, MD, MSc, Amanda A. Allshouse MS,
Krista M. Beckwith MSPH, and Ingrid A. Binswanger, MD, MPH, MS
Total N=211
© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. Published by Lippincott Williams & Wilkins, Inc.
Classifications are mutually exclusive
32
Self-Harm Results
• N=63 women
• Detailed records available for n=59
• Suicide: 4.0/100,000 live births (2x higher than other reports)
• OD: 5.3/100,000
Combined self-harm rate: 9.3/100,000 live births
33
Temporal distribution of maternal deaths from self-harm by trimester of pregnancy and number of months postpartum.
Mortality Risk: Self-Harm
Metz T, Rovner P, Hoffman MC, Allshouse A, Beckwith K, Binswanger I, Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012. Obstetrics & Gynecology. 2016; 128(6):1233-1240. DOI: 10.1097/AOG.0000000000001695
34
Variable Deaths N=59
CO Live Births N=614,154
Maternal age at death, yrs (mean±SD)
27.6 ± 5.5
Gravidity, mean (95% CI) 2.7 (2.3, 3.2) 1.8 (1.8,1.8)
Residence, n (%)UrbanRuralFrontierUnknown
47 (79.7)9 (15.3)2 (3.4)1 (1.7)
539,793 (87.9)61,175 (10.0)13,169 (2.1)
17 (0.0)
Race, n (%)WhiteHispanicBlackAmerican IndianAsian
44 (74.6)10 (17.0)
1 (1.7)2 (3.4)1 (1.7)
368,782 (60.0)169,344 (27.6)
29,477 (4.8)5900 (1.0)
22,424 (3.7)
Characteristics of Maternal Deaths in Colorado 2004-2012
35
Variable DeathsN=59
CO Live Births N=614,154
Employment status at delivery, n (%)Currently employedUnemployedUnknown
14 (22.2)42 (66.7)7 (11.1)
-
Married at delivery, n (%) 24 (41.4) 456,931 (74.4)
Married at death, n (%) 31 (49.2) -
Reference to FOC involvement, n (%) 43 (68.3) -
Insurance Statusa, n (%)MedicaidPrivate InsuranceSelf-Pay/UninsuredOther/Unknown
34 (54.0)15 (23.8)
5 (7.9)9 (14.3)
142,870 (35.2)213,321 (52.5)
19,425 (4.8)30,404 (7.5)
a Payer variable not collected until 2007, total n=406,020
Characteristics of Maternal Deaths in Colorado 2004-2012
36
Known Psychiatric Diagnoses
• 32 women (54%) had a known psychiatric diagnosis documented in medical record
– Depression, n=21 (36%)
– Anxiety, n=14 (24%)
– Bipolar Disorder, n=7 (12%)
– Schizophrenia, n=3 (5%)
– Other, n=5 (9%)
*some women had more than one listed diagnosis37
Psychiatric History
• 10% (n=6) had prior suicide attempts
• 43% (n=27) were taking psychiatric meds during pregnancy
– Largest category antidepressants (SSRIs)
• 13/27 (48%) stopped psych meds for pregnancy
– 9 cases self-discontinued– 4 cases recommended by provider
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Toxicology
39
Colorado Data Conclusions
• Likely have a higher rate of suicide and self-harm in CO
• Data consistent with some prior published data for demographics
• White non-Hispanic, rural/frontier, Medicaid, unmarried population at higher risk
40
• >50% had a known psychiatric diagnosis
– Most common diagnosis was depression
• Almost 50% stopped psych meds for pregnancy
– Either self-discontinued or provider recommended
Colorado Data Conclusions
41
Colorado Maternal Mortality, Next Steps
• Recognition of suicide and overdose as a leading causes of maternal death
• Psychiatric representation (+ SUD experts) on MMRC
• Provide outreach and education
• Change the conversation about psych meds in pregnancy
• Identify providers of psychiatric care in CO with perinatal expertise
42
Metz T, Rovner P, Hoffman MC, Allshouse A, Beckwith K, Binswanger I, Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012. Obstetrics & Gynecology. 2016; 128(6):1233-1240. DOI: 10.1097/AOG.0000000000001695
Tier of Intervention
• Individual patients
• Health care providers
Examples of Possible Interventions
• Pharmacotherapy for psychiatric conditions
• Patient education about available resources
• Health care provider education and access to available mental health and substance use disorder treatment
• Judicious prescribing of opioids
• Screening, identification and referral of women at risk
43
Metz T, Rovner P, Hoffman MC, Allshouse A, Beckwith K, Binswanger I, Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012. Obstetrics & Gynecology. 2016; 128(6):1233-1240. DOI: 10.1097/AOG.0000000000001695
Tier of Intervention
• Health Care Delivery
• Community, state, national
Examples of Possible Interventions
• Multidisciplinary care teams with System expertise in substance use and mental health disorders
• Improved access to psychiatric care with urgent availability
• Universal screening policies as part of care delivery
• Integrated care systems with obstetricians, primary care, and pediatrics
• Hotlines for women to call when in crisis
• Outreach through patient navigation or nursing home visitation programs
• Public education to reduce stigma associated with mental health disorders
• Surveillance and quality improvement reviews of maternal self-harm incidents
44
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The Perinatal Period is the ideal time for detection and treatment of PMADs
Regular opportunities to screen and engage women in treatment.
There is time to treat and improve!
Front line providers have a pivotal role.
De-stigmatize
Educate
Proactively initiate and welcome conversation.
©MCPAP For Moms 46
Manage Suicidal Ideation
Suicide accounts for approximately 20% of postpartum deaths in U.K. (Khalifeh, H, Hunt, I,
Appleby, L & Howard, L. (2016). Lancet)
Screen patients with depression foro Suicidal thoughts, how often in past 2 weeks?
o Suicidal intent/plan
o What has stopped them so far?
o Availability/lethality of method
Activate emergency referral protocol for women with suicidal/homicidal ideationo Consultation, transportation, admission
o Maintain open communication among team members
o Post event planning for care coordination and follow-up
47
So, where are the greatest opportunities for improvement?
• Bundles and Checklists- they are free!
–www.safehealthcareforeverywoman.org
• Start during prenatal care
–Assess risks
–Open the conversation
–Risk reduce (screening and treatment)
–Judicious prescribing
• Interdisciplinary team work
• County, local and state programs (SUDs)
• Patient/family resources 48
• https://www.nichd.nih.gov/ncmhep/MMHM/Pages/index.aspx
• http://www.postpartum.net
• http://store.samhsa.gov/shin/content/SMA14-4878/SMA14-4878.pdf
• www.safehealthcareforeverywoman.org
• www.mcpapformoms.org
• www.colorado.gov/pacific/cdphe/pregnancy-related-depression
Links for Clinicians
Links for Patients & Families
49
Thank you!
Maternal Mental Health: Perinatal Depression and Anxiety Patient Safety Bundle Workgroup
Chairs: Susan Kendig, JD, WHNP-BC
John Keats, MD
• Readiness• Emily Miller – Lead
• Susan Kendig
• Katherine Wisner
• Recognition • Tiffany Moore-Simas – Lead
• Ariela Frieder
• Chris Raines
• Response • Camille Hoffman – Lead
• Barbara Hackley
• Pec Indman
• Reporting & Systems Learning • Lisa Kay – Lead
• John Keats
• Kisha Semenuk
• Council Support• Lauren Lemieux
50
Thank you!
• CDC
• AMCHP and Merck for Mothers for funding the Every Mother Initiative Action Learning Collaborative
• Colorado data:
– Torri Metz, MD, MSc
– Krista Beckwith, MPH
– Polina Rovner, MD
– Ingrid Binswanger, MD
– CDPHE and the Colorado MMRC members
51
52
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Please type your questions into the Q & A pod
53
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