Quick Safety Issue 67: Mental health conditions leading cause of pregnancy-related deaths

Editor’s Note: In June 2022, the White House issued a report stating that the United States is facing a maternal health crisis.¹ The Joint Commission has been actively working to help address the myriad and complex causes of maternal mortality and morbidity. This Quick Safety addresses one aspect – mental health conditions and their role in pregnancy-related death. In addition, The Joint Commission is also issuing a Sentinel Event Alert that delves into eliminating barriers and racial disparities causing mortality and morbidity in pregnant and postpartum patients. See the Alert for additional resources and actions your organization can take to address the maternal health crisis.

Issue:

A recent report from the Centers for Disease Control and Prevention (CDC) evaluating causes for maternal death indicated issues related to mental health, such as depression, anxiety, death by suicide, and substance use disorders (SUDs) as the most frequent underlying cause, followed by clinical conditions (details below).² This finding signals the need for health care organizations to have a process to screen all pregnant patients for risk factors using evidence-based tools so that appropriate interventions may be instituted in a timely and ongoing manner.

Screening for depression or mental health disorders allows for treatment and control of symptoms that may help prevent self-harm and negative family outcomes, such as impaired infant bonding, or neglect.³ Pregnant and postpartum patients have significantly more contact with healthcare providers, increasing the opportunities for screening and referral for appropriate treatment.⁴

The CDC data is derived from Maternal Mortality Review Committees (MMRCs) in 36 states that investigated 1,018 pregnancy-related deaths; an underlying cause of death was identified for 987 of those deaths. Almost 23% of the deaths were related to mental health conditions (22.7%). The other most frequent underlying causes were hemorrhage (13.7%), cardiac and coronary conditions (12.8%), infection (9.2%), thrombotic embolism (8.7%), and cardiomyopathy (8.5%). These six conditions accounted for over 75% of pregnancy-related deaths. The MMRCs determined that of the 1,018 pregnancy-related deaths, 84% were preventable.²

The leading underlying cause of death varied by race and ethnicity, with mental health conditions being the leading underlying cause of death among Hispanic and non-Hispanic White persons.²

Of note, most pregnancy-related suicide deaths occur in the postpartum period, with 62% of pregnancy-related suicides occurring between 43-365 days postpartum, followed by 24% during pregnancy and 14% within 42 days postpartum.⁴

Depression, anxiety and SUD among leading mental health conditions for pregnant patients

The American College of Obstetricians and Gynecologists (ACOG) has reported that perinatal depression, which includes major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery, is one of the most common medical complications during pregnancy and the postpartum period, affecting one in seven patients.⁵ 

A 2016 study found perinatal depression to be under diagnosed and under treated; at that time, the study reported that of 8.2% depressed pregnant patients, only 12% had received mental health care in the prior year.⁶ This study took place several years before the coronavirus pandemic, which likely contributed to mental health conditions in pregnant patients.⁷

A prior MMRC of 14 states found that mental health conditions for pregnancy-related mental health deaths included:⁸

• Preexisting or history of depressive disorder
• Anxiety disorder
• SUD
• Other mood or psychotic disorder
• Postpartum depression

Another finding was that each person could have multiple conditions, and that substance use, life stressors, history of or current substance use (with or without diagnosis of SUD) was present in 67% of deaths. Common life stressors included medication instability, defined as an indication that the person stopped taking psychiatric drugs or medications for treatment of SUD or had a change in medication or dosage during pregnancy or postpartum (39%); removal of a child from the person’s custody or Child Protective Services involvement (24%); and previous suicide attempt or attempts (22%).⁸

Risk Factors for Perinatal Depression

Depression during pregnancy:

• Maternal anxiety
• Life stress
• History of depression
• Lack of social support
• Unintended pregnancy
• Medicaid insurance
• Domestic violence
• Lower income
• Lower education
• Smoking
• Single status
• Poor relationship quality

Postpartum depression:

• Depression during pregnancy
• Anxiety during pregnancy
• Experiencing stressful life events during pregnancy or the early postpartum period
• Traumatic birth experience
• Preterm birth/infant admission to neonatal intensive care
• Low levels of social support
• Previous history of depression
• Breastfeeding problems