Paper commentary by

Dr. Ruby Castilla-Puentes, IAWMH Secretary

Association between Suicidal Behaviour in Pregnant Women

and Pregnancy and Fetal Outcomes: A Systematic Review

and Meta-Analysis

A published research paper that recently captured my attention is titled "Association between suicidal behavior in pregnant women and pregnancy and fetal outcomes: : A Systematic Review and Meta-Analysis ". This study, which appeared in the Archives of Women’s Mental Health, evaluates the significant risks suicidal behavior poses to both maternal and fetal health, emphasizing the urgent need for early identification and intervention within prenatal care.

Significance of the work: The study makes an important contribution by quantifying the link between maternal suicidal behavior and pregnancy outcomes — a topic that, despite high global concern about perinatal mental health, remains under-explored. Previous meta-analyses have addressed perinatal depression or anxiety and their obstetric consequences (Gelaye et al., 2016; Accortt et al., 2015), but few have focused specifically on suicidality. Given that suicide remains a leading cause of maternal mortality globally (Oates, 2003; Knight et al., 2023), establishing its obstetric correlates is critical for clinical and public-health planning.

Strengths: The review’s large, pooled sample (over 30 million participants) enhances statistical power and generalizability. The use of multiple databases and adherence to PRISMA 2020 and Newcastle-Ottawa quality assessments reflect sound methodological rigor. Additionally, including multiple obstetric and fetal outcomes (preterm labour, low birth weight, stillbirth, and congenital anomalies) provides a comprehensive risk profile that extends beyond maternal psychiatric morbidity. The focus on observable suicidal behavior — rather than depression severity alone — adds value because suicidal ideation and attempts represent distinct clinical constructs with potentially unique biological and psychosocial correlations (Turecki & Brent, 2016). By synthesizing evidence across ideation, planning, and attempts, the study captures the full suicidal-risk spectrum in pregnancy.

Limitations and methodological considerations: Despite their strengths, several limitations temper the conclusions:



• Observational design and causality — All included studies were observational, limiting causal inference. Suicidal behavior may reflect underlying severe depression, trauma exposure, intimate-partner violence, or social deprivation — all independently associated with adverse obstetric outcomes (Howard et al., 2014; Orta et al., 2018). Thus, suicidal behaviour could act as a marker rather than a direct causal factor.
• Heterogeneity in definitions — “Suicidal behavior” includes ideation, intent, or attempts, but the definitions and assessment tools differed across studies (Posner et al., 2011). Similarly, “fetal anomaly” or “preterm labour” definitions may vary by context. Such inconsistencies can inflate or obscure true associations.
• Residual confounding — Even after statistical adjustments, residual confounding from unmeasured variables (e.g., substance use, prenatal care attendance, psychiatric medication exposure) likely remains (Liu et al., 2023).
•  Certainty of evidence — The authors rated the certainty of evidence as “low” to “very low” according to GRADE, mainly due to the observational nature of data, limited blinding, and measurement bias (Sukhadeve et al., 2025).
• Potential publication bias — Studies reporting null associations may be less likely to be published, potentially exaggerating pooled effect sizes (Egger et al., 1997). The remarkably large stillbirth risk (RR ≈ 12) could reflect such bias or rare-event instability.

Interpretation of findings: The findings have serious clinical implications. A 40 % increased risk of preterm birth and 80 % increased risk of low birth weight are both clinically meaningful. These outcomes contribute to neonatal morbidity and long-term developmental issues (Saigal & Doyle, 2008). The particularly elevated risk of stillbirth is alarming but should be interpreted cautiously. Possible mechanisms include physiological stress responses (elevated cortisol, inflammation), intentional self-harm, medication toxicity, or neglect of prenatal care (Newport et al., 2007; Gentile, 2010). Still, such a large effect size warrants replication in well-controlled cohorts.

The study also resonates with previous evidence linking maternal mental disorders to obstetric complications. Depression and anxiety in pregnancy have been associated with preterm delivery and low birth weight (Grote et al., 2010; Accortt et al., 2015). Suicidal behavior may represent the extreme end of this spectrum, signifying severe psychosocial distress that adversely influences maternal physiology and care-seeking.

Implications for clinical practice and policy: This meta-analysis underscores the necessity of universal perinatal mental-health screening. The American College of Obstetricians and Gynecologists (ACOG) already recommend screening for depression and anxiety at least once during the perinatal period (ACOG Committee, 2023), yet suicide-specific assessments remain inconsistently implemented. Clinicians should incorporate validated tools such as the Columbia-Suicide Severity Rating Scale (Posner et al., 2011) or the PHQ-9 item 9 (Kroenke et al., 2001) into prenatal visits.

Integrated care models — linking obstetric, psychiatric, and social-work services — have proven effective in reducing perinatal mental-health morbidity (Byatt et al., 2018). Health systems should ensure pathways for rapid referral, crisis intervention, and follow-up for women disclosing suicidal thoughts or attempts.

From a public-health perspective, policymakers must recognize that perinatal suicidality represents both a maternal-mortality and neonatal-risk issue. Resource allocation toward perinatal mental-health infrastructure (screening, training, community outreach) is essential, particularly in low- and middle-income countries where obstetric care often lacks mental-health integration (Fisher et al., 2012).

Concluding reflections. Sukhadeve et al. (2025) provide compelling evidence that suicidal behavior in pregnancy is strongly associated with adverse obstetric and fetal outcomes. Although causality cannot be confirmed, the consistency and magnitude of associations highlight the urgent need for clinical vigilance. Suicidal ideation or behavior should be regarded as an obstetric red flag, triggering enhanced maternal–fetal monitoring and integrated mental-health intervention.

The study’s key message: protecting fetal health requires addressing maternal despair. Suicide prevention in pregnancy is not solely a psychiatric imperative but a cornerstone of maternal–fetal medicine.

References

• Accortt, E. E., Cheadle, A. C. D., & Dunkel Schetter, C. (2015). Prenatal depression and adverse birth outcomes: An updated systematic review. Maternal and Child Health Journal, 19(6), 1306–1337. https://doi.org/10.1007/s10995-014-1637-2
• American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. (2023). Screening for perinatal depression. Committee Opinion No. 757.
• Byatt, N., Biebel, K., Friedman, L., Debordes-Jackson, G., Ziedonis, D., & Pbert, L. (2018). Women’s perspectives on postpartum depression screening in pediatric settings: A qualitative study. Archives of Women’s Mental Health, 21(5), 591–598.
• Dunkel Schetter, C. (2011). Psychological science on pregnancy: Stress processes, biopsychosocial models, and emerging research issues. Annual Review of Psychology, 62, 531–558.
• Egger, M., Davey Smith, G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109), 629–634.
• Fisher, J., Cabral de Mello, M., Patel, V., Rahman, A., Tran, T., Holton, S., & Holmes, W. (2012). Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: A systematic review. Bulletin of the World Health Organization, 90(2), 139–149.
• Gelaye, B., Rondon, M. B., Araya, R., & Williams, M. A. (2016). Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. The Lancet Psychiatry, 3(10), 973–982.
• Gentile, S. (2010). Suicidal mothers. Journal of Women’s Health, 19(8), 1485–1494.
• Grote, N. K., Bridge, J. A., Gavin, A. R., Melville, J. L., Iyengar, S., & Katon, W. J. (2010). A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Archives of General Psychiatry, 67(10), 1012–1024.
• Howard, L. M., Oram, S., Galley, H., Trevillion, K., & Feder, G. (2014). Domestic violence and perinatal mental disorders: A systematic review and meta-analysis. PLoS Medicine, 10(5), e1001452.
• Knight, M., Bunch, K., Tuffnell, D., Patel, R., Shakespeare, J., Kotnis, R., … & Kurinczuk, J. J. (2023). Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019–21. Oxford: National Perinatal Epidemiology Unit.
• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.
• Liu, X., Agerbo, E., & Webb, R. T. (2023). Suicide and self-harm in pregnancy and the postpartum period: A population-based study. The Lancet Psychiatry, 10(1), 34–44.
• Newport, D. J., Brennan, P. A., Green, P., Ilardi, D., Whitfield, T., Morris, N., … & Stowe, Z. N. (2007). Maternal depression and medication exposure during pregnancy: Implications for fetal development. American Journal of Psychiatry, 164(9), 1326–1333.
• Oates, M. (2003). Perinatal psychiatric disorders: A leading cause of maternal morbidity and mortality. British Medical Bulletin, 67(1), 219–229.
• Orta, O. R., Gelaye, B., Bain, P., Williams, M. A., & McDonald, S. E. (2018). Maternal depression and intimate partner violence: A systematic review and meta-analysis. Depression and Anxiety, 35(10), 1001–1014.
• Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., … & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies. American Journal of Psychiatry, 168(12), 1266–1277.
• Saigal, S., & Doyle, L. W. (2008). An overview of mortality and sequelae of preterm birth from infancy to adulthood. The Lancet, 371(9608), 261–269.
• Sukhadeve, S., Sawarkar, P., & Padole, S. (2025). Association between suicidal behaviour in pregnant women and pregnancy and fetal outcomes: A systematic review and meta-analysis. Life Science Publications. https://www.lifescience.net/publications/1496779/association-between-suicidal-behaviour-in-pregnant
• Turecki, G., & Brent, D. A. (2016). Suicide and suicidal behaviour. The Lancet, 387(10024), 1227–1239.Your copy should address 3 key questions: Who am I writing for (audience)? Why should they care (benefit)? What do I want them to do (call-to-action)?

Call for Applications:

Editorial Fellowship at Archives of Women's Mental Health

The Archives of Women's Mental Health is pleased to announce that applications for its Editorial Fellowship Program is open. This initiative is designed to mentor early-career professionals and researchers with a strong interest in academic publishing and women's mental health.

Editorial Fellows will work closely with the journal’s editorial team and section editors. Fellows will:

• Receive mentorship from experienced editors.Participate in editorial meetings and discussions.
• Assist in identifying peer reviewers for submitted manuscripts.Conduct manuscript reviews under guidance.
• This is a unique opportunity to gain hands-on experience in the editorial process and contribute meaningfully to the advancement of scholarship in women's mental health.

The fellowship is for one year, with the possibility of renewal based on continued interest.

We welcome applications from early-career researchers, clinicians, and professionals with demonstrated interest in women’s mental health and academic publishing.

How to Apply

Interested candidates should submit:

• A brief statement of interest mentioning why they want this position and what makes them qualified for it (max 500 words)
• Two Page Curriculum Vitae in the following format - Name, Country, Discipline/Subject, Highest degree obtained and when, Current Affiliation, Awards and Recognitions, List of conference presentations, List of publications.One writing sample (e.g., published paper, thesis excerpt, or review)

Deadline for Applications: November 30 2025, ongoing thereafter

Submit Applications CLICK HERE

We look forward to welcoming a new cohort of Editorial Fellows committed to advancing the field of women's mental health.

https://link.springer.com/journal/737/updates/27809956