Homicide is a leading cause of death in pregnant people, a new study finds. Black women are at greatest risk.

Pregnancy test art (iStock; Washington Post illustration) (Washington Post)
·7 min read

At the Safe Sisters Circle, a nonprofit in Washington, D.C., founder and executive director Alana Brown said she has worked with "countless" survivors of intimate partner violence who were abused while pregnant. While providing legal services to survivors in the city's predominantly Black Ward 7 and 8, Brown said she's witnessed that sometimes the abuse isn't only physical; she's seen survivors miscarry from the stress of emotional abuse.

Earlier this year, Brown published an article with the National Resource Center on Domestic Violence detailing the specific ways that medical racism, a long legacy of discrimination and reproductive coercion have resulted in Black women facing some of the highest rates of domestic violence and sexual abuse.

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So when she read a study published in November in the journal Obstetrics & Gynecology, which found that homicide is a leading cause of death among pregnant and postpartum people - and that Black women, and women and girls under the age of 25, were at the greatest risk - she wasn't surprised, she said.

The study, written by researchers at Tulane University, found that people who are pregnant or in the postpartum period are twice as likely to die by homicide than any other leading cause of maternal mortality. Using data from the National Center for Health Statistics from 2018 and 2019, the study's authors determined that about two-thirds of the incidents occurred at home.

And although decades of research (including a Washington Post investigation), have shown that pregnant people face a heightened risk of violence, this study is the first to include death records from every state in the country.

Part of what made this study novel was that 2018 was the first year every state had added a pregnancy checkbox to their death certificates. In 2003, the National Center for Health Statistics had revised its policies for issuing death certificates, requiring states to record on death certificates whether the decedent had been pregnant, less than 42 days postpartum or less than one year postpartum. But states were slow to implement the change.

When that data was finally available, in 2020, the Centers for Disease Control and Prevention published updated national maternal mortality rates for the first time since 2007. Maeve Wallace, a reproductive epidemiologist and assistant professor at Tulane University, and her colleagues decided to use that same data for another purpose. While maternal mortality rates include only obstetric causes of death, like hemorrhage or ​​eclampsia, Wallace wanted to track cases where pregnant or postpartum people were murdered.

Wallace said it was important to her and her colleagues to publish their findings soon after the CDC published its maternal mortality rates to show that "while maternal mortality is very concerning, there's also these other deaths that are happening that are not counted," she said.

Research dating back to the late 1980s shows that homicide is "a leading cause of death during pregnancy and the postpartum period in the United States," Wallace and her co-authors wrote. However, those studies tended to use the CDC's National Violent Death Reporting System, a voluntary reporting system that Aaron Kivisto, a clinical psychologist at the University of Indianapolis, said "is not nationally representative." Kivisto added that Wallace's study "is the first to provide truly nationally representative estimates of the rate of pregnancy-associated homicide victimization."

But an important factor to keep in mind, both Wallace and Kivisto noted, is that the National Center for Health Statistics doesn't provide the same detailed information as the National Violent Death Reporting System. While the NCHS only publishes death certificates, the NVDRS links to police, autopsy and other reports that can clarify whether the homicide was an incident of intimate partner violence.

Wallace and her co-authors used the data they did have access to: whether homicides occurred in the home. They found that two-thirds of them did - and that most involved firearms.

"Our overall main finding was that homicide is more common among pregnant postpartum women, compared to nonpregnant, non-postpartum women," Wallace said. "And that's particularly true for Black women, when we stratify by race, and for young women."

While the study found that Black women face a higher risk of homicide during pregnancy and the postpartum period, Wallace said that they found no difference in the homicide rate for White women during pregnancy and postpartum. Meanwhile, young women and girls ages 10 to 19 were six times more likely than their nonpregnant or non-postpartum peers to die by homicide, and that risk doubled among young Black women and girls.

Those findings are supported by a study Kivisto published in the Journal of Interpersonal Violence earlier this year. Using data from the National Violent Death Reporting System, Kivisto said what he and his co-authors "sought to clarify was who was killing these women, and in particular what role intimate partners were playing."

The authors found that "although nonpregnant Black and White women showed similar intimate partner homicide victimization rates, when we looked at the pregnant subset of women, we found that Black women had a threefold higher rate of partner homicide victimization," Kivisto said. "To give you a sense of how large the increase in risk was linked to pregnancy, we found that pregnant Black women were eight times more likely to be killed by their intimate partner than nonpregnant Black women."

Kivisto and Wallace both attribute those disparities to a long legacy of systemic racism.

"These data highlight broad societal failures," Kivisto said. He noted that other researchers have looked at some of the potential such failures that help explain racial disparities in pregnancy-associated homicide. Those studies have suggested a range of factors, including "perceived racism during prenatal health care encounters, which impedes Black women's access to consistent, quality prenatal care; and heightened rates of unwanted pregnancy among younger Black women, which is linked to partner conflict, stress and violence," he said.

Brown noted that "there's a history in this country of Black women being physically abused, sexually abused, having a lack of control over their bodies and people hurting their bodies," referencing legalized rape during slavery and forced sterilizations that continued until as recently as 2010.

There's also research that has found "people don't believe Black women" when they say they're in pain or being abused, Brown said.

Although the American College of Obstetrics and Gynecologists recommends universal screening for intimate partner violence during pregnancy, research indicates that fewer than 30% of women are actually screened. Brown noted that given the discrimination many Black women face in medical settings, "it's not surprise that it would be an ineffective place to do a screening for such a sensitive topic." She added that Black women may be reluctant to report intimate partner violence because of negative experiences with police.

"Even with routine screening, IPV is still hard to address," said Vijay Singh, a family medicine doctor and clinical assistant professor at the University of Michigan, who published a study on maternal rates of homicide and suicide in 2011. "There is no blood test or imaging test to diagnose IPV, and there is no medication to treat it. It's a complex problem impacted by various social determinants of health."

The inability to prevent or terminate a pregnancy can also put pregnant people at greater risk of violence - and Black women often face more barriers to accessing abortion or other reproductive health care. In the Turnaway Study, a decade-long study that followed women who were able to access an abortion and those who were "turned away" because they were past a clinic's gestational term limits, researchers found that those who were turned away "continued to experience violence," Wallace said.

To prevent intimate partner violence and homicide during pregnancy, Brown suggests anti-bias training for doctors, but also hiring more Black women medical professionals. In founding her own organization, she said it was important to her that "the people providing the services looked like the people getting the services."

She also noted that access to affordable and quality health care and prevention services is key. Recently, her team has been teaching middle and high school students about healthy relationships and reproductive justice to hopefully prevent them from needing their services in the future, she said.

Wallace hopes that her team's findings will now be used to support policy changes to protect pregnant people. This study "just documented" the problem, said Wallace. Next, she said, is figuring out "what we do about it."

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