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Pregnancy is risky, and Naima Joseph sees the perils firsthand every day. For some patients, it might be a cardiac injury, their heart issues worsened by having to pump enough blood for two. For others, it might be a uterine infection, or a hemorrhage, or a case of pre-eclampsia.

These are the complications we tend to imagine when we think of America’s maternal mortality crisis: Underlying chronic disease, insufficient access to care, cellular cascades gone wrong. Yet the leading cause of death during pregnancy and in the post-partum period is, in fact, homicide — and suicide rates in the months around pregnancy are on the rise.

To Joseph, those tragedies are all preventable, but there’s been a dearth of data that could help figure out how best to intervene. Now, in a study published Thursday, she and two colleagues have tried to address some of the gaps, looking at numbers from 2008 to 2019.  Even the most basic of numbers are troubling. Among female homicide victims whose pregnancy status was known, 20% died in the time leading up to or soon after giving birth, while among suicide victims, that figure was 9%.

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The research also showed a close link between two public health emergencies, with firearms used in 68% of homicides and 35% of suicides that took place around pregnancy. Another striking trend was that intimate partner violence was a factor not only in 71% of the homicides, but also in 45% of the suicides — figures that were lower in deaths not associated with pregnancy.

“It’s a call to action,” said Joseph, a maternal-fetal medicine specialist at Beth Israel Deaconess Medical Center, in Boston. She’s concerned that the overturn of Roe v. Wade will only make these issues worse by restricting access to reproductive care. “The medical, law enforcement, and criminal justice systems kind of work together in some ways to compound social risk for these violent deaths,” she said.

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As disturbing as the results may be, they are almost certainly underestimates. Researchers who are trying to track how violence plays a role in maternal mortality find themselves in a bind. Often, they use the Centers for Disease Control and Prevention’s Pregnancy Mortality Surveillance System to study these questions — but, as Joseph explained, that dataset doesn’t have much detail on the specific circumstances surrounding each death.

The National Violent Death Reporting System, on the other hand, has more of those details, which made it useful for this particular study. But the victim’s pregnancy status is often reported as unknown. In fact, among the 38,417 female victims between 15 and 44 who were identified for this paper, some 68% of them had to be excluded for that reason.

Racial and ethnic disparities are a huge issue in this field, with the maternal mortality rate being almost threefold higher for Black women than it is for their white counterparts — and these CDC datasets are often imperfect for fully delving into those sorts of questions, too.  As Abigail Echo-Hawk, executive vice-president of the Seattle Indian Health Board, pointed out, these federal sources doesn’t always include correct information regarding the victim’s race and ethnicity. “There are some law enforcement databases that will actually default people to white, if race is not collected,” said Echo-Hawk, who was not involved in this study. “There's a common saying in Indian country: ‘We are born native, and we die white,’ because that’s the most common racial misclassification.”

Even with such gaps and erasures in the data, the paper did reveal some potential avenues for intervention.

“We need to have more specifically directed resources for folks who are experiencing intimate partner violence. And I think for some, it's easy to see how that is connected to homicide. What is a really unique part of this paper is that folks who experienced suicide and suicidality were also being impacted by intimate partner violence,” said Echo-Hawk, emphasizing the need for culturally appropriate services.

To Corinne Williams, an associate professor of health, behavior, and society at the University of Kentucky, the paper highlighted the possibility of using the doctors’ visits that take place during pregnancy and after birth to prevent these sorts of deaths. “When you think about the health care that women get during pregnancy, it feels like there's a real opportunity for intervention,” said Williams, who was not involved in the research.

Many women are forewarned about the emotional upheavals that can come with post-partum hormonal changes. “I've heard other people tell women who are feeling a little sad, ‘Oh, that's just the baby blues,’” Williams went on. “For some women, it's not just the baby blues, and I think there needs to be some real education around that.” She also said there could be value in asking pediatricians to screen parents for issues involving mental health or intimate partner violence during visits that are technically about the newborn.

“There's been a lot of action developing standards of care for reducing cardiovascular deaths and hypertension deaths,” said Joseph. “We have to think about developing standards of care for reducing violent deaths as well.”

If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.

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