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Mental Health Risks Persist for Years Following Severe Maternal Morbidity in Pregnancy


Severe maternal morbidity during pregnancy increases the risk for mental health hospitalization or ED visits for as long as 13 years, a Canadian study found.

Mental Health Risks Persist for Years Following Severe Maternal Morbidity in Pregnancy / image credit depression: ©dodoardo/shutterstock.com

The experience of severe maternal morbidity (SMM) during pregnancy was associated with a 1.3-fold increased rate of hospitalization or emergency department (ED) visit for a mental health condition as many as 13 years after delivery, according to findings of a retrospective cohort study in Canada that included more than 1.5 million women.

The increase in risk was consistent for both ED visits and hospital admission and was highest during the first postpartum year, investigators reported. The highest risk among women with SMM who were treated either as inpatients or in the ED was for suicidality and self-harm.

The findings strongly suggest the need for improved surveillance and provision of postpartum mental health resources, particularly after an experience of SMM, lead author Natalie Dayan, MD, assistant professor of medicine, McGill University, Montreal, Canada, and colleagues wrote in JAMA Network Open.

Conditions considered SMM include severe hemorrhage, severe preeclampsia or eclampsia, septic shock, and other life-threating conditions that occur during pregnancy or in the immediate postpartum period, according to Dayan et al. Compared with women who do not experience SMM, affected women are at increased risk for chronic conditions such as cardiovascular disease, long-term functional impairment, and pain.

The researchers cite a sobering statistic that underscores the urgency to assess the postpartum mental health burden of SMM: up to 36% of maternal deaths within the first year after delivery have been linked to suicide. They point out that existing studies examining links between adverse pregnancy events and subsequent maternal mental health have focused on a single perinatal condition or include relatively short follow-up data.

Up to 36% of maternal deaths within the first year after delivery have been linked to suicide.

To help expand the knowledge base, Dayan and colleagues conducted a population-based cohort study that evaluated the association between SMM and hospitalizations and ED visits for mental health issues over 13 years in a multiethnic Canadian population with “universal antenatal health coverage.”

Population, methods

Eligible participants were between ages 18 and 55 years with a first recorded hospital delivery, live or stillbirth, following a pregnancy of 20 to 43 weeks’ gestation between April 1, 2008, and March 31, 2021. Researchers obtained administrative, clinical, and demographic data on all deliveries from the Canadian Institute of Health Information (CIHI) Discharge Abstract Database (DAD).

The CIHI DAD data were linked to the National Ambulatory Care Reporting System dataset for participant data from EDs. Individuals with a mental health hospitalization or ED visit within 2 years of the index birth were excluded.

Exposure was occurrence of SMM between 20 weeks’ gestation and 42 days post-delivery, according to the study. The research team defined a composite of mental health hospitalization or ED visits from 43 days after index birth hospitalization and beyond as the primary outcome of interest. Covariates included maternal age at delivery, delivery year, income quintile, maternal comorbidities, Canadian territory of delivery, hospital type, and urban or rural residential status.

The research team developed models for 3 follow-up periods: up to 1 year, 1 to 5 years, and more than 5 years, to assess how proximity to delivery might modify the association between SMM and mental health hospitalization or ED visit.


The final cohort for the analysis numbered 1 579 392 participants with a mean age of approximately 30 years; 2.3% had SMM. Compared to individuals without SMM, participants with SMM were more often older, more likely to deliver in a teaching tertiary care hospital, and to have preexisting conditions, according to the findings. Researchers also reported an increase in the rate of SMM from 15.5 to 22.2 per 1000 deliveries between 2006 to 2007 and 2020 to 2021.

ED visits, hospitalization for mental health

Of the original cohort, Dayan et al reported 43,066 individuals with recent childbirth were either hospitalized or visited an ED for mental health concerns, a rate of 73.2 per 10 000 person-years (PY). The rate for mood and anxiety disorders was reported as 59.2/10 000 PY and for substance abuse and related disorder as 17.1/10 000 PY.

For suicidality or self-harm, frequency of either presentation was 4.8/10 000 PY and for schizophrenia spectrum or other psychotic disorders, 4.1/10 000 PY, according to results. When they explored demographics associated with mental health hospitalization or ED visit, Dayan and colleagues found that rates decreased with increasing age and income quintile and were highest in patients residing in rural areas or with 2 or more comorbid conditions.

Mental Health Risks Persist for Years Following Severe Maternal Morbidity in Pregnancy

Among study participants with an experience of SMM, investigators reported a mental health hospitalization or ED visit in 96.1 per 10 000 compared with 72.7 per 10 000 among those without SMM (HR, 1.31, 95% CI, 1.24-1.39; aHR, 1.26, 95% CI, 1.19-1.34). The median time to either event was 2.8 years and 2.6 years, respectively, study authors said.

The team also reported an increase in relative risk after SMM for all components of the composite mental health outcome save schizophrenia spectrum and other psychotic disorders. They found the greatest risk of either mental health presentation was for suicidality and self-harm, with an aHR of 1.54 (95% CI, 1.26-1.88).

Individuals with SMM had the highest relative risk of hospitalization or ED visit for a mental health condition in the first year post-partum (aHR, 1.38, 95% CI, 1.24-1.53). And, although dissipated somewhat over time, Dayan et al reported risk persisted for those with more than 1 year but fewer than 5 years follow-up (1.23, 95% CI 1.14-1.34), and for those with more than 5 years of follow-up (1.21, 95% CI, 1.07-1.37).

The study findings suggest SMM is associated with adverse mental health outcomes well beyond the conventional postpartum period, the authors concluded, and that mental health screening should be enhanced for women who have experienced extreme pregnancy complications.

Blackman A, Ukah UV, Platt RW, et al. Severe maternal morbidity and mental health hospitalizations or emergency department visits. JAMA Netw Open. 2024;7(4):e247983. doi:10.1001/jamanetworkopen.2024.7983

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