Title: Self-Harm In the Perinatal Period: Prevalence, Risk Factors and Completed Later Suicide
Funder: Department of Health and Social Care

Abstract: Background Suicide is a significant cause of maternal deaths and frequently preceded by self-harm during the perinatal period (i.e. pregnancy and the year post-birth). However little is known about the prevalence and risk factors for perinatal self-harm and whether it is associated with later completed suicide. Perinatal self-harm is important because during pregnancy it can lead to direct foetal harm e.g. in cases of overdose. Postnatally, self-harm has the potential to limit a mother's ability to care for her dependent infant. Furthermore, in the general population, self-harm is associated with mental disorder and higher risk of suicide suicide. This may also be the case with perinatal self-harm. A population cohort study is required to fill existing research gaps in prevalence, risk factors and suicide prediction. An additional estimate within secondary mental healthcare service-users is important, as the protective effect of the perinatal period against suicide is lost in women with psychotic disorders, suggesting mental healthcare service-users may be at higher risk of perinatal self-harm.Aims I. To estimate the prevalence of self-harm in the perinatal period in women: a. in the general population b. in contact with secondary mental healthcare II. To investigate risk factors for perinatal self-harm III. To investigate the extent to which perinatal self-harm is associated with completed suicide Plan A systematic review of the literature will ensure there are no existing studies that answer these questions. My scoping search has not revealed any; if there are, my project will be informed by, replicate and add to them. A cohort study design will be used. A general population cohort will be generated from registry data from the National Center for Register-Based Research in Denmark. Amongst women with hospital deliveries beyond 24 weeks gestation (1996 2011), I will estimate prevalence by reporting the number of ICD-coded perinatal self-harm contacts with outpatient, inpatient and A&E departments of medical and psychiatric hospitals. Multivariable logistic regression will allow comparison of women who have self-harmed with those who have not, to detect risk factors. I will use Poisson regression to analyse whether perinatal self-harm increases the risk of ater completed suicide. A mental healthcare service-user cohort will be generated using the Clinical Records Interactive Search system (CRIS), a registry of de-identified electronic healthcare notes of South London and Maudsley NHS Foundation Trust service-users. Linkage with Hospital Episode Statistics will generate a cohort with hospital deliveries beyond 24 weeks gestation (2007 2014). I will estimate prevalence and use multivariable logistic regression to compare women who have self-harmed with those who have not, to detect risk factors. Linkage with Office of National Statistics data will allow me to investigate whether women who have self-harmed perintally are at increased risk of later completed suicide. Benefits The perinatal period is often one of the few times many women consistently access healthcare so is a key opportunity for services to detect self-harm and engage them in care. Knowing the prevalence and risks is essential. There is little research on what happens to patients with perinatal disorders other than depression and psychosis, so whether those such as personality disorder are associated with perinatal self-harm will address this gap and inform service planning. If I can replicate previous findings on trends in perinatal suicide, that during the last part of the postnatal period there is increased risk of self-harm, as pilot work suggests I will, this could further inform service planning. Rather than being a time of service detachment, this may be when women are most in need of support.

Lay abstract: Aims To find out how common it is to self-harm during pregnancy and one year after delivery (a time known as the perinatal period). To find out what factors might put women at higher risk of perinatal self-harm. To investigate whether women who self-harm during this period are at higher risk of suicide later in life. Background Research tells us that self-harm is associated with mental disorder and people who self-harm are at higher risk of suicide. Despite the fact suicide is a significant cause of death of pregnant and postnatal women, and is frequently preceeded by self-harm, there is little research into perinatal self-harm itself. Perinatal self-harm is important because: In pregnancy, methods affecting the whole body, e.g. overdose, could harm the unborn baby. The perinatal period is one of the few times women consistently access healthcare so may be a key opportunity for services to pick up those at risk of self-harm and help them access support. Understanding that people who self-harm are at higher risk of suicide helps healthcare providers assess what support they need. We do not know to what extent this association is true for women who self-harm in the perinatal period. Research tells us perinatal suicide might be more common in the last few months of the postnatal year. If this is also true for self-harm, this could mean women are most at risk of self-harm at the time their healthcare support is withdrawn. If I find this is a period of particular risk of self-harm, more support could be recommended for women at risk at that time. It is important to consider self-harm in both the general population and women who are in contact with mental healthcare because. Amongst women in the general population, the perinatal period is protective against suicide but this protective effect is lost for women with psychotic illness, suggesting women in contact with mental healthcare may be at higher risk of perinatal self-harm. Self-harm can take many forms, from life-threatening overdoses to superficial cutting, done with or without suicidal intent. However it is important to research all types of self-harm, as every act can result in harm. Methods I will review the research on perinatal self-harm, to ensure I am not missing any existing studies. I will then measure: how common perinatal self-harm is, including the different types what risk factors are associated whether women who self-harm in the perinatal period are more likely to die by suicide than whose who do not self-harm. I will examine two groups: the general population and women in contact with mental healthcare. For the general population, I will use national registries that record anonymous information about birth, contact with inpatient, outpatient and A&E healthcare aswell as date/cause of death. In the UK, records are not complete enough. However I have access to comprehensive Danish registries, via Arhaus University. Denmark is comparable to the UK as it is also a high-income EU developed nation with universal healthcare. Knowing the date of delivery of a baby, and that mother's ID number, I can search within their perinatal period for codes indicating contact with inpatient, A&E or outpatient services for self-harm. For women in contact with mental healthcare, I will use the Clinical Record Interactive Search (CRIS) system, a de-identified database of electronic healthcare notes of people who use South London and Maudsley NHS Foundation Trust (SLAM) for mental healthcare. CRIS is linked with Hospital Episode Statistics, a database which records when and why patients are admitted to hospital. This will allow me to find out how many SLAM service-users have a linked hospital episode' for giving birth. I can then search for self-harm events in their perinatal period, within CRIS.By comparing women who did self-harm in the perinatal period with those who did not, I can look for risk factors. By linking with a database that records date/cause of deaths, I can investigate whether they are at higher risk of suicide. Patient and Public Involvement I consulted Professor Howard's Perinatal Service-User and Carer Project Advisory Group (PAG) and Fast-R, an NIHR service providing service-user/carer feedback on research. CRIS is derived from service-users records. CRIS use is subject to approval by an oversight committee chaired by a service-user. Dissemination I will publish this research in academic journals and present at international healthcare conferences. I will run an advertised event to present to journalists and the public, as well as utilising social media. I will consult with the PAG for avenues of direct service-user dissemination.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS
Health categories: MENTAL HEALTH;REPRODUCTIVE HEALTH AND CHILDBIRTH