PUBLIC HEALTH OP-ED
New study helps us to understand perinatal suicide in South Africa
A new study of pregnant suicidal women suggests that one way to understand suicide might be as a response to disorientating biographical disruptions which are experienced as irreparable and incongruent with one’s sense of self and imagined future.
Maternal mortality in most parts of the world has steadily decreased over the past 80 years, mostly due to medical advances in antenatal care, antibiotic use, safer blood transfusion, hypertension management and the legalisation of termination of pregnancy.
But maternal mortality from trauma and injuries, such as suicide, remains a public health problem. While pregnancy is generally considered to be protective against completing suicide in high-income countries, there is evidence that pregnant women living under conditions of adversity in low- and middle-income countries, including South Africa, are at increased risk of suicide.
For example, a study of pregnant women from a resource-scarce community in Cape Town found that as many as 18% had thought about suicide in the previous month, while 6% had attempted suicide.
As with suicidal behaviour during other life stages, perinatal suicides are sometimes associated with mental health problems such as depression, substance use and psychotic disorders. But contextual factors — as well as women’s experience of being pregnant and their expectations about becoming a mother — also play a powerful role in maternal suicide.
A recently published study by researchers from the South African Medical Research Council (SAMRC), the Department of Psychiatry at Stellenbosch University (SU) and the Institute for Life Course Health Research, draws attention to the context in which perinatal suicidal behaviour occurs in South Africa.
Over a 10-month period, SAMRC and SU researchers interviewed all patients admitted to Groote Schuur Hospital following a medically serious suicide attempt. The researchers wanted to learn from the patients about what had contributed to their desire to die and what support they needed to prevent future suicidal behaviour once discharged from hospital.
Among the patients they interviewed were several young women who were either pregnant or who had recently given birth. It was clear from these women’s stories that they experienced their pregnancy as a fundamental rupture in the fabric of everyday life, which disturbed the way they understood themselves and saw the trajectory of their own lives.
These kinds of ruptures are called biographical disruptions because they alter the stories we use to make sense of ourselves and our place in the world.
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Five clear examples
There were five clear examples of biographical disruptions in the stories told by the women who had attempted suicide.
First, some said that pregnancy interrupted their education and thus erased the future they imagined for themselves. For them, education represented access to socioeconomic advancement and a life outside the impoverished and violent streets where they grew up.
One woman explained, “They sent me to school and I came home with a baby”; another said, “I lost everything dropping out of school.” These young women could not imagine an alternative future where it is possible to both have a baby and receive an education.
Second, some of the women described the trauma of placing a child for adoption or terminating a pregnancy. These traumas prompted them to modify the way they saw themselves and the world. The suicidal women were unable to reconcile their actions with their view of themselves, and felt out of place in the world.
Third, all the women described how pregnancy led to a loss of autonomy, agency and space for themselves. Cindy (not her real name) described her experience of the baby encroaching on her life and the restrictions imposed by pregnancy as follows: “It’s taking up your whole life, your body, everything! You can’t control the baby that’s inside you.”
The loss of autonomy and agency severely limited the women’s capacity to construct their own stories, causing them to feel that their lives were not their own.
Fourth, the women experienced criticism and judgment for their unplanned pregnancies. The stigma associated with being a young pregnant woman led to intolerable feelings of guilt and shame, and caused conflict and disruptions to their interpersonal relationships.
Three of the women were teenagers at the time of their pregnancies. These experiences forced the women to confront other people’s view of them as “bad”, and they had trouble reconciling feelings of guilt and shame with how they saw themselves. There was a sudden irreconcilable clash between the way they experienced themselves and the way they were being positioned by their family and community.
Finally, the women explained how difficult it was to make the transition into a new role as caregiver and the new identity of mother.
The young women said they felt ill-prepared for the transition, unsupported, abandoned and unable to ask for help. Khethiwe (not her real name) articulated her inability to step into the role of caregiver, saying, “I cannot provide anything!”
Many of the women said that the absence of the baby’s father left them feeling unsupported and alone to step into a role they were not ready for.
Biographical disruptions of the kind described by the young suicidal women in this study are not unique to pregnancy; they also occur when people face other disruptive life events such as developing a chronic illness or disability, or the unexpected death of someone close. These events often require us to reconstruct the way we see ourselves and re-imagine our future.
Assuming that this understanding of the suicidal women’s experience is accurate, it suggests that maternal suicidal behaviour might be reduced by supporting perinatal women (particularly those with unplanned pregnancies) to reimagine their future, reorganise their self image and re-establish the interpersonal relationships disrupted by pregnancy.
This could be facilitated by psychosocial interventions centred on biographical reconstruction and helping young pregnant women recreate a coherent narrative that restores a sense of order from the fragmentation produced by pregnancy.
Suicide might be prevented by reaffirming young pregnant women’s impression that life has a course, and the self has a purpose.
But the women in this study do not just need psychotherapy — their stories also remind us that maternal suicide rates in the country might be reduced by offering perinatal mothers practical support and material help with childcare and poverty alleviation, as well as strategies to engage fathers and to help young mothers to return to school.
Crucially, the new study of pregnant suicidal women suggests that one way to understand suicide might be as a response to disorientating biographical disruptions which are experienced as irreparable and incongruent with one’s sense of self and imagined future. Suicidal behaviour might be a way of reasserting control and authorship of one’s life, or a way of destroying an identity or future imposed on one.
Suicide is preventable and help is available. Anyone who is experiencing suicidal thoughts should talk to someone they trust, consult their doctor or make contact with one of the 24-hour support lines, such as the South African Depression and Anxiety Group (0800-567-567) or LifeLine (0861-322-322). Reach out, ask for help, stay connected. DM
Prof Jason Bantjes is a Chief Specialist Scientist in the Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council. He also holds an Extra-ordinary appointment as an Associate Professor at the Institute for Life Course Health Research at Stellenbosch University (SU).
Dr Kerry-Ann Louw is a psychiatrist in the Department of Psychiatry at SU and heads the Clinical Unit of Adult Psychiatry Services at Tygerberg Hospital.