Pregnancy-Associated Homicide and Suicide: An Analysis of the National Violent Death Reporting System, 2008–2019 : Obstetrics & Gynecology

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Contents: Original Research

Pregnancy-Associated Homicide and Suicide

An Analysis of the National Violent Death Reporting System, 2008–2019

Modest, Anna M. PhD, MPH; Prater, Laura C. PhD, MPH; Joseph, Naima T. MD, MPH

Author Information
doi: 10.1097/AOG.0000000000004932
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Maternal mortality in the United States is increasing, with most recent reports estimating a rate of 23.8 per 100,000 live births. Further, racial disparities in maternal mortality in the United States are staggering, with an almost threefold higher maternal mortality rate of 55.3 deaths per 100,000 live births for non-Hispanic Black women compared with 19.1 deaths per 100,000 live births for non-Hispanic White women.1Pregnancy-related deaths, defined as those caused by a pregnancy complication, a chain of events initiated by pregnancy or the aggravation of an unrelated condition by the physiologic effects of pregnancy, has received research and advocacy prioritization.2 Conversely, pregnancy-associated deaths, those attributable to a condition unaffected by pregnancy that occurs within 1 year of pregnancy, are increasingly understood as important contributors of potentially preventable maternal mortality but have been underexplored.

Deaths due to homicide, suicide, and drug overdose are said to constitute nearly one fifth of all deaths during pregnancy and the postpartum period.3 Pregnancy and the postpartum period represent independent risk factors for increased likelihood of violent death.4 Homicide is the leading cause of death during pregnancy and postpartum, with an estimated homicide mortality ratio of 3.62 homicides per 100,000 live births.5 Homicide prevalence during pregnancy and postpartum is 16% higher than among nonpregnant and nonpostpartum females of reproductive age, exceeding all obstetric causes of maternal mortality by twofold.5 Suicide mortality is an increasingly important cause of death after pregnancy. Pregnant women have lower rates of self-injury compared with age-matched nonpregnant women,4 but rates of suicidality, suicidal ideation, and self-harm during pregnancy have increased over the past decade, from 1.8% to 9.3%.6

Understanding how the risk of violent death is affected by geography, race, age, social factors, mental health, and substance use disorder (SUD) is important for identifying areas for intervention and prevention. More recent reports have used data from the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics,3,5 which triangulate maternal deaths from violent causes using birth and death certificates, with causes classified using the International Classification of Diseases, Tenth Revision. Although these represent national estimates, these data are unable to provide circumstantial information, which may better inform the social patterning of homicide and suicide risk in pregnancy. The CDC’s National Violent Death Reporting System (NVDRS) is a multistate database that uses multiple complementary data sources contributing circumstantial data for each violent death.7 In this study, we sought to describe the demographic characteristics and social factors associated with pregnancy-associated violent deaths due to homicide and suicide.

METHODS

We used NVDRS data from 2008 to 2019, which captures data from all 50 states, the District of Columbia, and Puerto Rico; however, states contributions vary by year (Table 1). The NVDRS collects data on violent death incidents, including data on victims, suspects, victim–suspect relationship, and the circumstances surrounding the death using death certificates, reports from law enforcement, and reports from coroners or medical examiners, including toxicology when available. These reports are entered into the data set by trained coders who include sociodemographic information, manner of death, and circumstantial data surrounding each incident (see https://www.cdc.gov/violenceprevention/datasources/nvdrs/index.html).

T1
Table 1.:
State Contributions to the National Violent Death Reporting System (NVDRS)

We restricted our data set to females of childbearing age (defined by the CDC as age 15–44 years)8 who died by suicide or homicide. Suicide was defined as intentional self-harm, and homicide was defined as intentional use of force against another person. We excluded unintentional violent deaths or deaths in which the intent could not be determined. We acknowledge that restricting the data to individuals aged 15–44 years excludes those who are pregnant at younger and older ages; however, this exclusion was made at the request of the CDC.

We stratified our population based on pregnancy status at the time of death. The NVDRS stratifies victims according to seven categories: 1) pregnant at the time of death; 2) pregnant within 42 days of death; 3) pregnant 43 days to 1 year before death; 4) not pregnant within past year; 5) not pregnant, not otherwise specified; 6) pregnant, not otherwise specified; and 7) unknown. For this analysis, we collapsed these seven categories into four mutually exclusive categories: 1) pregnant at the time of death, 2) pregnant within 42 days of death (early postpartum), 3) pregnant 43 days to 1 year before death (late postpartum), 4) not pregnant within 1 year of death. Victims whose pregnancy status was unknown were excluded.

Race and ethnicity, as recorded by NVDRS-trained coders based on law enforcement and medical examiner or coroner reports, were included as markers of interpersonal and structural racism. Classification of county of residence and county of injury was determined using the 2013 U.S. Department of Agriculture Economic Research Service Rural-Urban Continuum Codes (https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx). Codes 1–3 were considered metropolitan, and codes 4–9 were considered nonmetropolitan.9 Firearm deaths were any in which a firearm was used in the incident, regardless of whether the firearm injury was fatal. All other variables are presented as coded in the NVDRS.

We compared the distribution of demographics and socioeconomic status for homicide compared with suicide deaths, stratified by pregnancy timing. Data are presented as number and percent or mean and SD. Categorical variables were compared using χ2 or Fisher exact test. Continuous variables were compared using the Student’s t test. Analyses were performed using SAS 9.4. Of note, the CDC prohibits reporting frequencies less than five. Cell sizes less than five in the tables have been noted.

The IRB at Beth Israel Deaconess Medical Center determined that this study did not meet criteria for human subjects research. The study was approved by the CDC NVDRS Restricted Access Data Review Committee.

RESULTS

There were 38,417 female victims aged 15–44 years identified in the data set. Of these, 26,302 (68.5%) did not have information on pregnancy status and were excluded. An additional 1,704 (4.4%) individuals were victims of other violent deaths (eg, unintentional firearm deaths) and were also excluded. Among the 10,411 victims with known pregnancy status, 87.5% of deaths (n=9,111) occurred in nonpregnant individuals, with 6.6% of deaths occurring during pregnancy (n=690), 1.3% occurring within 42 days of pregnancy (n=137), and 4.5% occurring 43–365 days after pregnancy (n=473). Of these deaths, 3,203 were by homicide (30.8%) and 7,208 (69.2%) were by suicide; 1,300 of the deaths were pregnancy associated.

Compared with individuals who died by suicide, individuals who died by homicide were younger (29.4±8.2 years vs 31.5±8.6 years) (Table 2). Of individuals who died by homicide, 37.7% were Black or African American, 13.4% were Hispanic, and 56.0% were White. In comparison, 6.9% of individuals who died by suicide were Black or African American, 8.0% were Hispanic, and 85.0% were White. A higher proportion of individuals who died by homicide were single or never married (61.0% vs 50.0%) and a lower proportion had at least some college education (28.1% vs 43.9%). The majority of all victims resided in metropolitan areas. Firearm use was most common in homicide deaths (65.5%) and second most common in suicide deaths (29.2%). Hanging or suffocation was the most common means of death for suicide (35.4%).

T2
Table 2.:
Baseline Characteristics of Female Victims of Homicide and Suicide, Aged 15–44 Years, With Known Pregnancy Status, 2008–2019 (N=10,411)

Of homicide and suicide deaths, 660 (20.6%) and 640 (8.8%) occurred in pregnant and postpartum women, respectively. Individuals who died by pregnancy-associated homicide were predominantly Black or African American (48.8% vs 12.3%), single or never married (72.3% vs 50.5%), and had less than a high school diploma (61.7% vs 46.8%) compared with individuals who died by pregnancy-associated suicide. The majority of pregnancy-associated homicide deaths occurred during pregnancy (64.8%). Pregnancy-associated suicide deaths were split between occurring during pregnancy (40.9%) or in the late postpartum period (42.8%). Firearms were involved in 68.3% of pregnancy-associated homicide deaths and 35.3% of pregnancy-associated suicide deaths. Additional demographic and other characteristics of individuals who died by homicide and suicide are presented in Table 2.

For the majority of deaths, additional details were available about circumstances surrounding the homicide (86.0%) or suicide (92.1%). Having a mental health problem and SUD were significantly more prevalent among suicide deaths compared with homicide deaths (77.4% vs 7.2%, P<.001 for mental health problem; 33.3% vs 12.8%, P<.001 for SUD). A history of intimate partner violence (IPV) was apparent in both groups, although significantly higher in homicide deaths than in suicide deaths (57.3% vs 37.1%, P<.001). The presence of other violent crimes was more common in homicide deaths compared with suicide deaths (24.8% vs 1.7%, P<.001). All deaths and pregnancy-associated deaths are reported in Figure 1.

F1
Fig. 1.:
Circumstances surrounding homicide and suicide deaths—all deaths and pregnancy-associated deaths.

Across all pregnancy times periods, more than half of individuals who died by suicide were identified as having a current mental health problem; this was significantly higher than among individuals who died by homicide in all time periods (all P<.001). Of note, 31.2% of pregnant individuals who died by suicide, 44.9% of early postpartum individuals who died by suicide, 41.1% of late postpartum individuals who died by suicide, and 42.1% of nonpregnant individuals who died by suicide were in treatment for a mental health problem or SUD at the time of their death. Substance use disorder was also significantly higher among pregnant, late postpartum, and nonpregnant individuals who died by suicide compared with individuals who died by homicide (all P<.001). Among individuals who died in the early postpartum period, having an SUD was similar between those who died by homicide or suicide (20.7% vs 24.5%, P=.67). The prevalence of IPV was high across all time periods for individuals who died by either suicide or homicide. Individuals who died by homicide were more likely to have current conflict than individuals who died by suicide in all time periods, although the difference was not statistically significant in the early postpartum period. The late postpartum period had the greatest prevalence of IPV in individuals who died by homicide (70.8% vs 44.5% in individuals who died by suicide, P<.001), and the pregnant period had the highest prevalence of IPV among individuals who died by suicide (47.3% vs 61.2% in individuals who died by homicide, P<.001) (Table 3).

T3
Table 3.:
Circumstances Surrounding the Deaths of Individuals Who Died by Homicide or Suicide (Among Those With Known Circumstances)

DISCUSSION

In this study, we found that pregnancy-associated suicide was highest among women who were non-Hispanic White, married or partnered, and had at least some college education or an associate’s degree. Suicide occurred more frequently during pregnancy and in the late postpartum period. The most common methods included firearms or hanging or suffocation. An overwhelming majority of women had been identified as having a mental health problem and either were currently in treatment or had a history of treatment for a mental health problem or SUD, as well as had a history of suicide attempt. Other dominant factors included problems with a current or former intimate partner.

We found that pregnancy-associated homicide occurred more frequently in non-Hispanic Black women. This most often occurred in pregnancy or in the late postpartum period. Firearms were used in more than 60% of these homicides, and more than 60% involved immediate or ongoing conflict or violence between current or former intimate partners. Additional factors included other crimes in progress at the time of the homicide.

Every pregnancy-associated violent death should be considered preventable. There is an urgent need for scientific evidence informing actionable strategies to eliminate these maternal deaths. Prenatal care, during which women have frequent health contacts over a prolonged period, presents an optimal time to screen for and intervene on risk factors for suicide and homicide. Potential avenues for intervention include screening and referral for SUD, mental health disorders, and IPV. In addition, access to firearms in the home should be discussed, because it is an avenue for prevention of both suicide and homicide.

Suicidal ideation and self-harm among perinatal women with comorbid mental health disorders and SUD has increased over the past decade.6 A study examining the prevalence of suicidality in pregnancy found lower rates in the perinatal period compared with nonpregnant women; the authors hypothesize that this may be related to increased social supports, frequent health care contact, and higher degree of external concerns (ie, for well-being of family and children) and mediating factors.10 Indeed, a seminal analysis by Ahmedani et al11 found that 84% of persons who died by suicide had had health care contact in the 52 weeks before suicide, 30% with a primary care professional. The findings suggest that there are opportunities for suicide prevention in medical care, but this requires increasing attention to identifying individuals with mental health problems and suicidal ideation.

The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend universal screening for depression and anxiety in pregnant and postpartum women as a component of quality obstetric care.12,13 The Alliance for Innovation in Maternal Health (formerly the Council on Patient Safety in Women’s Health Care) developed the “Maternal Mental Health: Perinatal Depression and Anxiety, “safety bundle,” which uses existing evidence-based recommendations to provide actionable best practices in the prenatal care setting. In addition to universal screening, the bundle emphasizes the importance of universal education regarding perinatal depression for patients and their families, timely referral of patients with a positive screening result, receipt of follow-up from mental health care professionals, and ongoing, multidisciplinary review of adverse perinatal mental health outcomes.14 An evaluation of a perinatal collaborative care program for perinatal mental health found that use of an interdisciplinary approach was associated with significant improvement in screening for depression (81% vs 33%; adjusted odds ratio 8.5, 95% CI 7.6–9.5); identification, referral, and recommendation for treatment (61% vs 44%; adjusted odds ratio 2.1, 95% CI 1.2–3.7); and use of psychotherapy and pharmacotherapy treatment in pregnant patients with depression.15

Ensuring that SUD treatment is accessible to women with substance use problems in perinatal care is essential; we found that alcohol-related and non–alcohol-related SUD was relatively common among women who died by suicide (24.5–30.0%). The importance of this finding is heightened in the perinatal period, because women with SUD are less likely to seek both prenatal care and SUD treatment due to stigma.16,17 Providing care with nonstigmatizing language and offering resources,18 including suicide-prevention screening, is critical for these high-risk women.

Intimate partner violence has a lifetime prevalence of 15–71% in women and occurs in 2–13.5% of pregnancies.19 Intimate partner violence can represent a broad range of violent and coercive behaviors, ranging from psychological and emotional abuse to physical and sexual violence.20 Victims experience long-lasting consequences, such as physical injuries, traumatic brain injury, and chronic conditions such as headaches, insomnia, pelvic pain, depression, anxiety, and posttraumatic stress disorder, in addition to the fatal consequences of homicide and suicide.19 Pregnancy represents heightened risk for IPV; when experienced during pregnancy, IPV is associated with increased mortality compared with nonpregnant individuals.4 Intimate partner violence is also a leading contributor to pregnancy-associated suicide and homicide, independent of other demographic and circumstantial characteristics. An NVDRS analysis of deaths from 2003–2007 demonstrated that 54% of cases involved IPV in both pregnancy-associated suicide and homicide.21 Individuals who died by pregnancy-associated suicide were significantly more likely to be older and White or of American Indian descent relative to all live births; individuals who died by pregnancy-associated homicide were significantly more likely to be at the extremes of the age range and African American relative to all live births.21 Of note, Palladino et al analyzed females aged 15–54 years. In the current study, IPV was a circumstantial factor in 46% and 64% of pregnancy-associated suicide and homicide deaths, respectively.

Universal screening for IPV is currently recommended by the American College of Obstetricians and Gynecologists, and U.S. Preventive Services Task Force guidelines under the Affordable Care Act require free IPV screening and counseling.22–24 However, rates of screening remain low, with only 39% of patients routinely screened for IPV during prenatal care.25 Lack of formal education on IPV screening and referral has been cited repeatedly as a physician barrier to effective screening.26 Several tools have been developed, and recommendations for use emphasize longitudinal implementation throughout the prepartum and postpartum periods.20

In this study, we found that firearms were involved in 35% and 68% of pregnancy-associated suicide and homicide deaths, respectively, which is similar to published reports.27 A growing area of research is the contribution of firearms to pregnancy-associated mortality. Firearm-related morbidity and mortality is a major public health crisis, with increasing calls for health care professional involvement in intervention and advocacy.28 Several restrictive firearm policies may be relevant for prevention of homicide and suicide among women in the pregnancy and the postpartum periods. Diez and colleagues found a 14% reduction in firearm-related homicides and a 9.7% reduction in intimate partner homicide in states with laws that prohibited those with domestic violence–related protection orders from acquiring firearms and required relinquishment of existing firearms.29 Studies have found that state domestic violence–related protection order firearm restrictions were associated with 3.74 per 100,000 fewer homicide deaths per live births among women who were pregnant and in the postpartum period.30 Similar, extreme risk protection orders, civil orders to remove firearms for a limited duration and prevent the acquisition of new firearms, have shown some evidence of reduction in suicide mortality.31–33 Clinical guidance from relevant associations28 encouraging firearm screening in routine clinical care does exist, but evidence-based interventions to facilitate assessment and counseling on firearms have not been developed for pregnant and postpartum women for use in the clinical context.

There are some limitations to this study. Completeness of NVDRS data is limited in several ways. Although abstractors follow defined NVDRS rules in coding data and use multiple sources of information, they are limited by the completeness and quality of the reports they receive. Pregnancy ascertainment may be incomplete, because pregnancy information is not uniformly reported on death certificates and autopsies may miss early gestation or late postpartum status. In our study, 68% of female deaths in the NVDRS were coded as “unknown” pregnancy status; therefore, our results may underestimate the number of pregnancy-associated violent deaths. Suicide as a cause of death is likely undercounted due to stringent classification criteria and variation in criteria across state and local municipalities, disparately affecting persons of color.34–36 Another limitation is the variation in reporting by state and year, limiting generalizability and longitudinal analytic approaches. The results may be statistically biased toward states that contribute the most data. There is a critical need for improved surveillance for pregnancy-associated violent deaths.

Pregnancy-associated deaths are an understudied but important aspect of overall maternal mortality. Individuals who died by pregnancy-associated homicide or suicide differ on many demographic characteristics; however, IPV and mental health concerns are circumstantial in a large majority of these deaths. Furthermore, firearms contribute to both pregnancy-associated homicide and suicide deaths. More complete screening, referral, and treatment are needed to address these preventable deaths.

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