Mini Commentary on BJOG-23-1596.R1: Pregnancy and Birth Complications and Maternal Mental Health – The case is clearNicole Votruba - [email protected] of OxfordNuffield Department of Women’s & Reproductive HealthWomen’s Centre (Level 3)John Radcliffe HospitalOX3 9DU Oxford15 October 2024 Pregnancy and birth complications and long-term maternal mental health outcomes are clearly interlinked. Although commonly known, little research has been conducted to investigate these associations. Bodunde and colleagues have recently provided robust evidence that complications during pregnancy and birth increase the risks for long-term depression, anxiety and post-traumatic stress disorder (PTSD)(1).Birth complications are frequent, affecting up to 40% of pregnant women, and can continue to be burdensome for mothers and children beyond birth. Whilst there is a well-established body of evidence about the effect of these complications on mental health in the immediate postpartum period, particularly the first six months, much less is known about the impact these complications have longer term, during the first year after birth and beyond.(1)The authors have carried out the first, comprehensive meta-analysis estimating rates of long-term maternal mental health outcomes for women following pregnancy and birth complications. They performed a rigorous, substantial systematic review and meta-analysis, consolidating 33 studies with almost 4 million participants. The authors found significant associations between pregnancy terminations, miscarriage and preterm birth, with maternal depression and anxiety, and preterm birth (but not caesarean section) being significantly associated with PTSD.What do their findings tell us beyond the clear link of pregnancy complications and adverse maternal mental health outcomes? Firstly, that in spite of a relatively large number of studies and participants, there is an evident lack of high-quality studies on the associations of pregnancy complications and long-term mental health outcomes. Depression and anxiety were the most reported associations across all studies, and the authors note the absence of studies on other mental disorders than anxiety, depression and PTSD, which made further meta-analyses impossible.Secondly, with the total of 33 studies being from 15 countries, the findings confirm the striking lack of research from low- and middle-income countries (LMICs): Only four of the identified studies are from Asia, one from South America, and none from Africa. Whilst the extent of maternal morbidity is hard to estimate, looking at the burden of maternal mortality points at an excessive gap: nearly 95% of maternal deaths occurred in LMICs in 2020,(2), with the mental health related impact being largely hidden due to a lack of data.Thirdly, and perhaps most strikingly, we are missing the extent of maternal suicide as an adverse mental health outcome. The authors’ primary review outcomes were common and severe maternal mental disorders, and regrettably suicidality has been omitted as a primary mental health outcome. Maternal suicide is the leading cause of direct death in the postnatal period.(3) In high income countries 5-20% of maternal deaths are from suicide,(4) however stigma and challenges in unified approaches to reporting and measurement obscure the picture, with a lack of evidence beyond the immediate post-partum period, and particularly from LMICs.(5). Given the high burden, there is an urgent need to understand these links as substantial long-term adverse maternal mental health outcomes of adverse pregnancy outcomes.Beyond the post-partum impact, evidence on the long-term mental health outcomes in relation to adverse pregnancy outcomes is limited. What Bodunde and colleagues have added is clear and highly needed evidence for the direct associations of adverse pregnancy outcomes and long-term mental health conditions. What is now required is more robust evidence on prevalence and associations of these conditions and their long-term effects, particularly studies from LMICs, and including maternal suicide. Research examining more effective intervention is critical: studies should explore and test what interventions are acceptable, effective and scalable in different settings and communities, to support women who experience adverse pregnancy outcomes in their mental health, and prevent long term mental ill health particularly in populations with the greatest burden of disease.Disclosure of Interests: n.a.Funding: NV is funded by the Medical Research Council (Grant MR/Y503319/1), the Oxford MSD Improving Equitable Access to Healthcare grant, and partially supported by the UK Medical Research Council (UKRI) for the Indigo Partnership (MR/R023697/1) award1. Bodunde EO, Buckley D, O’Neill E, Al Khalaf S, Maher GM, O’Connor K, et al. Pregnancy and birth complications and long-term maternal mental health outcomes: A systematic review and meta-analysis.n/a(n/a).2. World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division: World Health Organization; 2023.3. Knight M, Bunch K, Tuffnell D, R P, Shakespeare J, Kotnis R, et al. Saving Lives, Improving Mothers’ Care-Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2021.4. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313-27.5. Simmons E, Gong J, Daskalopoulou Z, Quigley MA, Alderdice F, Harrison S, et al. Global contribution of suicide to maternal mortality: a systematic review protocol. 2024;14(9):e087669.