Self-harm was the leading cause of pregnancy-associated deaths in Colorado from 2004 to 2014, ahead of car crashes, medical conditions and homicide, according to researchers at the University of Colorado Anschutz Medical Campus.

The study, “Maternal Deaths from Suicide and Overdose in Colorado, 2004-2012,” found that of 211 maternal deaths, 30 percent were from self-harm, defined as suicide and nonintentional overdose deaths occurring during pregnancy and the first year after giving birth. In Colorado, the mortality rate from self-harm during the period was 9.6 per 100,000 live births. About 90 percent occurred in the postpartum period.

It is not known how the demographics and characteristics of maternal deaths in Colorado compare to other states or if such self-harm deaths are becoming more common. According to the study, in 2012 suicide was overall the most common cause of death in Colorado among those age 10 to 44.

“There is focus nationally on reduction in maternal mortality, and the majority of this effort has focused on in-hospital causes of death such as postpartum hemorrhage,” said lead author Torri Metz, MD, assistant professor of maternal fetal medicine at the CU School of Medicine. “As the Colorado Maternal Mortality Review Committee reviewed the maternal deaths in Colorado, we noticed that there was a large proportion of deaths from suicide and overdose. Our data supports that self-harm is in fact the leading cause of pregnancy-associated death in Colorado, which warrants our attention.”

The findings are published in the December edition of “Obstetrics & Gynecology.”

During the study period, 63 women died of suicide or a drug overdose. Of the 26 who died of suicide, asphyxia by hanging was the most common cause of death. In overdose deaths in which toxicology testing was performed at autopsy, opioids were the most detected class of drugs, chiefly pharmaceutical painkillers but also heroin.

Substance abuse and psychiatric disorders, most often depression, were present in a majority of the women with maternal deaths. However, no risk factor was present in 22 percent of the cases.

Although about half the self-harm cases were found to be taking prescription drugs for mental health care at conception, 48 percent stopped using the medications during pregnancy, in some cases with a care provider’s recommendation but in most without. During pregnancy, selective serotonin reuptake inhibitors (SSRIs) were the most commonly discontinued drug class alongside sleep aids, mood stabilizers and other antidepressants.

“This finding speaks to the importance of an informed discussion of the risks and benefits of continuing psychiatric medications during pregnancy,” Metz said. “Ideally this would occur prior to conception. The benefit of continuing medications, especially SSRIs in women with depression, frequently strongly outweighs the risk.”

Researchers also found that many of the women had documented social stressors, most notably unemployment (64%) or being single, divorced or separated (40%). Though such stressors, also including a history of domestic violence (18%) and unstable living situation (5%), were documented in a majority of the women, only one third engaged with a social worker either during prenatal care or at delivery.

During pregnancy and after delivery, woman at risk for self-harm may encounter health care providers such as social workers, nurses and physicians. Researchers say each point of contact with such women should be considered an opportunity for intervention throughout and after pregnancy. They suggest that raising awareness, better health screening, referrals for treatment of mental health and substance use disorders in pregnancy and recognition of the need for ongoing care beyond the early postpartum period is needed to reduce pregnancy-related deaths from self-harm.