The contribution of suicide and injuries to pregnancy-related mortality in low and middle-income countries: A systematic review and meta-analysis

Summary Background— Although suicide is one of the leading causes of deaths among young women in low and middle-income countries (LMIC), the contribution of suicide and injuries to pregnancy-related mortality remains unknown. Methods— We conducted a systematic review to identify studies reporting the proportion of pregnancy-related deaths attributable to suicide and/or injuries in LMIC. Random-effects meta-analysis was used 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 LMIC (burns, poisoning, falling or drowning) as suicide. Findings— 36 studies from 21 countries were identified. The pooled total prevalence across the regions was 1·00% for suicide (95% confidence interval (CI): 0·54–1·57) and 5·06% for injuries (95% CI: 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% (95% CI: 1·09– 2·37). Americas (3·03%, 95% CI: 1·20–5·49),the Eastern-Mediterranean region (3·55%, 95% CI: 0·37–9·37), and the South-East Asia region (2·19%, 95% CI: 1·04–3·68) had the highest prevalence for suicide, with the Western-Pacific region (1·16%, 95% CI: 0·00–4·67) and the Africa region (0·65%, 95% CI: 0·45–0·88) having the lowest. Interpretation— The available data suggest a modest contribution of injuries and suicide to pregnancy-related mortality in LMIC with wide regional variations. However, this study may have underestimated suicide deaths due to lack 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 LMIC.

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