For many providers the term “maternal mortality” may conjure thoughts of “hemorrhage, clot, and infection”, consistent with traditional clinical training. Yet, the causes of maternal mortality have significantly shifted over time. Our results indicate that pregnancy-associated homicide and suicide each account for more deaths than many other obstetric complications, including hemorrhage, obstetric embolism, or preeclampsia/eclampsia, which may be thought of as more “traditional” causes of maternal mortality.(21
) This is reflective of the fact that the causes of maternal mortality have significantly shifted, with improvement in mortality associated with many obstetrically-related events, but a steady rate of maternal mortality due to injury.(1
) Our results also confirm the need to focus on the relationships between socio demographic disparities and intimate partner violence with pregnancy-associated violent death.
The demographic patterns in our study are similar to those found in NVDRS reports from the general population.(22
)Among all female suicide victims, rates are highest in the 45–54 year age range and among Whites and women of American Indian descent. In the general population, women ages 20–24 have the highest rate of homicide, and African American women have the highest rate of homicide as compared to other race/ethnicities.(22
Our results demonstrate somewhat higher maternal mortality rates than those previously demonstrated in a national perinatal sample.(23
) Chang et al.
reported a pregnancy-associated homicide rate of 1.7 deaths per 100,000 live births between 1991 and 1999 in the Pregnancy Mortality Surveillance System (PMSS).(23
)Suicides were even less common in their sample. These differences may reflect the data collection methods used by the two systems. The PMSS is designed to collect data on all pregnancy-associated deaths, regardless of cause. Reporting states use death certificate data and/or matched death-to-birth certificate data to identify deaths, and the PMSS utilizes maternal death, infant birth, and fetal death certificates in addition to autopsy or maternal mortality review committee reports to assign a cause of death.(23
)The NVDRS is designed to collect data specifically associated with violent deaths. Abstractors code pregnancy and postpartum status based on findings from the victim’s death certificate and the medical examiner’s report. Cause of death is assigned based on data from death certificates, CME reports, and police reports.(18
) Mortality rates from other smaller studies of pregnancy-associated violent death have been closer to our results for suicide deaths and have demonstrated even higher mortality rates for pregnancy-associated homicide.(4
Despite these differences in mortality rates between the NVDRS and PMSS, the characteristics of pregnancy-associated homicide victims between the NVDRS and others, including PMSS, are strikingly similar. Victims of pregnancy-associated are more likely to be Black, younger, and unmarried.(23
) In addition, our finding of the association between intimate partner conflict and both pregnancy-associated homicide and suicide has been echoed by several studies in general and perinatal samples.(1
) In the NVDRS general population sample, over one half of female homicide deaths (59.1%) are associated with intimate partner violence, and over one-quarter of suicides in female victims (26.1%) were related to intimate partner problems.(22
) In a postpartum study, 38% of female homicide victims were killed by a boyfriend, husband, or ex-husband.(26
Our study has several limitations. While the NVDRS now collects data from many states, it is not fully nationally representative.(22
) Furthermore, because of the low rates of deaths in certain subpopulations (Asian/Pacific Islander and American Indian), we were not able to compare data among all ethnic groups. NVDRS abstractors are limited by the completeness and quality of the reports they receive, and personnel, death certificates, and law enforcement protocols may vary from one jurisdiction to the next. For this reason, the NVDRS uses multiple complementary data sources and abstractors follow defined NVDRS primacy rules in coding data.(22
) While the NVDRS codes pregnant and postpartum status from multiple data sources, pregnancy-associated deaths may still be underreported. Pregnancies, even if identified, may not be reported on death certificates, autopsies might not include examination for pregnancy(27
), early-gestation and late-postpartum status may be missed on autopsy, and family members and friends may have been unaware of early or unwanted pregnancies. Other surveillance methods such as vital record linkage between death and birth certificates may enhance case ascertainment.(28
) Also, because a majority of female deaths in the NVDRS are coded as “unknown” pregnancy or postpartum status (67.2%), our results may underestimate the number of pregnancy-associated violent deaths. In addition, we are unable to compare the rates of pregnancy-associated violent death in pregnant, postpartum versus nonpregnant, nonpostpartum women because so many deaths were classified as “unknown” status. Finally, protective factor data would be helpful but it is not collected by the NVDRS as reports associated with violent death often contain only circumstances associated with risk factors. Our data provides information regarding potential risk factors for maternal violent deaths but cannot prove causation. In addition, this analysis focus on demographic data and prevalence of intimate partner conflict among victims of pregnancy-associated violent data but did not cover all of the potential precipitating circumstances that may be related to violent death. Our future research will involve analyses of other potential precipitating circumstances around maternal violent death, including substance abuse, life stress, and mental health diagnoses and treatment.
Despite these limitations, our study highlights the unfortunate but important role of homicide and suicide as contributors to pregnancy-associated mortality. These findings suggest that effective prevention methods aimed at perinatal psychosocial health are imperative. Unlike some obstetric complications, violence is often potentially preventable. While studies have questioned the effectiveness of previous screening and prevention efforts related to homicide and to mental health/suicide(29
), research is moving forward in developing evidence-based guidelines for perinatal depression care(31
), identifying successful strategies for engaging and training perinatal healthcare providers in delivering mental health care(32
)and engaging perinatal women in receiving mental healthcare services(34
). Our findings also demonstrate the frequent association of intimate partner conflict with maternal violent death. IPV has been associated with adverse outcomes for both mother and baby, including preterm labor and low-birthweight, and may contribute to perinatal health disparities.(35
) Studies suggest that standardized screening for IPV is associated with increased identification rates in pregnant women, and experts have made recommendations for further research in IPV interventions, including research into the role of culture on intervention effectiveness(36
). In fact, a recent intervention was shown to lower recurrence risk for intimate partner violence victimization during pregnancy and the postpartum period (37
). As the perinatal period is a time when health care providers have recurrent encounters with potentially at-risk women, providers can play a vital role in delivering interventions which may help to prevent violent deaths. With continued focus on this important national health concern and a continued push toward the development of effective psychosocial interventions, particularly post-screening care, we may be able to reduce the impact of this unfortunate killer on American women, their children, and their families.