Lin, Peter MD; Gill, James R. MD
Homicidal injury is a leading cause of death among pregnant and postpartum women in the United States.1 Until the most recent international classification of diseases, injuries, and death (ICD-10), the definition of maternal death differed among various public health agencies. The Centers for Disease Control and Prevention used the terms pregnancy-related and pregnancy associated deaths because the ICD-9 did not include these deaths.2 The current ICD-10 includes deaths due to injuries (Table 1).3
In the United States, maternal mortality over the past century has dramatically decreased.4 Maternal mortality from injuries, however, has remained constant.5 Homicidal and other types of injuries are major contributors to maternal mortality.6 The homicide of a pregnant woman raises both medicolegal and legal issues with regard to death certification and the criminal justice system. In some jurisdictions, the death of the fetus may be considered in homicide charges.7
We review 11 years of homicides investigated by the New York City Medical Examiners Office in which the victim was pregnant at the time of death.
MATERIALS AND METHODS
The New York City Office of Chief Medical Examiner (NYC OCME) investigates all unexpected, violent, and suspicious deaths in New York City. By statute, these deaths must be reported to the OCME. Between January 1, 1998 and January 1, 2009, there were 6578 homicides investigated and certified by the NYC OCME. We searched all medical examiner death certificates and electronic autopsy reports between January 1, 1998 and January 1, 2009 in which the decedent was pregnant at the time of death and the manner of death was homicide. We reviewed the medical examiner records which included the autopsy, toxicology, police, and medical examiner investigators' reports. All deaths underwent autopsy and toxicology testing.
The manner of death is determined by the circumstances and the cause of death. It includes: natural, accident, suicide, homicide, therapeutic complication, and undetermined.8 The medicolegal definition of homicide is death at the hand of another or death due to the hostile or illegal act of another.9 In New York State, fetal death is defined as "death prior to the complete expulsion or extraction from its mother of a product of conception, indicated by the fact that after such separation, the fetus does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles" (Public Health Law Section 4160(1)). In New York, the fetal death certificate requires the cause of death but not the manner of death.
Postmortem blood was collected in each death, preserved with sodium fluoride, and stored at 4°C. All toxicologic testing was performed by the Forensic Toxicology Laboratory at the Office of Chief Medical Examiner. Ethanol concentrations were determined in blood using head space gas chromatography. Urine specimens were routinely tested for opiates, barbiturates, benzoylecgonine (BE), and methadone by enzyme immunoassay. If urine were not available, blood was tested for opiates, BE, and barbiturates using radioimmunoassay. Quantitations of morphine, codeine, and BE were done using gas chromatography/mass spectrometry (GC/MS). Urine or blood also was analyzed for basic drugs (including cocaine) by gas chromatography with a nitrogen phosphorous detector (GC/NPD).
Homicides were classified by the following circumstances: family dispute/abuse, current or former intimate partner, dispute, robbery, drug-related, sex-crime, random, unknown.
There were 27 homicides: the maternal age ranged from 15 to 41 years (mean = 27 years) and the racial/ethnic breakdown included 21 Black, 5 Hispanic, and 1 White. The causes of death included: 13 (48%) gunshot wounds, 7 (26%) asphyxial deaths (eg, neck compression), and 5 (18%) stabs, 1 (4%) blunt, and 1 (4%) blunt/stab. For homicides of all women between the ages of 12 to 44 years over a 3 year period, there were: 35% gunshot wounds, 30% sharp injuries, 19% asphyxia, 8% blunt, 4% thermal injury, and 4% combination.
The gestational age ranged from 8 to 40 weeks with an average of 24.5 weeks. In 2 instances, only a gestational sac was identified, and in one instance, only an implantation site was identified. In 2 instances, a liveborn infant was delivered but subsequently died, both of which involved gunshot wounds of the mother and infant. These 2 infants were certified as homicides.
In 22 of the 27 homicides, information concerning the relationship of the victim to the suspected perpetrator was available. In 3 homicides, the victim was an innocent bystander. The victim and suspected perpetrator were known to each other in 19 homicides. Of these, 16 involved an existing or prior intimate relationship (the suspected perpetrators included 2 current husbands, 1 ex-husband, 9 current boyfriends, 3 ex-boyfriends, and 1 father), 1 involved gang-related activity, 1 robbery, and 1 retaliation by a neighbor for a prior robbery. Of the intimate partner deaths, 9 were due to gunshot wounds, 4 due to asphyxia, 2 sharp injury, and 1 blunt and sharp injury. No suspect was known in 5 deaths.
Toxicological analysis on samples obtained from the autopsy was negative in 21 of the 27 homicides. Cocaine and ethanol were detected in 2 instances, cannabinoids in 2 instances, cocaine and methadone in 1 instance, and fluoxetine, benzodiazepines, and methamphetamine in 1.
Homicidal injury is a leading cause of death among pregnant women in the United States.1,4-6,10-16 We review 11 years of homicides in New York City in which the victim was pregnant at the time of the fatal injury. Maternal mortality in the United States due to all causes has decreased dramatically over the past century, however, maternal mortality due to injuries has not decreased.4,5 Until 1993, maternal mortality was defined by the World Health Organization (WHO/ICD-9) as deaths due to natural complications of pregnancy and the postpartum period, such as hemorrhage or pulmonary embolism; deaths due to unnatural causes, including homicidal, suicidal, and accidental injuries, were excluded.7 To better capture all maternal deaths, the Centers for Disease Control and the American College of Obstetricians and Gynecologists, recommended in 1987 the term "pregnancy-associated" death to include all natural and unnatural deaths that occur during pregnancy or the postpartum period, defined as anytime up to 1 year following termination of pregnancy (Table 1).
Using this broadened definition of pregnancy-associated death, recent studies have identified homicidal injury as a leading cause of death among pregnant women.5,12 Chang et al found homicidal injury to be the second most common cause of death among pregnant and postpartum women in the United States.1 Krulewitch et al found that pregnant adolescent women are 3 times more likely to be victims of homicide than their nonpregnant counterparts.10 Since a comprehensive national database of pregnancy-associated mortality was not readily available, the most reliable method for identifying pregnancy-associated deaths was through a combination of death record analysis (eg, linkage of death records with live birth and fetal death records, and review of medical examiner records).
The majority of maternal homicides in this study were due to gunshot wounds. This is similar to a study by Dannenberg et al that analyzed maternal homicides between 1987 and 1991 in New York City. They reported that 39% of maternal deaths were due to injury of which 63% were homicides. Of these, 51% were due to gunshot wounds, 19% from sharp injury, 14% from strangulation, 7% from thermal injury/smoke inhalation, and 7% from blunt injuries. A high percentage of nongunshot-wound deaths might be expected in the intimate partner cohort if these are impulsive homicides and the perpetrators use what is available. Gunshot wound deaths, however, occurred more frequently than all other causes combined. This differed from the distribution of homicides among nonpregnant women of child-bearing age which included 35% due to gunshot wounds (30% sharp injury, 19% strangulation, 8% blunt injury, and 4% thermal injury/smoke inhalation).
The medical examiner's role in these fetal/infant deaths is multifold. In instances where the fetus was delivered during or shortly after the maternal death, one must determine whether he/she was live born. The manner of death of the infant may have major legal repercussions.7 In New York State, a fetal death is defined as death "prior to the complete expulsion or extraction from its mother of a product of conception, indicated by the fact that after such separation, the fetus does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles" (Public Health Law Section 4160(1)). In these instances, a fetal death certificate is issued with only the cause of death and no manner of death listed. If there is any sign of life after expulsion, then this is a liveborn infant and he/she receives the standard death certificate with the cause and manner of death. Infant deaths due to homicidal maternal injury would be certified as homicides. If the fetus/embryo is "delivered" at the autopsy, no death certificate is issued for the product of conception.
Several procedures should be done during the autopsy of these homicides. The first is the collection of a DNA sample of the fetus or infant. This may include fetal/infant blood/tissue depending upon the size of the gestation. Placenta tissue is the least desirable because it has a mixture of DNA. The gestational age is determined by various body measurements (body and foot lengths). The extent of the examination of the embryo/fetus/infant will depend upon the size of the conception and the presence or absence of direct fetal trauma. Investigation of clinical observations and pathologic examination of the placenta should be done for evidence of placental trauma (eg, abruption due to blunt injury). Acute abruptions may best be detected by sonography or at delivery since little blood may remain attached to the placenta by the time it is examined pathologically.
Following the autopsy, the previously undelivered embryo/fetus is returned to the mother's body. The specific disposition of the fetal remains should be mentioned in the autopsy report. If the infant (or stillborn fetus) had been delivered prior to the autopsy, he/she should receive a unique laboratory number and is not returned to the mother's body.
A majority of suspected perpetrators were known to the victim and most were intimate partners. Intimate partner violence is a common scenario for female homicide regardless of whether the woman is pregnant. Anecdotal reports in some of the deaths in this study support the pregnancy as the motive for the homicide (boyfriend killed her because he did not want the responsibility) but without detailed information of all deaths of woman of child-bearing age, it is not statistically possible to confirm this risk factor.12,17
In the current ICD-10, changes were made to the classification and coding of maternal deaths. The changes pertain to indirect maternal causes and timing of deaths relative to pregnancy. "Late maternal death" and "pregnancy-related death" were introduced in the ICD-10. The terminology has become complicated because various US agencies (eg, CDC's Division of Reproductive Health) use different terms but with similar concepts. For example, the CDC's Division of Reproductive Health's (DRH) "pregnancy-related death" is similar to the ICD's "maternal deaths" and DRH's pregnancy associated death is similar to ICD's pregnancy related death (Table 1).18 The 2003 revision of the US Standard Certificate of Death introduced a standard format designed to use additional codes available in ICD-10 for deaths associated with pregnancy, childbirth, and the puerperium. Most States are expected to introduce or replace the pre-existing format with the standard items, so there will be greater standardization of pregnancy status across the country. As of 2009, approximately 30 states have done this (personal communication, Donna L. Hoyert, Division of Vital Statistics, NCHS, CDC).
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