The release of the new WHO estimates provided an opportunity to examine suicide rates across the globe including countries with relatively limited information. Therefore, the aim of this paper was to analyze the age-standardized suicide rates in 46 Muslim-majority countries from 2000 to 2019, and to compare the suicide trends with the global average. In addition, we compared the 2019 suicide rates with the global average and their respective regions/sub-regions; and examined the association between the age-standardized suicide rates and the male-to-female suicide rate ratio, with the proportion of Muslim population in a country, and the Human Development Index (HDI) in 2019. Our study found that the majority of the Muslim-majority countries (76.1%) had their average suicide rates below the global average in 2019. Despite some fluctuations, most of the countries (63.0%) showed an overall decline during the past 20 years (2000-2019).

Suicide rates in Muslim-majority countries across regions and sub-regions

Of the 46 Muslim-majority countries analyzed, 11 (23.9%) had an age-standardized suicide rate above the global average in 2019. Of the 11 countries, nine are located in Sub-Saharan Africa, including Burkina Faso, Chad, Comoros, Djibouti, Gambia, Guinea, Mali, Mauritania, Niger, Senegal, Sierra Leone, and Somalia. The other two are in South Asia and Central Asia, i.e., Pakistan and Kazakhstan. These 11 countries are estimated to have about 318.5 million Muslims out of the total Muslim population of about 1,393.0 million (22.9%). The remaining 35 Muslim-majority countries have age-standardized suicide rates below the global average, and they consist of about 1,074.5 million Muslim populations comprising 77.1% of total Muslim populations located in the Muslim majority countries included in the analysis.

Traditionally, Kazakhstan has had high suicide rates and showed a twice higher rate compared to the global average in 2019. A recent study found that unemployment was the factor most strongly correlated with suicide rates in Kazakhstan between 2000 and 2019 [32]. The suicide rate estimated in Pakistan was also slightly above the global average. A scoping review on suicidal behavior and self-harm in Pakistan found that individuals below 30 years old and males to be at higher risk of suicide in Pakistan [33]. There is a lack of suicide research from Africa to explain the high suicide rates of nine Muslim majority countries in Africa, however, the WHO estimates show that the African region has the highest average suicide rate in 2019 [34].

Based on the country-level comparisons, the age-standardized suicide rates of most Muslim-majority countries were consistently lower than the global average during the past 20 years. This could be partly explained by the role of their religion and may also be due to some countries integrating Islamic principles into their governance and social systems. Suicide is prohibited under Islamic law, based on evidence from the Qur’an, the Sunnah, and the consensus of Muslim scholars. The person who dies by suicide is liable to be eternally condemned and experience God’s wrath. According to the Qur’an, in the 4th surah, verse 29, “You shall not kill yourselves. Surely Allah is ever compassionate to you.” Apart from condemning suicide, the Qur’an emphasizes the sanctity of life, providing instructive guidance on the value of life and fulfilling the role as a human in this world whilst maintaining steadfastness, patience, and stability in all aspects of life (Qur’an, 17:33) [35]. In addition, adherence to the normative structures of collectivism such as cohesive communities, familial support, and collective goals together with religious commitment is important, and these may be protective against suicide [20]. Based on the above, the low suicide rates in most of the Muslim-majority countries may be related to the understanding of the Islamic concept of life within the matrix of Islamic thought such as legal thought, the Qur’an, and Prophetic Traditions. The findings are consistent with other studies reporting the protective effects of Islam in terms of reducing country- or region-wide suicide rates in Muslim countries [14,15,16,17,18].

On the other hand, suicide is also a major stigma in Muslim countries, which may lead to a reluctance to report a suicide death, and this may lead to the lower suicide rates in these countries [6, 36, 37]. The low rates of suicide in Muslim-majority countries which can be seen as a result of Islamic thought condemning taking one’s own life is not necessarily indicative of lower levels of suicidal ideation [38]. The suicidal ideation can manifest itself as non-fatal suicidal behavior or might be repressed by one’s religious belief. This is supported by higher attempted suicide rates in Ankara, Turkey [39], a high percentage of Turkish students considering suicide [40], and higher scores obtained in the suicide probability scale by Turkish university students compared to their American counterparts [38].

There were considerable cross-regional differences in the average age-standardized suicide rates in the seven regions and sub-regions of Central Asia, South Asia, Southeastern Asia, Western Asia, North Africa, Sub-Saharan Africa, and Southern Europe examined here. As a region, Sub-Saharan Africa recorded the highest average suicide rate among all the regions examined. According to Lester et al., gender inequalities may play a role in higher suicide rates in Africa and family power dynamics and domestic violence may contribute to this [41]. A narrative synthesis by Vijayakumar et al. further suggested that the suicide rate among African refugees was higher [42]. As Africa is home to the largest number of refugees, suicide among refugees might be an important factor behind the increasing overall rate of suicide deaths in African countries. In Sub-Saharan Africa, a meta-analysis among young people revealed that the median lifetime prevalence estimate of self-harm was 10.3% [43]. The high prevalence of self-harm may translate into a high suicide rate in this region.

In Western Asia, Muslim-majority countries recorded a higher average suicide rate than the overall Western Asia regional average, which included Muslim-majority and other countries. Of note, six out of 14 countries in this region recorded a male-to-female suicide rate ratio of more than 4.0. Future studies could expand on these preliminary findings to examine the reason behind the relatively higher suicide rates in Muslim-majority countries in the Western Asia region in comparison with other countries.

We found no association between the proportion of Muslims and age-standardized suicide rates. This finding is not consistent with Shah and Chandia’s [20] study on suicide rates of 27 countries based on WHO data between 1991-2002, where the higher proportion of Muslims was associated with lower suicide rates for both males and females. The difference may be because Shah and Chandia’s [20] study included countries where Muslims were not the majority. Therefore, further studies are needed to establish the protective effect of Islam for males and females. However, we found that the higher the proportion of Muslims in a country, the lower the male-to-female suicide rate ratio. This means females had a relatively higher risk of dying by suicide in Muslim-majority countries with a higher Muslim population proportion.

We also found that a higher HDI index was associated with a higher male-to-female suicide rate ratio, i.e. females had a lower risk of dying by suicide in countries with better quality of life and economic development. The findings were consistent with another study of 91 countries where a higher HDI was associated with higher suicide rates among males [44]. Factors contributing to higher female suicide rates such as greater gender inequality and lack of education and economic freedom [45] may be lower in Muslim-majority countries with a higher HDI. Our study also found that the higher the HDI index, the lower the age-standardized suicide rate in Muslim-majority countries. The results were dissimilar with another study in which high and very high HDI countries had significantly higher suicide rates in comparison with medium HDI countries [44]. However, the aforesaid study [44] did not include low HDI countries, which are more prevalent in our study. Therefore, HDI may be more protective of suicide among low and middle HDI countries in comparison with high and very high HDI countries, but this needs to be further investigated in future studies.

Suicide trends in Muslim-majority countries across regions

Overall, the suicide trend in a majority of Muslim-majority countries indicated a significant decrease in 2000-2019. This was shown for countries in Central Asia which have traditionally recorded very high suicide rates and, nevertheless, even after a significant decrease, they still recorded higher rates than the global average. However, a few countries in Western Asia (Azerbaijan and Saudi Arabia) and Brunei in Southeastern Asia recorded an overall increase in the AAPCs during the past 20 years. In addition, a few countries experienced an upward trend after an initial decrease, which were Bangladesh (2014 onwards), Kuwait (2011 onwards), and Syria (2006 onwards). Syria recorded an upward trend between 2000-2010, a downward trend between 2010-2015, and an upward trend between 2015-2019. While it is difficult to determine the causes of these trends, a number of legal, health, and psychosocial events may be contributing factors. In Bangladesh, the ban of class I pesticides in 2000 was successful in decreasing suicide deaths attributable to pesticide poisoning between 2001 and 2014 [46]. However, a psychological autopsy study conducted on suicide deaths between July 2019 to July 2020 in Dhaka, Bangladesh showed that pesticide poisoning was still the most prevalent suicide method [47]. The upward trend in suicide rates in Syria between 2006 to 2019 may be partly explained by the Syrian civil war which began in 2011 and was a factor contributing to between 16% to 84% of Syrians suffering from post-traumatic stress disorder, and 11% to 49% from depression [48]. Sierra Leone recorded an upward trend in suicide rates between 2015 and 2019, and this may be related to the increased incidence of grief, post-traumatic stress, depression, and unexplained somatic symptoms owing to the Ebola outbreak between 2015 and 2017 [49]. These may have stemmed from the social ramifications of the disease such as the loss of loved ones, and stigma and violence against those presumed infected, depriving affected individuals of the traditional social support needed to overcome the crisis [50, 51].

The results of this study have implications for suicide prevention in Muslim-majority countries. First of all, based on the WHOMiNDBank, only Uzbekistan has a national suicide prevention policy [52]. In Kazakhstan, the Adolescent Mental Health and Suicide Prevention (AMHSP) program was implemented in two regions and incorporated within the 2015-2020 National Action Plan. The multisectoral collaboration with UNICEF Kazakhstan and a strong national agenda on suicide prevention resulted in falling suicide rates among adolescents aged 15-19 years old and is now being scaled nationally [53, 54]. There is a need for similar national suicide prevention activities to be developed and implemented in the other Muslim-majority countries. In addition, the considerable differences in suicide rates between the Muslim-majority countries studied should encourage further research on the multifaceted influence (or limitations) of religion in affecting the country- and region-level suicide rates [55]. For example, the countries represented in this study are from different socio-economic stages of development. How religious influence interacts with socio-economic and other factors is still far from definitive. Hence, any endeavor which attempts to provide a common explanation is bound to suffer from shortcomings and criticism. Future research can benefit from investigating the underlying mechanisms behind the decrease of suicide rates in countries that recorded a significant decrease in suicide rates during the past 20 years.

Limitations

This was an analysis based on WHO estimated suicide data for each country. Of the 46 Muslim-majority countries surveyed, only three countries (Kazakhstan, Kuwait, and Kyrgyzstan) had vital registration data which was ranked high-quality, whilst 56.5% of the Muslim-majority countries, and all Muslim-majority countries from the Sub-Saharan Africa region, had death registration data which were either unavailable or deemed unusable due to their low quality. Therefore, these data need to be interpreted with caution [1]. Certain countries not listed as UN and WHO member states, such as Palestine, were not included in this study, as data on suicide rates were not available. Important insights from these countries may therefore be left out, and future studies are required. There was a wide range in the proportion of the population in each country that had a Muslim affiliation. No research has been done on the level of belief-specific practices followed in each country, which was beyond the scope of this paper. In addition, we did not disaggregate the 20-year suicide trend data by gender, age cohort, and other demographic indicators. This is recommended for future studies, which could contribute to a greater understanding of groups that contributed most to the changes, and therefore prevention initiatives could be tailored. The correlation analyses conducted between the proportion of the Muslim population, age-standardized suicide rate, male-to-female suicide rate ratio, and HDI did not control for other variables and was limited to 2019. Future studies should conduct panel analyses using multiple sources spanning several years.

The influence of Islamic culture or Islamic laws on gender roles was also not examined. Some countries may be governed by Syariah (Islamic) laws that may prohibit attempted suicide, including some which may criminalize attempted suicide. Effects of this on suicide rates were not investigated. Some countries may have under-reported suicide due to different levels of development and accuracy in their suicide reporting system. It is a custom for a Muslim to be buried early before decay sets in [56], normally, before the next day prayer. This practice may create pressure on the proper recording of suicide data as sometimes it limits the time available for the police, coroners, or pathologists to confirm the cause of death. Sudden death among women was also found to be less frequently reported as a suicide, in comparison with male suicide, due to the need to preserve family honor [57]. The WHO classified the mortality data quality of some countries as “poor”, and these need to be interpreted with caution [58].

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