PREGNANT

13 Pages·2005·1.4 MB·English

Attention is directed to an apparently high-risk of attempted or threatened
suicide in a cohort of young women who were pregnant before age 18.
Factors related to suicide attempts are discussed and stress is placed
on the need for preventive action, including early detection and
intensive treatment of long duration for suicide-prone girls and
for those who threaten or attempt suicide.
SUICIDE ATTEMPTS IN A POPULATION
PREGNANT AS TEEN-AGERS
Ira W. Gabrielson, M.D., F.A.P.H.A.; Lorraine V. Klerman, Dr.P.H., F.A.P.HA.; John B. Currie,
Ph.D.; Natalie C. Tyler,R.N.; andJamesF.Jeket,M.D.,M.P.H.
PREGNANCY, childbearing, and mother- The study population received its ob-
hood are normal biological events stetrical care in the period before the
rather than disease processes, but even emphasis on programs for teen-age
in the mature married woman they dis- mothers. Some were patients of private
turb the usual pattern of social life. physicians, but the majority were seen
For the teen-age girl, particularly if un- by obstetrical residents, medical stu-
married, pregnancy and the events dents, and staff physicians in the gen-
which follow are especially likely to eral obstetrical clinic.4 As a group they
cause difficulty for the individual, those were offered no special social services,
immediately associated with her, and although in individual cases the need
society. was so obvious that a social worker
Other authors1-3 have reviewed some was assigned. They were excluded from
of the problems associated with teen- school when their condition became ap-
age pregnancies, such as disrupted edu- parent and limited educational alterna-
cation, welfare dependency, and in- tives were provided.5
creased fertility. A review of the med- Today in New Haven, and in many
ical records of 105 pregnant females other cities throughoutthe United States,
17 years of age or younger admitted such girls are being offered programs
to the Yale-New Haven Hospital for that include unified medical care, aug-
delivery during 1959 and 1960 sug- mented social services, and special edu-
gested an additional potential difficulty cationafl provisions. It is hoped these
-the possibility of suicide-threatened, programs will make a significant dif-
attempted, or actually committed. This ference in the life of these young
study revealed that 14 of the young mothers and their children. Some re-
mothers were known to have made sub- ports are already indicating lower rates
sequently one or more self-destructive of medical complications among mothers
attempts or threats serious enough to and infants8 and decreases in early
require care or to be reported to a school terminations.1 Studies now under
physician at the hospital. way may show that the attention being
DECEMBER. 19970 2289
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DECEMBER, 1970 2291
paid to the psychological aspects of self-destructive acts: any self-mutilation
pregnancy and the early child-rearing such as wrist-slashing, jumping from
period result in mothers better able to buildings, the ingestion of any sub-
cope with the physical and emotional stance which the patient might have
problems of their environment. If the thought to be harmful, and the inges-
programs are able to accomplish these tion in obviously excessive amounts of
goals, a marked reduction in the num- any medication. In addition, two pa-
ber of self-destructive attempts or tients whose records showed a threat or
threats would be expected. This paper fear of suicide were included in this
hopes to assist those responsible for pro- group, hereafter referred to as the "sui-
grams for pregnant teen-agers by alert- cide attempt" group.
ing them to the need for listening for The first section of this paper will
possible hints of future irrational acts describe the 14 patients in the "sui-
and by stressing the urgency of long- cide attempt" group and the attempts
term follow-up of this population. Re- themselves. In the following section, the
search personnel may wish to use rate entire population of 105 meeting the
of suicide attempts as an additional previously described criteria for inclu-
measure of the success of special pro- sion in the study will be analyzed to de-
grams. termine which characteristics are as-
sociated with a higher risk of suicide
Study Method attempt or threat. Finally, the rate of
suicide attempts in this obstetrical popu-
The information about self-destruc- lation will be compared with the rates
tive attempts or threats was found in reported by others.
the course of a study concerned with
intervals between conceptions in a teen- Characteristics ofthe "Suicide
age population. The review of records Attempt" Group
was made at the Yale-New Haven Hos-
pital in 1968, eight or nine years after Selected characteristics of the 14 pa-
the "index delivery" of 1959 or 1960. tients who made suicide attempts or
The group of 105 patients retained for threats are shown in Table 1. They
study met the following three criteria: ranged in ages from 13 to 17 at the
they were 17 years of age or younger time of their first 1959-1960 delivery.
and residents of New Haven at the Eight were black, six white, and eight
time of the index delivery, and there were Catholic, six Protestant. At the
was follow-up information available in time of registration for care, nine were
the hospital chart for a period of at least single and five had been married. The
two years thereafter. (Four exceptions latter were all 17 and white Catholics.
were made to the latter criterion, where Only one patient had experienced a
the records showed an additional preg- pregnancy prior to the one in 1959-1960.
nancy within a period of less than two By the time they made the suicide
years, although the follow-up stopped attempt the patients ranged in age from
short of two years.) Such a review, 17 to 25. Eight were 17 or 18, one was
limited to only one of the two area hos- 20, and five were 22 to 25. Eleven of
pitals, and without a search of private the patients had been married by the
physicians' records, certainly underesti- time of the attempt, but four of these
mates the number of suicide attempts were already separated or divorced;
and threats. three were still single.
For the purpose of the hospital chart In two cases the patient was preg-
review, the following were classified as nant with a second pregnancy at the
2292
VOL. 60, NO. 12. A.J.P.H.
SUICIDE AMONG PREGNANT TEEN-AGERS
time of the suicide attempt. For the re- Marital Discord-Patient No. 3 in-
maining cases, the median number of gested antihistamine pills "after marital
months which had elapsed between the separation." Patient No. 9 was seen re-
last delivery and the attempt was 20, peatedly for psychoneurotic manifesta-
with a range of one month to 60 months. tions related to a broken marriage be-
Four attempts were made in the first fore being treated for a wrist lacera-
postpartum year and three of these were tion. Her husband "lives across the
within four months of delivery. The street with other women." Patients 6, 7,
median number of completed pregnan- and 8 also had reported quarreling with
cies at the time of the attempt was two.* their husbands.
Varied methods of suicide attempts Associated Physical lUness-Five of
were recorded. Ingestion was the most the patients were seen for gonorrhea or
common. Five women had swallowed pelvic inflammatory disease. Occasion-
excess amounts of tranquilizers, sleep- ally suicidal attempts occurred in close
ing pills, aspirin, or similar substances, temporal relationship to treatment for
and one claimed to have drunk am- one of these conditions. One patient
monia. Four were treated for lacerated suffered from chronic suppurative lung
hands or wrists. One patient jumped disease.
from a third story window, and another
tried to cut herself with a razor and
threatened to set fire to her clothing. Characteristics Associated with Risk
In two cases, only a threat or fear of of Suicide Attempt
suicide was noted. In both there was
also actual child abuse by the young Table 2 analyzes the frequency of
mother or apprehension concerning in- suicide attempts in the study population
fanticide. by selected characteristics.
Record review suggested that suicide Age-The total study population
attempts were often found in conjunction ranged in age from 12 to 17 at the
with the following: time of their first 1959-1960 delivery.
Emotional Illness-Chronic psychi- Age at delivery did not appear to in-
atric problems as well as acute episodes fluence the risk of subsequent suicide
of depression or anxiety were noted in attempt.
eight cases. Patients were described by Race-There was no appreciable dif-
terms such as ambulatory psychotic, de- ference in the risk of suicide attempt
pressed, disoriented, chronic anxiety, between the white and the black
sociopath, and severe psychoneurosis. mothers.
Patient No. 6 had an acute self-destruc- Religion-Twenty per cent of the
tive psychotic episode requiring hospital. Catholic patients were in the suicide at-
ization. Patient No. 13 had "acute anxi- tempt group as opposed to only 9 per
ety one month postpartum." Three pa- cent of the Protestant patients. This
tients-Nos. 1, 8, and 14-had histories excess risk of attempts among the Cath-
of previous suicide attempts. Patient No. olic mothers was found within each
7 put her hand through a window on racial group, although the numbers were
Christmas Day and No. 8 ingested not large.
aspirin on her 18th birthday. These lat- Marital Status-Subsequent suicide
ter two cases suggest the importance attempts were found in 22 per cent of
of situational stresses. those mothers who were single at regis-
tration but in only 7 per cent of those
*In Connecticut it was illegal forphysicians who were married at that time. One of
to prescribe contraception or counsel its use
the two who were separated or divorced
until June, 1965.7
DECEMBER. 1970 2293
at the index delivery made a suicide independent association between each
attempt. variable and suicide attempts. Being
When marital status was controlled both Catholic and single was associated
for religion, there was a suggestion of with approximately twice the risk found
Table2-Frequencyofsuicideattempts byselected characteristics
Suicide Suicide
Total attempts Total attempts
Item sample No. % Item sample No. %
Total 105 14 13.3 (b) New Haven,
nonpoverty area
Ageatdelivery Black:
15 and under 22 3 13.6 Catholic 0 0.0
16 and 17 83 11 13.3 Protestant 107 3 17.6
Race
Black 58 8 13.8 White:
White 47 6 12.8 Catholic 17 4 23.5
Protestant 7 0 0.0
Religion
Catholic 40 8 20.0
Protestant 65 6 9.2 Birthplace
Connecticut 62 9 14.5
Raceand religion Other northern states 7 0 0.0
Black: Southern states 34 5 14.7
Catholic 4 2 50.0 Non-U. S. or unknown 2 0 0.0
Protestant 54 6 11.1
White: Source of care
Catholic 36 6 16.7 None 8 1 12.5
Protestant 11 0 0.0 Clinic 79 10 12.7
Private 18 3 16.7
Marital status at registration
Married 62 4 6.5 Outcome of delivery
Single 41 9 22.0 Full-tenn live birth 94 14 14.9
Separated or divorced 2 1 50.0 Premature live birth 9 0 0.0
Marital status and religion Stillbirth 2 0 0.0
Single:
Catholic 8 3 37.5 Parity
Protestant 33 6 18.2 No previous
pregnancies 91 13 14.3
Married:
Catholic 30 4 13.3 One or more previous
pregnancies 14 1 7.1
Protestant 32 0 0.0
Separated ordivorced: Number of subsequent
Catholic 2 1 50.0 pregnancies
Protestant 0 0 0.0 (Todate oflastfollow-up)
Residence at index deEvery None 8 2 25.0
New Haven: 1-2 45 7 15.6
Poverty areas 64 7I MiUn.Y 3 or more 52 5 9.6
Nonpoverty areas 41 7 17.1
Complications of pregnancy
Residence, race and religion No complications of
(a) New Haven, pregnancy 29 0 0.0
poverty area
Black: Complication of
Catholic 4 2 50.0 pregnancy recorded 76 14 18.4
Protestant 37 3 8.1
White: Venereal disease
Catholic 19 2 10.5 Reported 24 5 20.8
Protestant 4 0 0.0 None reported 81 9 11.1
2294 VOL. 60, NO. 12, A.J.P.H.
SUICIDE AMONG PREGNANT TEEN-AGERS
among those who were either Catholic or during the study follow-up period
single. No suicide attempts were found (17%) as compared to those with three
among the married Protestants. or more subsequent children (10%).
Residence-The proportion of suicide Only eight of the total population had
attempts among mothers whose residence no pregnancy subsequent to the index
at the time of the index delivery was a pregnancy; of these, two attempted
nonpoverty area of New Haven (17%o) suicide.
was higher than the proportion of sui- Complications ofPregnancy-Seventy-
cide attempts among mothers from pov- two per cent of the study population
erty areas (11%).* Residence does not had complications recorded in the hos-
appear to alter the relationships found pital chart with one or more of their
previously, i.e., there was no difference pregnancies. These complications in-
in risk between racial groups within cluded such things as anemia, toxemia,
each of the two residential areas, but infection, and hemorrhage. (Venereal
Catholics showed higher rates than disease was considered separately.) All
Protestants within each. 14 suicide attempts were among those
Birthplace-There was no clear as- who had complications recorded. None
sociation between any particular area of of the patients without complications
birth and a higher or lower risk of were known to have made suicide at-
subsequent suicide attempt. tempts.
Source of Care-The risk of suicide Venereal Disease-Almost one-quar-
attempt was slightly higher among pa- ter of the study population had a diag-
tients receiving prenatal care from pri- nosis of venereal disease recorded in
vate physicians than among those cared the chart at some time. Those with this
for in the hospital clinics, or receiving diagnosis had approximately twice the
no prenatal care at all. The numbers risk of subsequent suicide attempt (21%o
are too small to reach definite conclu- to 11%).
sions, but the trend is consistent with It is not possible to demonstrate sta-
the finding of higher risk in pregnant tistical significance for the differeaces
girls from nonpoverty areas. related to the above characteristics, pri-
Outcome of Index Delivery-All of marily because of the small numbers
the suicide attempts were among mothers involved. Chi-square tests show that
who delivered full-term live babies. No only one of the above comparisons is
attempts were recorded among those de- significant at the conventional 5 per
livering stillborn or premature infants. cent probability level. Consequently, the
Parity-Of the total population of differences observed here are best re-
105, 91 were nulliparous at the index garded as suggestive leads. Further re-
pregnancy and 14 were having a second search may clarify the importance of
or third child. There was no evidence the association of these factors with
that women of higher parity were at the risk of suicide attempts.
greater risk for subsequent suicide at-
tempt. Relation to Other Studies of
Number of Subsequent Pregnancies- Attempted Suicide
There was a higher risk of suicide at-
tempt among those women who had no Before any conclusions can be drawn
more than two subsequent pregnancies about the possible relationship between
suicide attempts or threats and teen-age
* Defined as the lowest quartile nationally of pregnancy, it is necessary to determine
the "Health Opportunity Index," developed by
whether the frequency of attempts is
the Children's Bureau, based on the 1960
Census. higher in this sample than in the gen-
DECEMBER, 1970 2295
eral population or in other adolescent especially striking: for males the ratio
groups. Although the incidence of sui- was about 5 or 6 to 1, but for females
cide carried out to completion is rela- it was between 69 and 78 to 1.t For all
tively well known, at least for those ages combined, barbiturates and poison-
cases reported to the medical examiner, ing accounted for 52 per cent of the
few attempts have been made to de- female suicides and 63 per cent of the
velop directly an incidence rate of at- attempts (for males the comparable per-
tempted suicide. Moreover, since previ- centages were 17% and 43%); no
ous studies have shown that major dif- breakdown of method by age is given.
ferences exist between individuals who Working in New York City where
make suicide attempts and those who the reporting of accidental and inten-
actually commit suicide,8'9 extreme cau- tional poisoning is mandatory under the
tion must be exercised in using suicide city health code, Jacobziner10 developed
rates in connection with studies of at- a ratio of attempted to completed sui-
tempts. An alternative method of de- cides based on reports of ingestion in
riving comparative figures is by using the adolescent population. For the years
studies which have developed a ratio be- 1960-1961, he found 568 attempted and
tween attempted and completed suicide. 5 completed suicides by ingestion of
For the year 1957, Shneidman and chemical agents in the under-20 age
Farberow9 collected information on com- group, yielding a ratio of over 100 at-
pleted suicides from the Los Angeles tempts to 1 completed suicide.
coroner's office; and on attempts from Comparing the information from
the records of the Los Angeles County Jacobziner about attempts in 1960-1961
General Hospital and the 16 Los An- with his classification by sex and method
geles municipal emergency hospitals, of completed suicide in 1961-1962, the
and from a questionnaire sent to all ratios for males and females were each
private physicians and osteopaths in the found to be over 100 to 1. On the
Los Angeles area. The hospitals reported hypothesis that ingestion represents 50
2,019 attempts and the doctors an ad- per cent of the attempts among female
ditional 3,887 for a total of 5,906. Since teen-agers (as was found in our sam-
there were 768 completed suicides in the ple), the ratio for all methods would
same period, the over-all ratio between beabout 50to 1.
attempts and completed suicides was The discrepancy between these two
7.69:1.* sets of ratios (based on Shneidman-
Unfortunately, of those cases reported Farberow and Jacobziner) can be par-
by doctors, data on only 633 were com- tially explained by differences in the
plete enough to analyze by demographic study populations and research designs.
variables such as sex and age. Based on The Jacobziner study depended upon
these incomplete data, the ratio of at- reporting, which is less complete in at-
tempted to completed suicides for fe- tempted than in committed suicides.
males of all ages was almost identical Shneidman and Farberow, on the other
with the over-all rate, 8:1; for males it hand, sought out the information, al-
was only 1.5 to 1. For both sexes at
though their success with returns from
ages 10 to 19, the ratio of attempted
doctors was not outstanding. The smaller
to completed suicides was considerably
higher: about 18 to 1. The difference
tThese ratios were extrapolated from
between the sexes in this age group is Shneidman and Farberow's tables in which
entries are rounded towholepercentage points.
*This figure is quite close to the less than The ratios which can be deduced from these
6 to 1 figure quoted by Stengel and Cook8 data have the following ranges: for both sexes
which they state is based on data from the 18:1 to 19:1; formales5:1 to6:1; forfemales
police reports of Los Angeles and Detroit. 69:1 to78:1.
2296 VOL. 60. NO. 12, A.J.P.N.
SUICIDE AMONG PREGNANT TEEN-AGERS
size of the sample in the Jacobziner attempted suicide among teen-age
study also might result in greater varia- mothers is in excess of that which would
bility. Sampling fluctuations and the be expected in the general urban adoles-
rather crude methods used to produce cent population. The first explanation is
comparable figures also may have con- that the stresses of pregnancy and child-
tributed to discrepancies. Unfortunately rearing in some young girls are so enor-
neither study provides the data neces- mous that they react by attempting sui-
sary for a more accurate estimate, since cide. An equally interesting possibility,
Jacobziner does not deal with suicide at- however, is that the suicide attempt is
tempts other than by chemical inges- not a direct result of the pregnancy, but
tion, and Shneidman and Farberow do that both the pregnancy and the suicide
not classify their population by both age attempt stem from a common process.
and sex. Both these events may represent dis-
In the study reported in this paper, turbed behavior by adolescent girls.
105 patients were followed for a total Girls who become pregnant in their
of 7,084 patient-months, or 590.3 pa- teens may be demanding attention or
tient-years. Thus there are about 590 trying to punish or inflict pain on their
"women years" of risk at average ages parents or other significant persons in
of 16 to 22 years. On the basis of the their environment. Similarly, the sui-
12 mothers who made actual suicide at- cidal act or threat may be a way of
tempts, this is a yearly rate of striking out or seeking revenge.
A study of suicide attempts in preg-
12x100 =2.03%, attempts
or 2,030 nant women by Whitlock and Edwards12
590.3
per 100,000 per year. seems to support this latter alternative.
Inorderto determinewhether this rate Theynoted thatthe "majority ofsuicidal
of suicide attempts was larger than that attempts by the pregnant women were
impulsive, often precipitated by violent
expected among young females in an ur-
ban population, the rates based upon the interpersonal disputes which did not
Shneidman-Farberow and Jacobziner necessarily relate to the pregnancy. The
studies were applied to suicide rates women showed marked instability of
from Cook County, Illinois, in 1959- personality and many had experienced
life-long interpersonal and sexual diffi-
19631" where the rate was 2.5 per
100,000 per year among females in culties. A follow-up survey of two-thirds
the 15 to 24 age group. Applying this of the patients showed that 37 per cent
suicide rate to the estimated ratios of of the women continued to show major
psychiatric disorders."
suicide attempts to suicides, one would
expect between 173 and 195 suicide Further research would be necessary
attempts per 100,000 per year using the to determine whether either of the al-
ratios based upon Shneidman and Far- ternative explanations offered would ac-
berow's data, and 125 per 100,000 per count for the increased rate of suicide
year using the ratio based upon Jacob- attempts or threats in this population.
ziner. The rate of suicide attempts in
the study sample is roughly 10 times Risk of Suicide Affempf
larger than the largest ofthese estimates.
The data reported earlier in this arti-
cle on the association between specific
Discussion
characteristics and suicide attempts
At least two alternative explanations suggest that a higher-risk group might
can be advanced to explain the major be defined within a population of teen-
finding of this study, that the rate of age mothers. The factors associated with
DECEMBER. 1970 2297
an increased risk of suicide attempt nancies undoubtedly occur in large num-
within New Haven were: being Cath- bers in the middle and upper socioeco-
olic, not having married, living in a nomic groups, in the public mind preg-
nonpoverty area, experiencing a com- nancy at a young age is associated with
plication of pregnancy, and having a illegitimacy and with the lower socio-
venereal disease at some time. The re- economic class. Therefore, when a teen-
ligion and marital status variables are age girl who is single and/or Catholic
especially notable since they run con- and/or living above the poverty level
trary to some studies of committed sui- finds herself pregnant, she may be more
cides. Since Durkheim's13 classic study, aware of the disapproval of her social
it has been assumed that committed group than she would be if she were
suicides were lower among Catholics a married and/or non-Catholic and/or
than other religious groups. Recently, a poverty-level teen-ager. This aware-
this conclusion has been questioned.14 ness of deviance from the norms of the
Relative to marital status, Seiden15 re- group may make a suicide attempt or
cently pointed out that although suicide threat more likely.
is less frequent among married persons, Several of the findings indicate that
this is not true in the young married those who attempt suicide represent a
population. Under the age of 24, and disturbed population: the high rate of
especially under 20, the death rates from venereal disease-which is often asso-
suicide are higher among married men ciated with promiscuity-and the fre-
and women than among single men and quent histories of emotional illness iDn
women. Seiden suggests that "perhaps cluding psychiatric symptomatology, of
youngsters who marry in their teens are previous suicide attempts, and ofmarital
seeking to escape from unsatisfactory discord. Moreover, the high rate of
home environments, or perhaps early pregnancy complications among those
marriage, per se, introduces stresses who threatened or attempted suicide,
which lead tosuicide." and the presence of physical illness in
The fact that women who were conjunction with several of the attempts
single, Catholic, and not living at a pov- suggest that physical conditions should
erty level were more likely to attempt not be overlooked. Venereal disease may
or threaten suicide than other women be viewed as both an emotional and a
who also had borne children in their physical factor.
teens would seem to suggest that the
acceptability of the pregnancy in the
The Significcance of fhe Suicide Affempt
womens social group might be a con-
tributing factor. Certainly in almost all Given what appears to be an excess
groups, regardless of age, it is more ac- number of suicide attempts among
ceptable to be pregnant if one is mar- women who become pregnant in their
ried than if one is not. Catholic re- teens, a question can be raised about
ligious training places strong proscrip- the importance of this act. Is committed
tions on sexual activity outside of mar- suicide a real possibility in this popula-
riage.* Finally, although teen-age preg- tion? If it is not, is the suicidal be-
*Kinsey18 studied the association between havior important in itself?
religion and feelings ofregret about premarital Several studies have shown a high
coitus among women. Although the differences rate of completed suicide among those
were greater between the more or less devout who previously attempted or threatened
within the religious groups, 35 per cent of the
devout Catholics as compared to 23 percentof suicide, i.e.,suicideattemptersareahigh-
the devout Prostestant women regretted the risk group for completed suicide.1718
experience. In addition, another study undertaken
2298 VOL. 60, NO. 12, A.J.P.H.