Key Takeaways
Young women under the age of 30, Black women, and women with lower education levels are disproportionately affected by intimate partner homicide during pregnancy, reflecting the need to better serve and protect these vulnerable populations.
Particularly by firearms, increasing rates of intimate partner homicide of women who are pregnant or recently pregnant are occurring in states that have limited access to abortion.
Researchers describe a 'dire need' to develop effective interventions that break the cycle of intimate partner violence and prevent further deaths.
CHICAGO: Pregnant women living in states with limited access to abortion are experiencing higher rates of intimate partner homicide, particularly by firearms, according to a new study published in the Journal of the American College of Surgeons (JACS).
In an analysis of 9,140 homicides of women aged 12-50 years old, researchers at the University of Chicago found that women who were pregnant or recently pregnant (defined as up to one year post-partum) at the time of their death were 14% more likely to die from homicide at the hands of an intimate partner compared to women who were not pregnant.
They also found that homicides of women who are pregnant or recently pregnant occur at significantly higher rates in states that have limited access to abortion. This state-based trend was not observed in homicides of men, suggesting that access to reproductive health care services may be one factor of many that increase a woman's risk of intimate partner homicide, the authors said.
"This study reveals that in the United States, there's an epidemic of preventable violence that disproportionately affects vulnerable populations, including peripartum people," said Grace Keegan, a third-year medical student at the University of Chicago Pritzker School of Medicine and lead author of the study. "There's a stark reality that the U.S. health care system lags behind many comparable nations in the prioritization of women's health. Our country's maternal mortality rates are extremely high, and what's even more striking is that the greatest contributor to the high mortality rate is homicide."
The researchers analyzed data from the National Violent Death Reporting System (NVDRS) of homicides that occurred between the years 2018-2020, before the U.S. Supreme Court decision that overturned Roe v. Wade in 2022. States were classified as restrictive, neutral, or protective towards access to abortion based on classification from the Guttmacher Institute.
Among other key findings of the study:
Between 2018-2020, nearly 500 women aged 12-50 years old were killed by an intimate partner during their peripartum period.
Women who were victims of homicide during the peripartum period were younger (27 years old vs. 33 years old), had lower education status, and were less likely to be married (17% vs. 20%) compared to women not in the peripartum period.
Black women, who make up about 13% of the U.S. population, were disproportionately affected by intimate partner homicide during the peripartum period, accounting for half of the victims. The authors note that this disparity reflects factors in our social and economic systems that contribute to reduced access to reproductive health care in this population.
Firearms were the most frequent weapon used in peripartum homicide, accounting for 63.4% of homicides among the peripartum group compared to 49.5% in women who were not pregnant or recently pregnant.
States categorized as being restrictive to abortion access had a 75% higher rate of peripartum homicide. Peripartum homicide deaths per total state population were highest overall in two states considered restrictive to abortion, Louisiana and Missouri, and one state considered protective to abortion, Nevada.
As a comparison, homicides of men across the same age range and state-based categories did not show the same trends.
"These numbers are staggering. Compared to other high-income countries, the U.S. is a standalone nation in the number of peripartum homicides that we're seeing," said co-author Tanya Zakrison, MD, MPH, FACS, a professor of surgery and director of critical trauma research at University of Chicago Medicine. "Intimate partner homicide is absolutely an epidemic of preventable violence, and I think something else that was shocking is how firearms figure so predominantly in the peripartum homicide group compared to the non-peripartum homicide group."
Although this research did not focus on why women may be most vulnerable to violence during or just after pregnancy, previous research has revealed that several social determinants of health, including food insecurity, psychosocial stress, and housing instability, are associated with an increased risk of firearm violence. These factors are likely exacerbated during pregnancy, when couples may experience increased demands and economic vulnerability.
Breaking a vicious cycle
In their paper, the authors say there is a 'dire need' of increased universal screening efforts and effective interventions to break the cycle of violence. Several screening tools for intimate partner violence (IPV) are available, but medical professionals may not be adequately trained on how to provide women with tangible resources once they screen positive for IPV.
"As a society, we need to address the intersectional root causes that have driven our society to this sad reality that we're in today," said senior author Justin Cirone, MD, an assistant professor of surgery at Wake Forest School of Medicine in Charlotte, North Carolina.
Stephanie L. Bonne, MD, FACS, FCCM, FAMWA, Chair of the ACS IPV Task Force who was not involved with the research study, noted that all medical professionals should be aware that IPV is a serious, preventable cause of mortality in the U.S. Data from this paper should serve as a warning call to improve resources for vulnerable populations.
"The authors of this peer-reviewed study have shown a specific risk to pregnant women, one that is increased by lack of access to abortion care and easy access to firearms," said Dr. Bonne, who also serves as chief of trauma and surgical critical care at Hackensack University Medical Center in Hackensack, New Jersey. "These data can be used to inform the development of specific health, policy, and social interventions that can mitigate this problem and keep women and their children safe and healthy."
The authors noted some limitations of their study. While the NVDRS database is one of the most comprehensive databases of violent deaths, the study is retrospective and does not include near-death experiences that may have occurred. In addition, the researchers could not discern from the data women who were killed but did not know they were pregnant at the time of their death; other reports may be lacking if the police homicide report did not note a recent pregnancy.
"There's a near certainty that we're missing many more women than were actually documented," Dr. Cirone noted.
Lastly, the authors excluded four states from the analysis (Florida, Idaho, North Dakota, and South Dakota) because these states joined the NVDRS in 2018 and had incomplete data at that time; the data also includes the year 2020, during which COVID-19 pandemic lockdowns were prevalent and domestic violence was reported to be higher than usual.
Study coauthors are Mark Hoofnagle, MD, PhD; Julie Chor, MD, MPH; David Hampton, MD; Jennifer Cone, MD, FACS; Abid Khan, MD; Susan Rowell, MD, MBA, FACS; Timothy Plackett, DO, MPH; Andrew Benjamin, MD; Neha Bhardwaj, MD, MS; Selwyn O. Rogers, MD, FACS.
The study is published as an article in press on the JACS website. The study was also presented at the American Association for the Surgery of Trauma (AAST) Annual Meeting on September 21, 2023, in Anaheim, California.
Resources
Disclosures: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Dr. Zakrison is supported by the NIH (1UG3HD111325, 3UG3HD111325), the Office of Juvenile Justice and Delinquency Prevention, and the Robert Wood Johnson Foundation. The authors have no disclosures to report related to the scope of this research.
Citation: Keegan G, Hoofnagle M, Chor J. State-Level Analysis of Intimate Partner Violence, Abortion Access, and Peripartum Homicide: A Call for Screening and Violence Interventions for Pregnant Patients. Journal of the American College of Surgeons, 2024. DOI: 10.1097/XCS.0000000000001019
