The United States has one of the highest rates of maternal mortality among high-income countries. According to the Centers for Disease Control and Prevention, every year about 700 women die during or soon after pregnancy, a disproportionate number of them Black. We talk about addressing the underlying causes: a lack of access to quality care, the prevalence of chronic illnesses, racial and ethnic inequities, or high rates of cesarean deliveries. What we don't talk about is the most frequent cause of death in pregnant women-homicide, most often at the hands of an intimate partner.
Homicide mortality rates are more than double those of other leading causes of maternal death, according to Wallace and colleagues (Obstetrics and Gynecology, 2021), and over half of these deaths are a result of intimate partner violence (IPV) (Obstetrics and Gynecology, 2022). The numbers may be even higher-surveillance and data collection are limited, as homicides of pregnant women are not counted as pregnancy-related deaths and IPV is not included in maternal mortality data.
As noted in an October 2022 BMJ editorial, these are preventable deaths "linked to the lethal combination of [IPV] and firearms." A systematic review of IPV prevalence rates in 24 countries in the Americas (Pan American Journal of Public Health, 2019) found that the United States had the second highest rate of women who had experienced IPV, 37%. According to Wallace and colleagues' study of pregnancy-associated homicide mortality rates, seven out of 10 pregnancy-related homicides were committed with a gun.
Although this is not a new phenomenon, little attention is being paid to it and even less is being done. Experts on IPV have long warned that pregnancy and the immediate postpartum period is a dangerous time for women, particularly Black women. The study by Wallace and colleagues found that pregnant Black women 20 to 24 years old are at a 65% higher risk for homicide than nonpregnant women.
Here are steps we can take as individuals and nurses:
First, pay attention. There are warning signs. Homicide is rarely the first incidence of abuse in a relationship. Studies have found that as many as 80% of women killed were abused by the perpetrator before their death. If you suspect someone is being abused, ask, using a nonjudgmental and caring approach: Are you safe? Is there anything happening with John that scares you? Bob calls to check up on you constantly; is there a problem at home? I noticed your arms are always bruised; are you okay at home? Don't badger. If someone denies a problem or refuses help, just let them know they can talk to you if needed.
Offer assistance. Provide resources such as contact information for the local domestic violence hotline and shelter. Help them develop a safety plan.
Screen patients for IPV. The U.S. Preventive Services Task Force recommends screening all women of reproductive age. Make screening for IPV a priority in obstetric care. The American College of Obstetricians and Gynecologists recommends screening for IPV at the first prenatal visit, once every trimester, and at the postpartum visit.
Do a lethality assessment. Lethality instruments are highly sensitive in identifying women at risk for homicide. Use a lethality instrument, such as the Danger Assessment (http://www.dangerassessment.org), with every woman who discloses abuse.
Advocate for laws restricting gun possession for IPV perpetrators. Access to guns is a risk factor for IPV homicide. There is evidence that state policies that keep guns out of the hands of people with IPV-related restraining orders or convictions are effective in reducing intimate partner homicide. For example, a study of laws related to gun access for perpetrators of domestic violence and rates of intimate partner homicide over a 25-year period (Annals of Internal Medicine, 2017) found that such laws were associated with a 14% reduction in intimate partner homicide risk. Check out the laws in your state and let your representatives know that arming IPV perpetrators puts all women, but especially young mothers, at high risk for death.