Perinatal self-harm: an overlooked public health issue
Authors: Karyn Ayre, Rina Dutta, Louise Michelle Howard
Journal: The Lancet Public Health (2019)

Self-harm is most common in adolescents and young adults, particularly in women. Thoughts of self-harm can also happen during pregnancy and the year after birth (perinatal period).1Lindahl V Pearson JL Colpe L Prevalence of suicidality during pregnancy and the postpartum.Arch Women Ment Health. 2005; 8: 77-87Crossref PubMed Scopus (478) Google Scholar However, little is known about perinatal self-harm: the effect on the fetus or infant, or whether these behaviours predict suicide. Understanding perinatal self-harm might be important for maternal death prevention strategy. Moreover, self-harm in pregnancy has potential consequences on the fetus and might reflect difficulties in maternal emotional regulation. Evidence suggests that self-harm during the perinatal period is rare in the general population; however, in women with severe mental disorders, it is more common with some studies reporting prevalence of up to 20%.2Brameld KJ Jablensky A Griffith J Dean J Morgan VA Psychotropic medication and substance use during pregnancy by women with severe mental illness.Front Psychiatry. 2017; 8: 28Crossref PubMed Scopus (6) Google Scholar Appleby and colleagues showed a protective effect of the perinatal period against suicide in general,3Appleby L Suicide during pregnancy and in the first postnatal year.BMJ. 1991; 302: 137-140Crossref PubMed Scopus (213) Google Scholar but an increased risk of suicide in women with severe postpartum psychiatric disorders, highest in the postnatal year.4Appleby L Mortensen PB Faragher EB Suicide and other causes of mortality after post-partum psychiatric admission.Br J Psychiatry. 1998; 173: 209-211Crossref PubMed Scopus (134) Google Scholar Most studies investigating the prevalence of perinatal self-harm use population administrative datasets based on hospital discharge coding, which, particularly in relation to stigmatising issues such as self-harm, have a high risk of misclassification bias, and do not capture women who self-harm but do not present to hospital. Studies using non-administrative data are usually small and use measures that do not identify self-harm throughout pregnancy and the year after birth, thus failing to establish the true prevalence for any given period. The effect of perinatal self-harm on future maternal and child mental health is also unclear. Untreated maternal mental disorder can negatively affect infant outcomes.5Stein A Pearson RM Goodman SH et al.Effects of perinatal mental disorders on the fetus and child.Lancet. 2014; 384: 1800-1819Summary Full Text Full Text PDF PubMed Scopus (1166) Google Scholar Perinatal self-harm could be a marker of untreated illness. There is mounting evidence suggesting a link between parental self-harm and a wide range of adverse outcomes for the child later in life.6Lunde I Myhre Reigstad M Frisch Moe K Grimholt TK Systematic literature review of attempted suicide and offspring.Int J Environ Res Public Health. 2018; 15: E937Crossref PubMed Scopus (9) Google Scholar Maternal suicidal ideation can affect mother and infant bonding,7Sockol LE Battle CL Howard M Davis T Correlates of impaired mother-infant bonding in a partial hospital program for perinatal women.Arch Womens Ment Health. 2014; 17: 465-469Crossref PubMed Scopus (24) Google Scholar and even preconception self-harm has been associated with bonding difficulties in the first year after birth.8Niederkrotenthaler T Floderus B Alexanderson K Rasmussen F Mittendorfer-Rutz E Exposure to parental mortality and markers of morbidity, and the risks of attempted and completed suicide in offspring: an analysis of sensitive life periods.J Epidemiol Community Health. 2012; 66: 233Crossref PubMed Scopus (74) Google Scholar Perinatal self-harm is likely to be a marker of bonding difficulties and potentially deficits in mother and infant interactions, which mediate childhood mental health problems. Indeed, there is evidence of an inverse trend between the risk of offspring suicide or attempted suicide and the age of exposure to a parental suicide attempt.8Niederkrotenthaler T Floderus B Alexanderson K Rasmussen F Mittendorfer-Rutz E Exposure to parental mortality and markers of morbidity, and the risks of attempted and completed suicide in offspring: an analysis of sensitive life periods.J Epidemiol Community Health. 2012; 66: 233Crossref PubMed Scopus (74) Google Scholar Perinatal self-harm could therefore be a substantial public health issue that is overlooked by the research community and health services, despite the perinatal period being a crucial time to identify such problems, as pregnant and postnatal women are in frequent contact with health-care professionals. Research on perinatal self-harm is crucially needed. Targeted interventions, including routine enquiry about self-harm, have the potential to improve maternal and child outcomes. We declare no competing interests.