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Perspective: Why are so many of our pregnant women dying?

The United States has one of the worst maternal mortality rates in the developed world. The reason why isn’t what you think

Researchers have suggested personal health factors, such as higher rates of obesity and diabetes, may be a factor in these rising maternal mortality rates. But there’s a more disturbing explanation.
Associated Press

It is widespread knowledge that the maternal mortality rate of the United States is terrible. With 17.4 maternal deaths per 100,000 live births, we tie for the 57th worst rate in the world, alongside Romania, Oman, Moldova, Latvia and Ukraine. We are so far below North Macedonia, Kazakhstan, Albania, Russia, Tajikistan, Turkmenistan and Turkey that it’s depressing.

Worse still, our maternal mortality rate has been steadily rising in the 21st century despite what one would assume has been a period of scientific progress and more sophisticated medical procedures. The lowest rate for the U.S. was found in 1988, more than three decades ago. To find the time period when the U.S. was last at today’s level of deaths, you have to go all the way back to 1972.

Why are so many of our mothers dying?

Researchers have suggested personal health factors, such as higher rates of obesity and diabetes, may be a factor in these rising maternal mortality rates. That is no doubt true, but there is a deeper and more disturbing explanation: homicide.

In a stunning new study amplified recently in Nature, and originally published this month in Obstetrics and Gynecology, Maeve Wallace of Tulane University and several co-authors find that homicide is the leading cause of death of pregnant women. More pregnant women die from homicide than from all the leading medical causes of pregnancy-related death — such as pre-eclampsia/hypertension, hemorrhage or sepsis — by more than two-fold. Between 2018 and 2019, homicide-related deaths made up 21% of the maternal mortality rate in the United States.

Furthermore, this rate was elevated in comparison to a control group of women of childbearing age who were neither pregnant nor postpartum — 16% higher, in fact. A woman is at greater risk of being murdered if she is pregnant or postpartum than if she is not.

Two-thirds of the homicides occurred in the home, and 70% of deaths involved firearms. Assault by sharp object and strangulation were the next two most frequent modes of murder. In the 20-24 age group, the homicide rate of pregnant/postpartum women was almost twice that of the control group. Pregnant/postpartum women were 11% more likely to be killed in their homes than non-pregnant/postpartum women. And the authors cite a separate study finding that non-Hispanic Black pregnant women were killed at a rate more than eight times higher than non-Hispanic Black women who were not pregnant.

The authors note these figures are likely an underestimate, because women could be classified as non-pregnant if their pregnancy status was unknown, such as if they had just discovered they were pregnant and had just told their partner but the medical community had not confirmed their condition.

These conclusions shock the conscience. Of all pregnant/postpartum women who die, 1 in 5 will be murdered, more than likely by their partner. Indeed, in most cases, that partner is the father of the child.

Which brings the discussion to one of domestic violence. While there are agreed-upon recommendations for ensuring pregnant women aren’t at risk for intimate-partner violence — the American College of Obstetricians and Gynecologists has formal recommendations for prenatal IPV screening — the authors of the study note that the implementation of those recommendations is far from adequate. Moreover, they say, a lack of universal procedures for responding to a woman at risk for violence means we’re overlooking crucial opportunities to intervene and potentially save more than one life.

It’s also important to ask how many of these homicides occurred because the woman refused her partner’s request to abort the child. There are numerous cases where this has in fact been the motivation for the murder of a pregnant woman, and it brings us to a critical point of discussion. Every proposed legal ban or partial ban on abortion has always included an exemption where the life of the mother is in jeopardy. When we hear that exemption, we are no doubt thinking of the woman with pre-eclampsia or hemorrhage who will die without an abortion. Do we ever think of the women who will be murdered without access to abortion or who will be murdered because they refused an abortion? Shouldn’t both these situations be part of the policy debate?

If homicide is indeed the single largest cause of death among pregnant women, then that simple fact suggests that they should. Policymakers should take this opportunity to fill the gaps and ensure women faced with this situation actually can get the help they need.

Valerie M. Hudson is a University Distinguished Professor at The Bush School of Government and Public Service at Texas A&M University. Her views are her own.