'There is no greater loneliness in the life of a human being than being alone with one's own suffering; and no suffering is greater than the mental torture of impending agony from which there is no escape and of which there is no understanding.' Grantly Dick-Read, 1959, p.50

Grantly Dick-Read was right. Suffering alone breeds a sense of inescapable despair for which there are few words, if any. Lack of language is a kind of quintessential, ontological divide between a person's experience and the observer's understanding - what Biro (2011) noted as the starting point for change. Language can 'replace isolation with community' (Biro, 2011, p. 15). This site is testimony to that! Listening to mothers is both our privilege, our scientific premise (the landmark study by the same name), and our standard of practice as childbirth professionals. In the spirit of listening to mothers, and learning to replace isolation with community - I would like to share a recent study regarding quite possibly the worst mental torture imaginable: suicidal ideation in pregnancy.

One of the first of its size and breadth, a recent study published in the Archives of Women's Mental Health (2011) examined prevalence of suicidal ideation in a large sample of pregnant women. Two objectives were presented: (1) examine the prevalence of suicidal ideation and comorbid psychiatric disorders during pregnancy; (2) identify the risk factors for suicidal ideation during pregnancy:

'Although our understanding of the prevalence and consequences of antenatal major depression has improved, our understanding of suicidal ideation - a common aspect of major depression - during pregnancy is limited.' (Gavin, Tabb, Melville, Guo & Katon, 2011, p. 244)

Comparing prevalence rates of suicidal ideation in a pregnant population with those in general, non-pregnant population could substantiate or refute the commonly held belief that pregnancy is a protective mechanism against thoughts of suicide (Zajicek, 1981; Kendell, Chalmers, & Platz, 1987), offering a fuller vocabulary regarding this rare, yet tragic suffering. The authors built a strong rationale for their study by reviewing the scant literature that does exist, and its compelling evidence:

• 'Suicide is a leading cause of death among pregnant and postpartum women in the United States' (Gavin, et al., 2011 p. 239; Chang, et al., 2005).
• The precursor to suicide in most cases is suicidal ideation, and the presence of major depression (Perez-Rodriguez, et al., 2008; Lindahl et al., 2005).
• Women of childbearing years are at greatest risk for depressive disorders (Perez-Rodriguez, et al. 2008).
• Pregnant women are less likely to be screened for suicidal ideation during pregnancy (Stallones, et al., 2007; Paris, et al., 2009; Gausia, et al., 2009; Copersino et al., 2005; Newport et al., 2007).
• Adverse outcomes experienced by women who did report suicidal ideation in pregnancy (Stallones, et al., 2007; Paris, et al., 2009; Gausia, et al., 2009; Copersino et al., 2005; Newport et al., 2007; Bowen, et al., 2009; Eggleston, et al., 2009; Chaudron et al., 2001).
• Suicidal ideation in pregnancy is a strong predictor for postpartum depression (Chaudron et al., 2001).
• Pregnant women with depressive disorders are less likely to receive treatment for depression (Vesiga-Lopez et al., 2008).
• Depressive disorders remain under-detected in prenatal settings because most women seeking prenatal care are not screened for depression (Kelly, et al. 2001).
• Most patients fail to tell care providers of suicidal plans or attempts (Isometsa et al., 1994).

Lack of prenatal depression screening, known risk factors for comorbid mood disorders and their adverse effects are noted:

'Given the risks associated with antenatal suicidal ideation to women and their offspring, identifying effective methods of detecting women with antenatal suicidal ideation is a paramount challenge.' (Gavin, et al., 2011)

Study Design

Authors employed a cross-sectional analysis design of data from a longitudinal study of 3,347 pregnant women receiving prenatal care at a single site university-based obstetric clinic (University of Washington) from January 2004 to 2010. After exclusion, the final sample size was 2,159 women. Study protocol mandated screening a minimum of two times, once in early second trimester, (16 weeks) and once in third trimester (36 weeks). Suicidal ideation was measured using the Patient Health Questionnaire (PHQ-9)'a screening instrument that has demonstrated both high sensitivity (73%) and specificity (98%) for major depression (Spitzer, et al., 2009). To examine suicidal ideation specifically, the authors measured women's responses to item 9 of the PHQ-9:

'Over the last two weeks how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way? 0 = not at all, 1= several days, 2 = more than half the days, and 3= nearly every day.' (Gavin, et al., 2011, p. 241)

Participants self-reporting a score of 1 or greater (suicidal ideation several days a week in last 2 weeks), were considered positive for suicidal ideation. With the protocol in place, authors then applied multiple covariate logistic regression analysis.

Study Results

Results demonstrated 2.7% of the 2,159 sample scored positive for suicidal ideation - similar to the prevalence rates for general, non-pregnant populations recorded in both the National Comorbidity Survey 1990-1993 (NCS) 2.8% ; and the National Comorbidity Survey Replication 2001-2003 (NCS-R) rate of 3.3% in general, non-pregnant population:

'The prevalence of antenatal suicidal ideation in the present study was similar to rates reported in nationally representative non-pregnant samples. In other words, pregnancy is not a protective factor against suicidal ideation'. (Gavin, et al., 2011, p. 239)

Of the 2.7% prevalence rate:

• 78.0% reported thoughts of suicide 'several days' in last 2 weeks
• 15.3% reported thoughts of suicide 'more than half the days' in the last 2 weeks
• 6.7% reported thoughts of suicide 'nearly every day'
• 52.5% experienced comorbid antenatal depression
• 15.7% experienced comorbid antenatal panic disorder

Speak My Language

Consider for a moment a group of 2,159 women attending standard prenatal childbirth education classes at a local hospital over the course of several years. Generalizing from this study and national statistics, 59 of them are having thoughts of ending their lives. Of those 59:

• 48 (78%) have considered killing themselves several days in the last two weeks.
• 9 (15.3%) have considered suicide more than half of the week,
• 4 (6.7%) of those moms have contemplated killing themselves nearly every single day.

And those are the women who admit it. The mothers who speak it. What do we do? Final recommendations put forth by the authors here included 'efforts to identify those women at risk for antenatal suicidal ideation through universal screening' (Gavin, et al., 2011, p. 239).

I think it is pretty fair to say that the majority of childbirth educators and doulas are trained to screen for difficulties in breast feeding. When problems or risk factors present themselves, or a mom suffers from the agony of mastitis, we use language to help. We lean over the void of suffering and listen to our mothers.

We speak the language of lactation quite easily,
and have organizational support and training to do so.
Yet, how many of us feel comfortable with the language of suffering alone in major depression? Go to your certifying organization's website and look for resources for moms, or family members who feel suicidal. Anything? For you as a professional certified by that organization to offer emotional support to your clients, are there resources there for you to access, to help your clients? Consider writing your certifying organization and request they update training for prenatal courses to include screening for depression. Ask them to post suicide prevention materials for consumers. Your organization(s) should offer assistance in learning how to screen, referral sources in your area, and after care resources for your own healing should you need it. Not doing so, not having public position papers, not speaking the language, in my mind is tantamount to silencing women's suffering, and perhaps contributing to the loneliness of those who feel misunderstood. As David Biro (2011) states: 'The consequences of silence are unacceptable... if we wish to relieve pain, we must first hear it' (p. 14).
'Listening to Mothers''¦I'm in.

Posted by: Walker Karraa, MFA, MA

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Resources

The Suicide Prevention Life Line offers free buttons, logos and links to add to your websites, and free downloads to give clients/students. You can also call them yourself to ask them how to talk to a mom about her symptoms.

Edinburgh Postnatal Depression Scale (EPDS)

PHQ-9

Postpartum Support International (PSI)

References

Biro, D. (2011). The language of pain: Finding words, compassion, and relief. NY: Norton.

Bowen, A., Stewart, N., Baetz, M., et al. (2009). Antenatal depression in socially high risk women in Canada. J Epidemiol Community Health, 63:414-416.

Brand, S. Brennan, P. (2009). Impact of antenatal and postpartum maternal mental illness: How are the children? Clinc Obstet Gynecol, 51:441-455.

Chang, J., Berg, C., Saltzman, L., et al. (2005). Homicide: a leading cause of injury and deaths among pregnant and postpartum women in the United States, 1991-1999. Am J Public Health, 95:471-477.

Chaudron, L., Klein, M., Remington, P., et al. (2001). Predictors, prodromes and incidence of postpartum depression. Psychosom Obstet Gynecol, 22:103-112.

Copersino, M., Jones, H., Tuten , M., et al. (2005) Suicidal ideation among drug-dependent treatment -seeking inner-city women. J. Maint Addict, 3:53-64.

Eggleston, A. Calhoun P., Svikis, D., et al. (2009). Suicidality, aggression, and other treatment considerations among pregnant, substance-dependent women with posttraumatic stress disorder. Compr Psychiatry, 50: 415-423

Gausia, K., Fisher, C., Ali, M., et al. (2009). Antenatal depression and suicidal ideation among rural Bangladeshi women: A community-based study. Arch Womens Ment Health, 12:351-358.

Gavin, A., Tabb, K., Melville, J., Guo, Y., & Keaton, W. (2011). Prevalence and correlates of suicidal ideation during pregnancy. Arch Womens Ment Health 14(239-246).

Kelly, R., Zatzick, D., Anders, T. (2001). The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in osbstetrics. Am J Psychiatry, 158:213-219.

Kroenke, K., Spitzer, & Williams, J. (2001). The PHQ-9: Validity of a brief depression severity measure. Gen Intern Med. September; 16(9): 606-613.

Lindahl, V., Pearson, J., Colpe, L. (2005). Prevalence of suicidality during pregnancy and postpartum. Arch Womens Ment Health, 8:77-87.

Newport, D., Levey, L., Pennell, P., et al. (2007). Suicidal ideation in pregnancy: Assessment and clinical implications. Arch Womens Ment Health, 10:181-187.

Paris, R., Bolton, R., Weinberg, M. (2009) Postpartum depression, suicidality, and mother-infant interactions. Arch Womens Ment Health 12:309-321

Perez-Rodriguez M., Baca-Garcia E., Oquendo M et al. (2008). Ethnic differences in suicidal ideation and attempts. Prim Psychiatry 15:44-58

Spitzer, R., Williams, J., Kroenke, K., et al. (2000). Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD patient health questionnaire obstetrics-gynecology study. Am J Obstet Gynecol 183:759-769

Stallones, L., Leff, M., Canetto, S. et al. (2007). Suicidal ideation among low-income women on family assistance programs. Women Health 45:65-83

Vesga-Lopez, O., Blanco, C., Keyes, K., et al. (2008). Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 65:805-15

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