For years, Suzanne Petroni, senior director at the International Center for Research on Women, would speak — backed by mountains of evidence she studies — about the number one cause of death among women around the world: maternal mortality.
Then, in September, 2014, the World Health Organization released its report on "Health for the World's Adolescents: A Second Chance in the Second Decade."
"I read the report, and there was one line tucked away," says Petroni. The line addressed females age 15 to 19. "The number one cause of death had changed," she says. "It was suicide."
That finding made headlines around the world last month after it was cited at a Bill & Melinda Gates Foundation event.
Petroni checked and rechecked, even made some phone calls to friends at WHO, and confirmed that it was true. The number one cause of death around the world for older teen girls had shifted from maternal mortality to "self-harm." Self-harm can refer to any form of violence to oneself: cutting, drug overdosing. Some self-harm is survivable. But when the term ends up in a column labeled "mortality" in a WHO report, it means suicide.
But curiously, the shift doesn't reflect a sudden increase in self-harm.
What it does reflect is a bit of good news: Maternal mortality has been dropping. The number of women dying from pregnancy and childbirth complications has dropped for women of all ages by almost 50 percent between 1990 and 2013, according to WHO. And in the age range of 15 to 19, the rate of death from maternal conditions fell from 15.74 per 100,000 in 2000 to 9.72 in 2012.
Rates of suicide have also been dropping in that same time period, but the rate is still high enough to outpace maternal mortality among females 15 to 19. The suicide rate in that age group fell from 15.85 per 100,000 in 2000 to 11.73 per 100,000 in 2012.
It's also worth noting that suicide in the 15-to-19 age range already had passed maternal deaths by the year 2000 by fractions of percentage points. But the trend wasn't noticed until the release of the 2014 report.
The suicide statistic is propelled by extraordinarily high rates in Southeast Asia, a WHO-designated region that includes Bangladesh, Bhutan, Democratic People's Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. There, the rate of death by suicide is 27.92 per every 100,000 females between 15 and 19, more than twice the global rate in that group.
"Those numbers make peoples' heads turn," says Petroni. "Clearly, Southeast Asia is the predominant driver." The rate there is about five times higher than in Europe or the Americas.
Numbers on suicide are not easy to compile. WHO acknowledges gaping holes in some nations' vital statistics along with cultural taboos that often seek to cover up suicide as a cause of death. But the organization stands by the data as an accurate representation of suicide. Each year, WHO asks its 194 member nations to report on causes of death for their population. Not every country can comply. "We can say that there are 90 countries who report on an annual basis on suicide," says Alexandra Fleischmann, a project coordinator for WHO's "Preventing Suicide" report, based on the same statistics used in the organization's adolescent report. Of those, 60 countries are deemed by WHO to have good quality vital statistics on suicide, and 28 countries have a national strategy for suicide prevention.
But some countries don't even officially register births and deaths. In those cases, WHO relies on country or regional surveys and other published data, and extrapolates to a national level. "Suicide is still a taboo issue, and yes, there is some underreporting," says Fleischmann, "but it's the best we have, and we believe overall it is a picture of reality."
With those caveats in mind, Petroni says the statistics on suicide among older teen girls ring true. "In South and East Asia, there are very stark gender differences in expectations," she says. "You see girls excluded from education, forced into marriage, being victims of violence, abuse, trauma, social isolation. Those risk factors are higher for girls in many parts of the world, putting them at higher risk for suicide."
Indeed, one study of Nepali girls and young women found suicide the leading cause of death in women between 15 and 34. The suicide rate was 22 per 100,000 in 1998; it rose to 28 per 100,000 by 2009. Those most vulnerable, according to the study, were socially isolated, poor, rural women. They often marry young and are victims of domestic abuse. Wives are often considered their husbands' property and "become trapped in a perennial cycle of dependence which may lead some to view suicide as their only option," the study says. The recent earthquakes could well increase suicides in Nepal. Displacement, in this case due to a natural disaster, increases suicide rates for men and women of all ages, according to the study.
The overall rate of suicide among girls and young women has fallen somewhat in the years studied by WHO. In 2000, the worldwide rate was 15.85 per 100,000; it fell to 11.73 per 100,000 in 2012, though it remains the leading cause of death in females 15 to 19.
The report doesn't explain the drop, but efforts by a few countries offer some clues.
"China is just one major example. It has brought down youth suicide rates, especially in women in the past ten years, through a range of interventions," says Vikram Patel, professor of International Mental Health at the London School of Hygiene and Tropical Medicine. "Both social interventions, such as improving employment opportunities in rural areas, and improving mental health care."
India, too, has made changes after noticing that some young people, under great stress to do well in school, resorted to suicide if they felt they did poorly. "In South India, they observed higher suicide rates after exam periods among schoolchildren who failed," says Fleischmann. "Then they introduced the possibility of redoing the exams, and that reduced the suicide." That information was reported to WHO from a collaborating center in India.
And there are proven preventive efforts that can help reduce suicide around the world. "Irrespective of the variations between nations, there are universal strategies which will work in all societies, such as means restriction and improving access to mental health care for young people," says Patel. By "means restriction" he is referring to reducing access to the methods of suicide.
In high-income countries, hanging is the leading method of suicide, accounting for half of suicide deaths, followed by 18 percent due to firearms (led by the Americas, where firearms account for 46 percent of suicides.) In low- and middle-income countries, methods are less clear, though WHO estimates that about 30 percent of global suicides are due to pesticide poisoning, mostly among men and women of all ages in poor, rural areas.
But it's easier to restrict access to pesticides than to address the cultural and societal issues cited as risk factors for suicide: young girls being forced to marry or seeing educational opportunities closed to them, for example.
"Changing a society, and how equal or not equal it is, is more difficult than changing, say, the harmful use of pesticides," says Fleischmann. "Fighting poverty, fighting for equality — certainly that plays an important role. That, however, takes more time."
It will also take time to tease out additional information about self-harm. In a report whose scope is the cause of death for every adolescent on earth, there are findings buried deep within the data.
"Actually, in the suicide prevention report," says Fleischmann of WHO, "among the key messages was that [self-harm] was the second leading cause of death for both sexes. This might be even a stronger point."