By Rebecca H. Allen, MD, MPH, Editor
SYNOPSIS: In this national study, there were 3.62 homicides per 100,000 live births among females who were pregnant or within one year postpartum from 2018 to 2019. This rate was slightly higher (16%) than the rate among nonpregnant and non-postpartum females of reproductive age. Homicide was found to be a leading cause of pregnancy-associated mortality.
SOURCE: Wallace M, Gillispie-Bell V, Cruz K, et al. Homicide during pregnancy and the postpartum period in the United States, 2018-2019. Obstet Gynecol 2021;138:762-769.
The authors used the following definitions for the study: Pregnancy-associated mortality was defined as deaths during pregnancy and within one year postpartum from any cause, based on the Centers for Disease Control and Prevention definition; and maternal mortality was defined as deaths while pregnant or within 42 days postpartum from causes related to or aggravated by the pregnancy, based on the World Health Organization definition. By 2018, every U.S. state had added the required “pregnancy check box” to their Standard Certificate of Death, which classifies deaths as not pregnant at time of death, pregnant, within 42 days postpartum, or 43 days to one year postpartum. The authors of this study sought to use this national data to estimate the prevalence of pregnancy-associated homicide.
The investigators used data from the 2018 and 2019 mortality files from the National Center for Health Statistics, which include a death record from every person who dies in the United States. The data were restricted to females, ages 10 to 44 years, whose manner of death was homicide and a checkbox value indicated the individual was pregnant or within one year postpartum. Both pregnancy-associated mortality and direct maternal mortality were calculated. Data on race, ethnicity, mechanism of injury, and whether the death occurred within the home also were collected.
From 2018 to 2019, there were 273 homicides of pregnant women or women within one year postpartum out of 4,705 total homicides among women of reproductive age. About two-thirds of the deaths occurred in the home and 70% involved firearms. Assault by a sharp object and strangulation were the second and third most common causes of death. Compared with nonpregnant, non-postpartum victims of reproductive age, pregnant and postpartum women who were killed were more likely to be non-Hispanic Black and of younger ages. The 2018-2019 national pregnancy-associated homicide ratio was 3.62 deaths per 100,000 live births. This was 16% higher than the rate among nonpregnant, non-postpartum reproductive-age women (3.12). Homicide mortality during pregnancy and within the first 42 days postpartum was 2.21 per 100,000 live births and exceeded all leading causes of maternal mortality, including hypertensive disorders, hemorrhage, and infection.
COMMENTARY
This study revealed that pregnancy and the perinatal period increases the risk of homicide. This finding is not new but this study is the first to confirm the association with national data, taking advantage of the updated U.S. Standard Certificate of Death reporting system that uses a pregnancy checkbox.1 The analysis was not able to identify the perpetrators of the homicides or confirm intimate partner violence as the potential cause, but the authors found that two-thirds of the deaths occurred in the home. The increased risk was found especially in non-Hispanic Black women and women of younger age (10 to 24 years). The authors postulated that there may be racial inequities in the occurrence of unintended pregnancies, which has been associated with violence, as well as systemic racism that may prevent girls and women from accessing needed services both in the medical arena and also with law enforcement.
There are some limitations to this study, since it relies on a national database that depends on accurate data entry and does not contain many details regarding the circumstances of the death. There have been some concerns that the pregnancy checkbox may have both false positives and false negatives.2 However, the authors thought that, most likely, the pregnancy checkbox on death certificates is not used sufficiently and these current results represent an underreporting.
I wanted to highlight this study because it is important that all women’s healthcare providers are aware of this issue. Although this investigation could not identify which homicides were associated with intimate partner violence, it is standard of care to screen pregnant women for this risk factor at the first prenatal visit, at least once per trimester, and at the postpartum visit. According to the American College of Obstetricians and Gynecologists, “intimate partner violence is a pattern of assaultive behavior and coercive behavior that may include physical injury, psychologic abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion.”1
Intimate partner violence screening should be performed universally, privately, and with validated questions. Providers should be prepared to offer resources and support for those individuals who screen positive. Intimate partner violence during pregnancy has been associated with adverse outcomes, such as low birth weight, placental abruption, fetal injury, stillbirth, and preterm delivery. Intimate partner violence crosses all racial, social, and economic lines. It is estimated that one in three women in the United States has experienced it at some point during their lifetime.1 We have a unique role as providers to try to mitigate some of this violence with screening and intervention.
REFERENCES
- [No authors listed]. ACOG Committee Opinion No. 518: Intimate partner violence. Obstet Gynecol 2012;119:412-417.
- Catalano A, Davis NL, Petersen EE, et al. Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. Am J Obstet Gynecol 2020;222:269.e1-269.e8.
