[Confidential enquiry into maternal suicide: lessons for clinical practice]

In the Netherlands, suicide is the leading cause of maternal death up to one year postpartum. Understanding underlying causes and care processes is essential to reduce maternal mortality. Structured case analysis can help identify factors contributing to deaths in the perinatal period.

To identify gaps in care for peripartum women experiencing suicidality and to formulate recommendations.

Retrospective qualitative analysis of five cases reviewed in 2021 and 2024 by the Dutch Audit Committee Maternal Mortality and Morbidity. Information was available from primary care and/or mental health services. Additional committee documentation was used to formulate lessons learned, and a vignette was derived from discussed case histories.

The analysis yielded lessons in five themes: 1. identification of non-medical risk factors and suicidality, 2. regional network agreements for perinatal mental healthcare, 3. safety-planning in peripartum suicidality, 4. reporting and 5. peer-support.

The analysis highlighted important lessons for the care of peripartum women with suicidality, particularly in the areas of recognition, multidisciplinary collaboration, and access to specialized perinatal psychiatric care. Limitations include incomplete documentation and underreporting.