While it is easy to think that once a new mother has survived delivery, the threat of mortality drops -- many patients remain at elevated risk over the following year. The WHO defines late maternal deaths as a death occurring between 42 days and one-year postpartum. These cases make up a substantial proportion of maternal deaths. In the United Kingdom from 2014–2019, an average of 55% of maternal deaths occurred after 42 days postpartum1,2; in France from 2012–2015, 24% of maternal deaths occurred after 42 days3; in the United States in 2018, 42% of maternal deaths were after 42 days4; and in New South Wales, Australia from 2000–2006, a staggering 71% of maternal deaths occurred after 42 days5. While there has been a global decrease in maternal mortality, there has not been a corresponding decline in late maternal deaths6.
Recently, the medical community has given increased attention to the role that psychiatric illnesses play in maternal mortality. Both suicide and accidental overdoses are leading causes of death in this population2. These causes of deaths have been deemed to be more preventable than obstetrical causes of maternal death2, meaning efforts to treat and prevent these conditions during and after pregnancy have the potential to create a strong impact. In the UK, an average of 80% of maternal deaths from suicides and 84% of maternal deaths due to accidental overdose were after 42 days post-partum1,2, and in France, 77% of maternal deaths from suicides were after 42 days post-partum3. A report from Queensland, Australia from 2004–2017 showed similar results, with 74% of maternal mortality due to suicide occurring between 42 days and one-year7. These causes of death are not occurring in an evenly distributed manner across the pregnant and postpartum periods, highlighting the need for specific interventions during this late postpartum period.
Given that a considerable portion of psychiatric causes of death occur in the late maternal death period, increased attention is needed on maternal mental health and substance use between 42 days and one-year postpartum. During this period, obstetricians, pediatricians, and primary care providers should be aware of the continuing risk of mortality to the mother and can mitigate this risk by screening for depression and substance use using validated tools, such as the Edinburgh Postnatal Depression Scale and The 5 P’s. Postpartum maternal support, especially for those returning to the work force, is critical during the first full year considering sleep deprivation and increased stress of changing family dynamics. We have previously suggested increased psychiatric participation on maternal mortality review boards8 to help guide prevention and treatment. Globally, countries that only track maternal mortality to 42 days postpartum need to expand to one-year postpartum so that critical information on late maternal deaths is not missed. Ensuring that all maternal deaths in the 42 days to one-year period are included in the maternal mortality ratio will help to improve the accuracy of reporting, increase awareness and resources, and hopefully lead to a reduction in maternal deaths.
Synopsis:
Increased awareness and psychiatric intervention is needed to reduce late maternal deaths
Conflict of Interest
Wesley R White- No disclosures to make.
Jessica L Coker- Currently receives funding from NIH/NIDA (R34DA050261, 1UG1HD107650-01). This funding does not pertain to the subject of this commentary.
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