Maternal Deaths From Suicide and Overdose in Colorado, 2004–2012

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I congratulate Metz et al1 on their recent publication regarding causes of maternal mortality in Colorado from 2004 to 2012, and I embrace their findings as representative of a major cause of maternal deaths in this country. In Maryland, our Maternal Mortality Review has noticed very similar patterns in our recent history, where 49% of maternal deaths in 2013 were associated with behavioral health factors, including unintentional overdose, suicide, and intimate partner violence and homicide. Across the United States, many states do not have individual Maternal Mortality Reviews, although a number are in the process of developing legislation or policy to develop their own. Among those that do have functional Maternal Mortality Reviews, not all agree with the inclusion of “self-harm” deaths in their maternal review. As evidenced by this article, it is important to include all maternal deaths during pregnancy or up to 1 year postpartum from any cause.
One of the challenges nationally is that different states use different criteria in their selection of cases for maternal mortality reviews. Colorado appropriately includes all deaths within 1 year of pregnancy, unlike the Centers for Disease Control and Prevention recommendation of exclusion of accidental or incidental causes. We in Maryland share with those in Colorado the idea that all maternal deaths occurring during pregnancy or up to 1 year postpartum should be reviewed. States that do not consider substance use disorder or violence in their reviews as incidental should re-evaluate this position. We feel strongly that to overlook these deaths attributed to substance use disorder, suicide, or homicide misses a significant proportion if not a majority of the deaths, as evidenced by the research by Metz et al. Based on their findings, and what we see in Maryland, we would expect that this pattern would be seen nationally.
Preventability is widely assessed in Maternal Mortality Reviews across the country. We propose that deaths related to substance use disorder, suicide, and intimate partner violence are largely preventable when there is a concerted effort to do so. Metz et al appropriately describe the significant burden of maternal deaths attributed to these behavioral health conditions in Colorado. It is up to individual states to produce their own data to demonstrate their contribution to the national burden.
Individual states are encouraged to review all behavioral health–related maternal deaths within 1 year of pregnancy in their annual reviews. Pregnancy is a known risk factor for increased intimate partner violence and increased risk of resulting death. We suspect that the postpartum period is a period of increased risk of death due to substance use disorder after a pregnancy in which a patient attempts to minimize substance use followed by a postpartum relapse with decreased tolerance. In addition to basic science and clinical research, we as a community need to advocate for our patients to minimize these deaths. Only when deaths are described and get appropriate attention as the preventable conditions they are can we meaningfully reduce these preventable maternal deaths in our country.
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