Concealment, failed help-seeking, and the conditions of safe disclosure in perinatal suicidal behaviour

<title>Abstract</title> <p>Suicide is a leading cause of maternal death during the perinatal period. Current prevention strategies rely on screening, risk assessment, and “reach out” campaigns, all built on two untested assumptions: that a woman who is asked will answer honestly, and that an honest answer will be met with support. This study interrogated both premises through reflexive thematic analysis, within a critical realist orientation, of a participatory family qualitative study in Australia. The 43 participants comprised women with lived experience of perinatal suicidal behaviour, family members and carers, and perinatal health professionals. Three themes were constructed. “I couldn’t tell anyone” describes how women concealed distress as a deliberate, self-protective response shaped largely by fear of child removal. “One step closer” captures what happened when they sought help. Participants reported being dismissed, minimised, disbelieved, or met with adverse responses, and each unsuccessful effort became, in their own reasoning, evidence that they were beyond help. “Safe to tell” identifies the conditions that made honest disclosure possible and ensured it was adequately answered. We interpret concealment and dismissal as two expressions of the same underlying condition: an inadequate response environment, meaning how services and individuals react when a woman discloses distress. Based on these findings we argue that prevention policy should prioritise the safety of disclosure and the capacity of services to respond effectively.</p>