The Suicide Risk Among Women with High-Risk Pregnancies

Conclusions: Results point towards a low prevalence of suicidal ideation among pregnant women, possibly due to the fact that practically no assessment of mental state is done during the antenatal period. A prevention strategy targeted at identifying harmful pregnant women’s behavior and psychosocial aspects is needed, so as to early diagnose depression, suicidal ideation and other risk factors among this population. The Suicide Risk Among Women with High-Risk Pregnancies OPINION

depressive symptoms, and this can be of greater impact when women are dealing with a high-risk pregnancy (Araújo, Andrade, Silva et al. 2015).
Suicide is now placed among the leading causes of death during the perinatal period worldwide (Zhong, Gelaye, Rondon et al., 2014).Castro e Couto, Brancaglion, Cardoso et al. (2016) highlighted that the occurrence or recurrence of depressive symptoms related to child bearing can be experienced by vulnerable women during pregnancy, a disorder known as antenatal depression.This condition is a risk factor for suicide or suicide attempt.Suicidal ideation, known to be a precursor and early predictor of death by suicide later on, has an important role during perinatal period, its prevalence during pregnancy ranging from 5 to 14%.In spite of that, systematic screening for suicidal ideation during antenatal period is scarce, mainly considering time constraints in prenatal care services, shortage of adequate screening instruments and the fact that suicide is still a stigma among certain cultures (Zhong, Gelaye, Rondon et al., 2014).Ferreira, Orsini, Vieira et al. (2014) estimate that 20% of pregnant women from developing countries, among which Brazil is included, are subjected to anxiety situations, and that the prevalence of antenatal depression ranges from 7 to 15%.There is also evidence that psychosocial aspects may negatively influence pregnancy (Ferreira, Orsini, Vieira et al., 2014).Araújo, Andrade, Silva et al. (2015) state that the need to cry, feelings of sadness and failure, and fatigue due to the excess of extra work are the most common depressive symptoms among women with high-risk pregnancies.
The Edinburgh Postnatal Depression Scale (EPDS) is widely used as an instrument to assess antenatal depression.EPDS is a 10-item self-report measure that assesses emotional aspects of women in the seven days prior to the evaluation, assigning a score of 0, 1, 2 or 3 for each given answer, according to the increasing gravity of symptoms experienced (Castro E Couto, Brancaglion, Cardoso et al., 2016).Besides EPDS, the study of Zhong, Gelaye, Rondon et al. ( 2014) also used the Patient Health Questionnaire-9 (PHQ-9), a 9-item scale that assesses depressive symptoms in the 14 days prior to the evaluation.A score of 0, 1, 2 or 3 was assigned, respectively, to the answers "not at all", "several days", "more than half the days" or "nearly every day".
In Western modern civilization, maternity is often seen as a source of happiness to women.It is then unlikely to relate sadness to the status of pregnancy, which is corroborated by the almost inexistent body of evidence documenting epidemiological data regarding antenatal depression and suicidal ideation during pregnancy (Correa, Zapata, Arbeláez et al, 2014).This helps to understand why depressive and anxious feelings on pregnant women often tend to go unnoticed by healthcare professionals and even by those closely related to them.However, it is essential to understand that intrapsychic changes during pregnancy may alter mental balance, triggering and increasing common depressive behaviors (Abel, Heuvelman, Jörgensen et al., 2014).
There is scientific evidence that women with higher schooling levels, which allows better professional opportunities, have a protective factor against depression, while previous abortions, unplanned pregnancy and previous psychiatric disorders represent risk factors for antenatal depression (Araújo, Andrade, Silva et al. 2015).Alves, Alves, Antunes et al. (2013) highlights that death by suicide was a finding among women younger than 25-years-old, figuring as a last resource for na individual who does not have access to family planning or in whose country abortion is an illegal practice.
Castro e Couto, Brancaglion, Cardoso et al. ( 2016) assessed 255 patients during the second trimester of pregnancy using a questionnaire consisting of questions regarding maternal age, level of education, ethnicity, marital status, pregnancy planning, prenatal care, parity, thoughts of abortion, domestic violence, and sociodemographic status, reaching the conclusion that bipolar disorder alone or any current anxiety disorder are risk factors for suicide.Alves, Alves, Antunes et al. ( 2013 that intimate partner violence is a consistent risk factor for a women's suicidal behavior.Future studies on suicide must carefully analyze the social determinants of self-inflicted behavior and the underlying psychological factors that might represent a permanent risk for suicide, as well as investigate the possible links between traumatic experiences and suicidal behavior (Castro e Couto, Brancaglion, Cardoso et al., 2016).Close attention must also be paid to suicidal ideation in prenatal care clinics, making the distinction between suicidal ideation and depression itself.Considering that the majority of previous studies on pregnancy solely focused on identifying suicidal behavior in the presence of depression, suicidal ideation may have been underreported, resulting in an artificially lower prevalence of this condition.Due to the negative consequences for the woman as well as the fetus during the antenatal period, screening for suicidal ideation should be mandatory for both depressive and non-depressive pregnant women in prenatal care services.Future research are needed to identify additional prepartum suicide preditors, and to determine the adequate duration of the screening period for suicidal ideation and depression (Zhong et al., 2014).
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