In June, M., a 28-year-old woman jumped from the second floor of her home in Madurai, India — 20 feet above a rocky, tar road — after a bitter argument with her husband. He had accused her of having an affair.
This was M.'s second attempt to kill herself. She survived the fall. M. had been prescribed antidepressants after her first suicide attempt seven years before but had stopped taking them. She was admitted to Madurai's Government Rajaji hospital shortly after her second suicide attempt. Three weeks later, doctors recommended that she have surgery using metallic plates to fuse her shattered spine, but her mother, uncertain and fearful about the outcome, refused to let M. go under the knife.
She was discharged a month after her ordeal and remains bedridden in her mother's home, unable to walk. Her two children, an 8-year-old girl and a 5-year-old boy, who last visited her a week ago, still live with their father. Her mother gave us the details of her story and asked that only her daughter's initial be used to protect her privacy.
M. is one of many Indian women who struggle with depression and suicide.
As a part of the Global Burden of Diseases, Injuries and Risk Factors Study 2016, a group of 30 public health researchers and doctors across India examined and evaluated data from national sources to study the suicide death rates for men and women. Their findings, published last week in the medical journal Lancet Public Health, brought out some startling revelations. India accounted for 37 percent of all suicides reported globally for women and 26 percent for men. In 2016, an estimated 230,300 Indians died of suicide, a 40 percent increase from 1990 and only slightly less than the casualties from traffic accidents reported that year.
NPR spoke by phone with two of study authors: Rakhi Dandona, a public health expert at the Public Health Foundation of India and the University of Washington, and Dr. Lakshmi Vijaykumar, a psychiatrist with 25 years of experience in suicide prevention strategies. In 1986 she set up SNEHA, a suicide prevention hotline in Chennai.
The study was funded by Bill & Melinda Gates Foundation, the Indian Council of Medical Research and the Department of Health Research, Ministry of Health and Family Welfare, Government of India. The Gates Foundation is also a funder of NPR and of this blog.
The interviews have been edited for length and clarity.
Tell us a little about the study. Was the goal to look at suicide rates?
Dandona: The Global Burden of Diseases, Injuries and Risk Factors study covers every disease/condition that you can think of. GBD is a standardized way of measuring the health of different countries across age groups, sexes and time. Our team focused on injuries, which included suicide.
Did the revelations from the study come as a surprise?
Dandona: Yes, very much, particularly the gender differences in suicide deaths. Typically, in India, the suicide death focus has only been on Indian farmers. We found that 15 out of every 100,000 Indian women died because of suicide in 2016 and this rate was double the world average for women. Twenty-one out of every 100,000 Indian men died because of suicide, too, and the rate is higher than that of the women. And while it is true that more Indian men die from suicide every year, one has to keep in mind the more women attempt suicide than men. Men adopt more lethal measures to commit suicide.
Vijaykumar: One interesting observation is that young women between the ages of 15 and 30 were the most vulnerable and more prone to dying by suicide [than older women]. After 30, suicide rates among women dropped drastically. What changed? Indian women below the age of 30 were exposed to major life changes and social pressures that come after marriage. Many lived with their in-laws in a patriarchal joint family setup and were denied basic freedom. But after 30, most women had children and [their] status in the family changed. Even though the pressures and difficulties remained the same, her attention shifted to her children. She became less suicidal. Suicide rates among males however, remained the same regardless of their age.
In 2014, the World Health Organization examined women's suicide across various countries. We learned that Asian women have the highest suicide rates in the world. Sixty percent of all women who died by suicide are from India and China. Interestingly, over the last five years, the suicide rate in rural Chinese women has drastically reduced, but in India, the figures haven't gone down.
How was the data for your study collected and examined?
Dandona: The biggest chunk of our data came from examining the Sample Registration System, which is a part of India's national registration system, providing vital information on the cause of death. They conduct what are called "verbal autopsies."
What do these verbal autopsies involve?
Verbal autopsies are a way of gathering information about a deceased [individual] from conversations and interviews with those familiar with or related to them. It's a scientific process for data gathering that is later analyzed by health-care professionals. We utilized over 450,000 such "verbal autopsies" for this report. In addition, we used the medically certified causes of death and some other verbal autopsy studies. Underreporting of suicide is a common problem, and these verbal autopsies give researchers a lot of insight.
Is it difficult for people to report suicide in India?
Vijaykumar: In 2017, India passed a Mental Healthcare bill which did state that people should not be penalized for attempting suicide because their actions stemmed from great distress. However, few people realize that suicide still has not yet been decriminalized. A law in the Indian Penal Code (IPC 309) still lays down punishment for attempted suicide and it has not been repealed. As a result, the stigma against suicide exists. It's something we battle every day. Unless that law goes, we cannot make progress in addressing the issue.
What were the key factors that drove Indian women to suicide?
Dandona: We did not examine key factors for suicide in this report. We have reported previously on a wide gamut of personal and social reasons that drove suicide deaths. This involved tensions between family members, arguments with husband and in-laws. Domestic violence is known to be an important cause of suicides — particularly for housewives.
Suicide deaths were not limited to low income or uneducated women. In developed states like southern state of Tamil Nadu, the rate of suicide death was high for women when compared to less developed states in India.
Do you have a theory as to why?
Dandona: It is believed that educated women expect more from their lives and hence have deeper dissatisfaction when they were thwarted from achieving their goals, such as higher education and career advancement. Interestingly, the suicide rate among women was lowest in the southern Indian state of Kerala, which does not have a patriarchal system.
Vijaykumar: Alcoholism, domestic violence and suicide often cropped up together. We need to examine these issues at a societal level to prevent the rise in suicides in the future. Education and financial empowerment of women will help drive these rates down. Data from the southern Indian states proved that though the suicide numbers were still high among women there, with better opportunities, the numbers were declining.
Kamala Thiagarajan is a freelance journalist based in Madurai, India, who has written for The International New York Times, BBC Travel and Forbes India. You can follow her @kamal_t.