Suicidal ideation and intentional self-harm in pregnancy as neglected agenda in maternal health; an experience from rural Sri Lanka
Authors: Archchi Nimna Sachini Mallawa , Ganegama Ranjan , Husna Abdul Wahib Fathima , Chandima Delo Lashan , Hettigama Nandana , Premadasa Jagath , Herath Jagath , Ranaweera Harindra , Agampodi Thilini Chanchala , Agampodi Suneth Buddhika 
Published: November 2018

AbstractBackgroundSuicide only present the tip of the iceberg of maternal mental health issues. Only a fraction of pregnant women with suicidal ideation proceeds to intentional self-harm (ISH) and even a smaller proportion are fatal. The purpose of the present study was to determine the prevalence of depression, suicidal ideation (present and past) and history of ISH among pregnant mothers in rural Sri Lanka.MethodsWe have conducted a hospital based cross sectional study in the third largest hospital in Sri Lanka and a another tertiary care center. Pregnant women admitted to hospital at term were included as study participants. The Edinburgh Postpartum Depression Scale (EPDS), a self-administered questionnaire for demographic and clinical data and a data extraction sheet to get pregnancy related data from the pregnancy record was used.ResultsThe study sample consisted of 475 pregnant women in their third trimester. For the tenth question of EPDS “the thought of harming myself has occurred to me during last seven days” was answered as “yes quite a lot” by four (0.8%), “yes sometimes” by eleven (2.3%) and hardly ever by 13 (2.7%). Two additional pregnant women reported that they had suicidal ideation during the early part of the current pregnancy period though they are not having it now. Four (0.8%) pregnant women reported having a history of ISH during the current pregnancy. History of ISH prior to this pregnancy was reported by eight women and five of them were reported to hospitals, while others were managed at home. Of the 475 pregnant females included in the study, 126 (26.5%) had an EPDS score more than nine, showing probable anxiety and depression. Pregnant women who had primary/post-primary or tertiary education compared to those who were in-between those two categories were at higher risk of high EPDS with a OR of 1.94 (95% CI 1.1-3.3). Reported suicidal ideation prior to pregnancy had a OR of 6.4 (95% CI 2.3-17.5).ConclusionsBased on our data, we conservatively estimate around 3000 ISH annually in Sri Lanka, which should be considered as a high priority for an urgent intervention.Plain English SummaryMental disturbances are common during pregnancy. Most of the time, these are normal. However, these disturbances may become serious and lead to self-harm and suicide. In this study, we estimated the proportion of pregnant women who had depression and idea of self-harming during pregnancy.Respondents were pregnant women admitted to two large hospitals for the childbirth. They answered a list o questions about the thought of self-harm and attempts of self-harm during the present as well as past pregnancies.Respondents included 475 pregnant women. Of them, 3.1% reported that “the thought of self-harming has occurred to them during last seven days quite a lot (0.8%) or sometimes” (2.3%). Four (0.8%) pregnant women reported that they actually did it to some extent. Of the 475 pregnant women included in the study, 126 (26.5%) had symptoms of anxiety/depression. Level of education seemed to have an association with anxiety and depression. When women reported that they had thought of self-harm prior to pregnancy, they were about 6.4 times more likely to have depression/anxiety during the pregnancy. Adding a simple screening question (as we used in this study) during the initial pregnancy assessment to detect history of suicidal thoughts will be helpful in identification of high-risk mothers for depression and suicide.