Breaking the Silence: Towards Increased Awareness and Identification of Perinatal Suicide Risk
About the Authors
Arianna Lane, MA, is a third-year Clinical Child Psychology PhD student at the University of Denver. Arianna’s research explores processes of risk and resilience underlying pathways between early experiences (e.g. childhood adversity, benevolent childhood experiences) and adulthood mental health outcomes, with a particular focus on perinatal suicide risk in parents of diverse backgrounds and identities. She received her BA in Psychology from the University of Southern California (2018). She is beginning a clinical externship at the Asian Pacific Clinic, a behavioral health clinic that serves local immigrant and refugee populations in Aurora, CO.
Angela Narayan is an Associate Professor in the Clinical Child Psychology PhD program in the Department of Psychology at the University of Denver (DU). She has studied the enduring effects of early childhood maltreatment, exposure to violence and homelessness on long-term pathways of risk and resilience. She focuses on how the perinatal period is a window of opportunity to promote resilience and reduce traumatic stress for low-income, underserved families. Dr. Narayan founded the PROTECT Lab at DU, which investigates how risk and resilience transfer across generations. She is a recipient of ZERO TO THREE's 4th Annual Infant and Early Childhood Mental Health (IECMH) Emerging Leadership Awards.
Pregnancy and childbirth mark a transformative period for parents, often celebrated as a time of hope, joy, and new life. However, for many parents, welcoming a baby into the world also comes with unanticipated stress and unique challenges.
Although postpartum depression is increasingly recognized as a common experience, another critical perinatal issue remains overlooked: risk for suicide. Astonishingly, death by suicide is a leading cause of mortality during the perinatal period (defined as pregnancy, delivery, and one year after childbirth), with the highest risk being 9-12 months post-partum (Grigoriadis et al., 2017).
Perinatal suicidal ideation and attempts (which will be referred to as suicidal thoughts and behaviors, or STBs, in this article) are well-documented risk factors for death by suicide and are also on the rise. Reports of perinatal STBs nearly tripled from 2006 to 2017 in the United States (Admon et al., 2021). Although death by suicide appears to occur at a lower rate during the perinatal period than in the general population, suicidal ideation is more common in pregnant individuals than the general public (Gelaye et al., 2016). Thoughts about suicide are not only severely distressing for parents, but when they occur during pregnancy, these thoughts increase risk for developing subsequent mental health issues, such as post-partum depression (Turkcapar et al., 2015). Despite recent research on the prevalence and impact of perinatal STBs, this critical public health issue remains largely unacknowledged and insufficiently addressed.
Efforts to understand and treat perinatal suicide risk are largely (cis) woman-centric with a focus on “mothers,” neglecting childbearing individuals with diverse gender identities. Gender-diverse parents may be at amplified risk for perinatal STBs due to discrimination, stigmatization, and lack of gender-affirming care. Moreover, information about perinatal STBs rarely extends to non-gestational caregivers (e.g. fathers or partners who identify as sexual or gender minorities), despite their impact on these individuals. Studies demonstrate that approximately 4.8% of non-gestational caregivers report STBs during the postpartum period (note: the few existing studies are conducted with cis men/fathers; Quevedo et al., 2011). Fathers’ mental health difficulties are linked with mental illness in the gestational caregiver, ineffective parenting, dysfunctional family dynamics, and poor developmental outcomes for children (Paulson et al., 2010; Giallo et al., 2015; Sweeney & MacBeth, 2016). Further, death by suicide of a non-gestational caregiver results in profound grief and leaves families with young children grappling with the complete absence of a primary caregiver. Thus, identifying and addressing perinatal suicide risk in both gestational and non-gestational caregivers is not only crucial for individual well-being, but also imperative for the overall health and resilience of families.
More broadly, the impact of perinatal STBs on child well-being can be pervasive throughout development. Infants and young children are highly sensitive to their caregivers’ emotional states and may experience disruptions in attachment when a parent experiences suicidal thoughts or behaviors. Parental STBs may either be directly observable to children or may be indirectly evident via unpredictable and confusing changes in parents’ affect, mood, and responsiveness to children (Nakić Radoš, 2021). In turn, attachment, which is crucial for healthy emotional and cognitive development, can be compromised and increase risk for children’s long-term emotional and behavioral problems, severe distress, and difficulties coping. Research shows that children who undergo the trauma of parental death by suicide are more likely to have mental health problems, academic difficulties, and STBs themselves (Berg et al., 2016; Guldin et al., 2015). Despite the diffuse, pervasive, and pernicious impact of perinatal STBs, this issue lacks proper attention. In this article we aim to 1) shed light on oversight of perinatal STBs; 2) raise awareness about perinatal suicide risk in parents with diverse identities; and 3) advocate for thoughtful, inclusive, evidence-based screening protocols for perinatal STBs to protect the health and well-being of all parents, infants, and families.
Historical Oversight of Perinatal STBs
Epidemiological oversight of perinatal suicide risk has been limited by historical and ongoing challenges in reporting perinatal deaths by suicide. The CDC’s current reporting system for maternal deaths relies heavily on information included in death records processed by the National Center for Health Statistics (NCHS). In 2003, the CDC began to implement a pregnancy status checkbox on death certificates, allowing medical examiners to identify whether individuals were currently pregnant or pregnant within the last year (Horon & Cheng, 2011). Since then, U.S. states have gradually adopted procedures for revising death reporting certificates, but it was not until mid-year 2017 that all states had implemented the pregnancy status checkbox. As a result, researchers estimate that pregnancy status was unknown in 30.0% of deaths by suicide from 2005 to 2010 (Wallace et al., 2016).
Though adoption of the pregnancy checkbox was a step towards more accurate measurement of perinatal STBs, several outstanding limitations led to underestimations of perinatal suicide in the current reporting system. For one, certainty of death by suicide is difficult to measure in any population. More notably, until 2012, death by suicide and overdose were considered “incidental” and excluded from death counts during the perinatal period, which have historically been referred to as “maternal deaths” (Chin et al., 2022). Thus, “maternal mortality” rates were severe underestimations, as they did not encompass deaths associated with suicide or overdose. Following reclassifications, it was estimated that 13.0-36.0% of deaths from pregnancy through one year postpartum are due to suicide (Lommerse et al., 2019). These numbers demonstrate the frequency and gravity of this issue (as well as the ongoing lack of precise estimates) among pregnant and postpartum individuals. Furthermore, STBs during the pregnancy period and the year following birth have different antecedents, consequences, and implications for parents and infants — simply reporting “pregnancy status” is far from enough information to meaningfully measure perinatal death by suicide. To standardize reporting of maternal deaths, the U.S. passed the Preventing Maternal Deaths Act in 2018, which provides state-level funding for Maternal Mortality Review Committees or Panels (MMRCs) to track perinatal “maternal” deaths. One of the first formal reports from a coalition of MMRCs (2018) identified suicide as an emerging issue that is in serious need of attention (Building U.S. Capacity to Review and Prevent Maternal Deaths, 2018). 
However, a glaring limitation of this current legislation is the lack of inclusiveness inherent in the term “maternal,” which as noted above, excludes pregnant individuals of diverse gender identities, as well as non-gestational parents who may also experience perinatal STBs.
Barriers to Reporting Perinatal STBs
In addition to measurement and classification issues, perinatal STBs often go underreported due to mental health stigma, societal pressures that influence expectations of parents and their parenting, and lack of provider awareness about the importance and process of screening for STBs. Though mental health challenges during the perinatal period (e.g. postpartum depression [PPD]) have recently gained recognition and awareness, stigma endures, and many parents still face barriers to disclosing their suffering. Recent studies in the United States estimate that approximately 13.9% of individuals experience post-partum depression (Getahun et al., 2023), yet only 18.1% of those with symptoms seek help from a healthcare provider (Manso-Cordoba et al., 2020). Undetected STBs may be even greater, due to even more limited awareness of their frequency, and parents’ fears about repercussions, such as being separated from children as a result of psychiatric hospitalization or child welfare involvement.
For pregnant individuals who are minoritized according to race, ethnicity, immigration status, gender identity, sexual orientation, or identification within other underserved groups, mental health stigma and fears of repercussions are compounded by unique barriers that hinder safe disclosure of STBs and limit access to care. These individuals may face stigma related to cultural values, lack of provider diversity and cultural sensitivity, provider discrimination, linguistic differences, and past negative healthcare experiences that produce mistrust in the healthcare system (Eylem et al., 2020). Furthermore, child welfare involvement unfairly and disproportionately affects families with minoritized ethnic and racial identities, which may enhance these caregivers’ fears about disclosure (Harris, 2021). Due to these kinds of barriers, individuals who identify as racial and ethnic minorities are less likely to disclose mental health symptoms, in comparison to White individuals (Eylem et al., 2020; Rüsch et al., 2009). For sexual and gender minority individuals specifically, disclosing STBs may be particularly challenging during the perinatal period, due to lack of gender-affirming and trauma-informed care; societal pressures to confirm to expectations of traditional, cis, heterosexual two-parent households; lack of legal parental rights, and increasingly restricted access, or complete lack thereof, to reproductive health care and decision making (Pezaro et al., 2023). Reducing the stigma of perinatal STBs is crucial for improving access to proper care, and healthcare providers play a significant role in encouraging or discouraging help-seeking behaviors (Parcesepe & Cabassa, 2013). Perinatal healthcare providers must be educated about perinatal STBs to screen for them, spread awareness of their prevalence, create a safe environment for caregivers to disclose STBs, and connect high-risk individuals with targeted referrals. Further, it is imperative that they receive comprehensive training to be able to facilitate conversations and provide optimal care to pregnant individuals and partners of diverse identities and backgrounds.
Known Risk Factors for Perinatal STBs
Distinct risk factors create susceptibility for STBs during pregnancy and one-year postpartum. The prenatal period is characterized by psychological, hormonal, and biological changes that interfere with emotion regulation; sleep latency and length; elevated symptoms of anxiety; and potentially, unresolved traumatic stress in individuals with histories of adversity (Davis & Narayan, 2020; Svelnys et al., 2023). Following birth, many parents experience additional stressors including ongoing sleep deprivation, social isolation, and self-doubt. Perinatal mental health disorders, such as perinatal anxiety and PPD, are the most common complication of childbirth, out of all other labor and delivery complications (Reid et al. 2022), and they each uniquely as well as additively increase risk for perinatal STBs (Svelnys et al., 2023). Studies estimate that postpartum individuals with a diagnosed psychiatric disorder are 6.2 times more likely to engage in self-harm than those without a disorder (Johannsen et al., 2020). Low social support is also strongly associated with suicidal ideation during the perinatal period, indicating that the stress of pregnancy and caring for a newborn may weigh particularly heavily on gestational parents who lack supportive families, friends, or communities (Bright & Tuohy, 2022).
Experiences of interpersonal trauma, including current or previous intimate partner violence (IPV) victimization and childhood maltreatment, are also risk factors for perinatal STBs (Svelnys et al., 2023). IPV victimization during pregnancy is fairly common (estimated to range from 3.5% to 28.6% across community samples), and up to 42.9% of postpartum parents who have suicidal thoughts report that IPV occurred during pregnancy (Atzl et al., 2021; Kozhimannil et al., 2023; Roman-Galvez et al., 2021; Supraja et al., 2016). For those who experienced childhood abuse, pregnancy is a time of particular vulnerability, as pregnant individuals reflect back on their history of caregiving in anticipation of caring for a new baby (Slade et al., 2009; Svelnys et al., 2023). Physiological and physical changes associated with accommodating the fetus may also elicit reminders of bodily violations and invasions, rendering pregnant individuals increasingly susceptible to severe distress and emotion dysregulation (Sperlich & Seng, 2008). Victims of childhood abuse are already at increased risk for STBs even before pregnancy, due to the multi-finite pathways of childhood abuse to adulthood emotion dysregulation, psychological distress, and interpersonal conflict, and the added experience of pregnancy can further exacerbate these risks (Svelnys et al., 2023).
Additional pregnancy-specific risk factors for suicidal ideation may include health complications, substance misuse, pregnancy loss, birth trauma, and neonatal abnormalities, (Bright & Tuohy, 2022). Unplanned, unintended, or unwanted pregnancies are other potent predictors of STB risk (Garman et al., 2019), which is particularly critical to note, given the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization on June 24, 2022, which overturned Roe v. Wade. The court’s decision has severely limited many childbearing individuals’ access to pregnancy termination services, contributing to increased stress and decreased control over reproductive choices, further intensifying risk for STBs. Provider awareness about common risk factors for perinatal STBs is particularly crucial in the current sociopolitical context.
Limitations of Current Perinatal STB Screening Protocols
Screening of STBs is currently not widespread in prenatal or postpartum care. Within current protocols, suicide is often assessed alongside prenatal or postpartum depression symptoms, using tools like Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire, (PHQ-9) both of which only have a single item corresponding to suicidal ideation (Chin et al., 2022). Though these tools are widely-used, validated measures of perinatal depression, they are limited in their measurement of STBs. For instance, both measures only capture recent suicidal ideation (EPDS measures the past 7 days, while PHQ-9 assesses the past two weeks). Suicidal ideation is dynamic in nature, tending to vary in timing and severity; therefore, these measures will likely miss individuals who experienced suicidal thoughts just outside of the given timeframe. Furthermore, a study of pregnant individuals in Peru found differences in each measure’s detection of suicidal ideation: 15.8% of individuals reported prenatal suicidal ideation on the PHQ-9, and yet only 8.8 % of the same individuals reported it on the EPDS (Zhong et al., 2015). In addition to timeframe, this discrepancy may also be due to differences in language; the suicide item on the EPDS assesses thoughts about self-harm (“the thought of harming myself has occurred to me”) whereas the PHQ-9 assesses passive suicidal ideation and thoughts about self-harm (“Thoughts that you would be better off dead or of hurting yourself in some way”). Research demonstrates that single-item measures of STBs may not capture the range of specific suicidal or self-injurious thoughts that different individuals experience (Millner et al., 2015).
Another major limitation to current prenatal and postpartum screening protocols is that STBs are usually assessed at the beginning of an appointment, via an oral response of yes/no, or with a paper-and-pencil or tablet questionnaire. Patients may be unlikely to disclose STBs when they feel pressured to respond quickly to screening questions or have had limited time to build rapport with providers. While many providers have limited time to conduct more lengthy prenatal mental health screening assessments, using formats that allow for multi-part, open-ended questions in addition to yes/no questions or building rapport during the appointment and screening for STBs towards the end may facilitate more authentic patient disclosures. Given these limitations, there is a clear need for a more thoughtful, comprehensive screening process for perinatal STBs.
Call to Action for Increased Screening and Identification of Perinatal STBs
Pregnancy provides a unique opportunity for increased healthcare access due to regular prenatal care visits. Thus, with appropriate training, perinatal healthcare providers are well-positioned to identify patients experiencing perinatal STBs through evidence-based screening protocols. The Columbia-Suicide Severity Rating Scale (C-SSRS) (Posner et al., 2011) and the National Institute of Mental Health “Ask Suicide-Screening Questions” (ASQ) Toolkit (Horowitz et al., 2012) are suicide-specific rating scales that offer more precise assessment of STBs. Both tools are free and publicly available, take only a few minutes to administer, and have already been successfully used in prenatal and postpartum care (Horowitz et al., 2012; Posner et al., 2011; Szpunar et al., 2020). A strength of these tools is that they separately assess active and passive suicidal ideation, as well as suicidal behavior, increasing the likelihood of identifying distressed individuals with a range of suicidal severity. Furthermore, these tools swiftly assess imminent risk and include built-in triage guidelines for safety planning and referral to appropriate mental health-care professionals and resources. We urge healthcare providers to incorporate these tools into prenatal and postpartum care for all patients in order to prevent individuals who are experiencing STBs from falling through the cracks and, potentially, losing their lives to perinatal suicide.
Further, as partners of gestational caregivers are often neglected in perinatal care, it is critical to include non-gestational caregivers in perinatal screening for STBs. As discussed above, non-gestational partners are also at risk for suicide, and their stress and STBs can lead to adverse outcomes such as trauma, loss, and grief for the gestational partner and the baby (Paulson et al., 2010). We recommend that both parents are assessed routinely for STBs, ideally at each healthcare visit, given the fluctuating nature of suicidal thoughts. Through this process, healthcare providers will be able to better identify all caregivers who are at risk for suicide, reduce STBs before the baby is born, and provide appropriate resources and referrals.
It is recommended that hospital systems and clinics also provide comprehensive training to healthcare professionals when implementing suicide-risk protocols in prenatal and postpartum care. Trainings should cover how to effectively and non-judgmentally administer suicide screeners, as well as the importance of fostering a safe environment when querying about and discussing STBs in perinatal individuals and non-gestational partners, as many individuals may be hesitant to disclose suicidal thoughts. Using affirming language and inclusive practices, such as proper use of pronouns and acknowledging diverse family structures, is essential to creating an environment where caregivers feel safe to disclose. Normalizing perinatal STBs prior to using the recommended screening tools may also encourage disclosure and reduce distress. We recommend saying something similar to the following, which was adapted from the “Maternal Suicide and Risk Assessment Toolkit” at the University of North Carolina School of Medicine (University of North Carolina School of Medicine, 2003, p. 3):
“It is common for expecting individuals to have scary thoughts. When people are suffering, they might have thoughts about death or wanting to end their life. These thoughts are painful, and we don’t want you to feel alone. We ask all patients if they have had thoughts about death or hurting themselves so that we can identify the best way to help.”
Providers should be trained with the understanding that many individuals experience STBs in a way that is frightening, intrusive, and unwanted. Trainings should inform providers that many individuals experience suicidal thoughts without intent to harm themselves; thus, endorsing STBs does not mean that psychiatric hospitalization is warranted (much less child welfare involvement). Should individuals disclose STBs, providers should respond with empathy and concern, as providers’ responses to caregivers’ STB disclosure may influence the likelihood of future disclosure, thereby facilitating versus hindering access to proper care and resources.
Furthermore, clients may bring up triggers for their suicidal thoughts, such as aspects of the pregnancy and postpartum periods, or systemic and contextual stressors (e.g. unemployment, housing insecurity, trauma, systemic racism, cumulative stress; Wang & Wu, 2021). Providers’ non-judgmental validation can assist patients in using emotion-regulation and coping skills (Koerner & Linehan, 2003), which may help STBs to pass. Healthcare providers should aim to validate each individual’s unique experience and the way their individual context contributes to distress and STBs.
Finally, healthcare providers must be proactive in recognizing and initiating conversations about risk factors for suicide during the perinatal period. Certain recognized risk factors, such as depression symptoms, ongoing substance use or misuse, and IPV victimization are already screened for in routine prenatal and postpartum care. However, other known risk factors, such as childhood abuse or neglect, current PTSD symptoms, and unplanned, unintended, or unwanted pregnancy status, are not often screened, despite that they all have established health consequences to parental and fetal/child wellbeing (Davis & Narayan, 2020; Svelnys et al., 2023). Healthcare providers should be informed about how to screen for all risk factors for perinatal STBs using validated, publicly-available and brief assessment tools (which exist for all of the above risk factors; Atzl et al., 2021; Narayan et al., 2017). By integrating existing screening processes and expanding on additional risk factors along with including specific suicide screening protocols, healthcare providers can better identify perinatal individuals at high risk for STBs and then tailor mental health referrals and support to individual and family needs.
Conclusions
Perinatal STBs are on the rise, and increased research and clinical efforts are urgently needed to efficiently and effectively address and prevent risks to the mortality of pregnant and postpartum individuals, and the health and wellbeing of their babies. Increased attention is particularly needed for expectant individuals of diverse gender and sexual identities and non-gestational caregivers. It is imperative that healthcare providers are well-informed about risk for STBs during the perinatal period in order to identify those who are struggling and provide them with timely safety-promoting interventions. Training healthcare professionals to integrate sensitive and non-stigmatizing STB screening during prenatal and postpartum care, and ensuring referrals to specialized mental health and relationship support services are made, are vital steps in supporting perinatal mental health and ultimately improving outcomes for both gestational and non-gestational parents and their children.
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