Contribution of suicide and injuries to pregnancy-related mortality in low-income and middle-income countries: a systematic review and meta-analysis

Abstract

Background: Although suicide is one of the leading causes of deaths in young women in low-income and middle-income countries, the contribution of suicide and injuries to pregnancy-related mortality remains unknown.

Methods: We did a systematic review to identify studies reporting the proportion of pregnancy-related deaths attributable to suicide or injuries, or both, in low-income and middle-income countries. We used a random-effects meta-analysis to calculate the pooled prevalence of pregnancy-related deaths attributable to suicide, stratified by WHO region. To account for the possible misclassification of suicide deaths as injuries, we calculated the pooled prevalence of deaths attributable to injuries, and undertook a sensitivity analysis reclassifying the leading methods of suicides among women in low-income and middle-income countries (burns, poisoning, falling, or drowning) as suicide.

Findings: We identified 36 studies from 21 countries. The pooled total prevalence across the regions was 1·00% for suicide (95% CI 0·54-1·57) and 5·06% for injuries (3·72-6·58). Reclassifying the leading suicide methods from injuries to suicide increased the pooled prevalence of pregnancy-related deaths attributed to suicide to 1·68% (1·09-2·37). Americas (3·03%, 1·20-5·49), the eastern Mediterranean region (3·55%, 0·37-9·37), and the southeast Asia region (2·19%, 1·04-3·68) had the highest prevalence for suicide, with the western Pacific (1·16%, 0·00-4·67) and Africa (0·65%, 0·45-0·88) regions having the lowest.

Interpretation: The available data suggest a modest contribution of injuries and suicide to pregnancy-related mortality in low-income and middle-income countries with wide regional variations. However, this study might have underestimated suicide deaths because of the absence of recognition and inclusion of these causes in eligible studies. We recommend that injury-related and other co-incidental causes of death are included in the WHO definition of maternal mortality to promote measurement and effective intervention for reduction of maternal mortality in low-income and middle-income countries.

Funding: National Institute of Mental Health.

Figure 1

Selection of studies

Figure 2

Proportion of pregnancy-related deaths/maternal deaths attributable to injuries Footnote: The discrepancy in the pooled and individual estimate for the single study in the EURO region arises as the exact binomial confidence interval for single studies is shown, while the normal approximation is used to calculate the confidence interval in the random effects meta-analysis.

Figure 3

Proportion of pregnancy-related deaths/maternal deaths attributable to suicide Footnote: The discrepancy in the pooled and individual estimate for the single study in the EURO region arises as the exact binomial confidence interval for single studies is shown, while the normal approximation is used to calculate the confidence interval in the random effects meta-analysis.

Figure 4

Proportion of pregnancy-related deaths/maternal deaths attributable to suicide, falls, drowning, poisoning and burns Footnote: The discrepancy in the pooled and individual estimate for the single study in the EURO region arises as the exact binomial confidence interval for single studies is shown, while the normal approximation is used to calculate the confidence interval in the random effects meta-analysis.