Homicide tops list of pregnancy risks

Md. study shows higher rate for new, expectant mothers

March 21, 2001|By Jonathan Bor | Jonathan Bor,SUN STAFF

Homicide has emerged as the leading cause of death among Maryland women during pregnancy or in the months that follow - outstripping heart problems, bleeding and other medical causes, state health officials said yesterday.

Drawing from a wider array of statistical sources than previously used, researchers found that homicide accounted for 50 of 247 deaths between 1993 and 1998.

Homicides surpassed cardiovascular problems and blood clots, known as embolisms, traditionally regarded as leading risk factors of pregnancy.

The study, reported in today's Journal of the American Medical Association, raised concerns that women involved in abusive relationships might be at higher risk for violence - even death - once they become pregnant or bear a child.

"Pregnancy is a very stressful time, even under the best of circumstances," said Isabelle Horan, director of vital statistics for the Maryland Department of Health and Mental Hygiene.

"If you have a pregnancy under the worst of circumstances, you can just imagine the stress involved," she said.

Horan, one of two authors of the report, said she couldn't be sure how many of the homicides were directly related to the victim's pregnancy. But many of the killings, she was sure, could not be explained as random acts of violence.

That is because homicides accounted for a much larger share of deaths among women who were pregnant or had recently been pregnant than among other women in the same age group. A fifth of the deaths among pregnant women were attributed to homicide - almost five times the rate in the other group.

Pointing to a statistical limitation, Horan said the study did not measure homicide rates among all pregnant women. Instead, it only looked at the causes of death - including homicides - among pregnant women who died.

"We can say that a woman in Maryland who becomes pregnant is more likely to be a victim of homicide than to die of any other causes," she said.

The health department did not set out to discover the role of violence in the deaths of pregnant women, Horan said. The finding, which she called surprising, grew out of an effort to gauge the true magnitude of maternal death - a problem that has decreased drastically over the past century but, according to many experts, is underreported.

Researchers did find that doctors filling out death certificates were failing in many cases to note that women who had died of medical disorders had been pregnant. Doctors, in some cases, indicated hemorrhage or embolism as the cause of death, omitting the fact that the women just delivered a child when the problem occurred.

The old method of counting maternal deaths included deaths during pregnancy or in the first 42 days after pregnancy. In its new study, the health department employed an expanded definition used by the World Health Organization that counted deaths within a year.

Using the expanded definition and new sources of data, researchers found an additional 30 deaths that occurred for purely medical reasons. But the researchers found another 88 women who died of homicide, accidents, substance abuse and suicides - nonmedical factors that were never before taken into account.

In all, researchers documented 247 deaths - four times the number found using old statistical methods.

She said the findings raised concerns that some women who took their own lives might have suffered from postpartum depression.

Last year, the health department contracted with Med-Chi, the state medical society, to study more closely the root causes of death among pregnant women. The group has been examining medical records and reports of hospital peer-review organizations that could explain the circumstances behind the deaths.

"Some of the deaths might not be preventable, but in some areas we can clearly do better," said Dr. Harrold Elberfeld, an obstetrician at Franklin Square Hospital who heads the Med-Chi committee directing the study.

Some who died of high blood pressure, he said, might not have had an early diagnosis and proper medical care. Some who died of ectopic pregnancy - a pregnancy occurring outside the uterus - might not have had prenatal care when the problem occurred.

The group also hopes to learn the circumstances behind homicides by examining court records, he said.

Some studies have indicated that women in abusive relationships are more likely to be beaten when they become pregnant.

"We see a lot of women who leave at the point or shortly after the point they become pregnant, because the abuse has escalated," said Carole Alexander, executive director of the House of Ruth, a Baltimore shelter.

"At that point the woman is more vulnerable or is perceived as more vulnerable."

Alexander also said she has seen many women who lost their babies after being beaten.

In an editorial accompanying the study, the former director of a New York injury-prevention program said that scenario has been borne out by research.

"Research indicates that much of the violence that women experience during pregnancy is perpetrated by intimate partners and that, for some, intimate partner violence begins during pregnancy," said Victoria Frye, who is now with the Center for Health and Gender Equity in Takoma Park.

Between 1987 and 1996, Maryland had the 10th-highest maternal mortality rate in the nation. The rate was 9.1 deaths per 100,000 live births, compared with 12.3 deaths per 100,000 in Mississippi, the state with the highest rate.

The District of Columbia's rate was 22.8 deaths per 100,000 live births, surpassing all states.

A century ago, the problem was much more severe. Lacking antibiotics, sanitation, transfusions and other advantages, roughly one in 120 women died around the time of childbirth.

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