RESEARCH AND PRACTICE:
Jeani Chang, Cynthia J. Berg, Linda E. Saltzman, and Joy Herndon
Homicide: A Leading Cause of Injury Deaths Among Pregnant and Postpartum Women in the United States, 1991–1999
Am J Public Health 2005; 95: 471-477
[Abstract][Full text][PDF]
Chang et. al. recently reported in the Journal on risk factors for
pregnancy-associated homicide by examining data from the pregnancy mortality
surveillance system (PMSS) at the Centers for Disease Control and Prevention.1
The authors discussed the increasing importance of examining
"pregnancy-associated" deaths in conjunction with "pregnancy-related" deaths.
This is a call a growing numbers of others have been making as more inclusionary
factors of maternal demise have caught up to and surpassed the declining
historical definition of maternal mortality that excludes trauma and other
conditions deemed “causally” unrelated to pregnancy.2, 3 In 2002, the National
Center for Health Statistics reported 357 cases of maternal mortality (while
pregnant or within 42 days of termination of pregnancy).4 Although the actual
number of injury deaths among pregnant women is unknown due to the limitations
discussed in the article by Chang et. al., if one assumes for calculation
purposes that pregnancy does not greatly change the age specific risk of death
among women of reproductive age (15-39) and factors in the birth rate and a
gestational period exposure adjustment of 9/12, it is estimated for comparison
that about 600 pregnant women die each year from injuries and violence. From the
fetal mortality perspective, of course, it matters little whether the cause of
maternal death was "associated" or "related" to the pregnancy; the end result is
almost always fetal death.
Another limitation from utilizing the PMSS (not meant as a criticism of the
system) is the inherent focus on maternal death. A full understanding of
mortality during pregnancy should arguably include consideration of fetal and
maternal deaths. By only focusing on maternal death during pregnancy, more
inclusive patterns of maternal injury and violence that lead to fetal demise and
neonatal injury may be missed. There are always two potential victims impacted
when injury and violence occur during pregnancy; the mother and the fetus. With
trauma center studies showing the ratio of fetal to maternal death ranges from
3:1 to 9:1,5 maternal mortality should be seen as encompassing a minority of the
injury attributable fetal loss. The limitations of other data sources, such as
fetal death certificates,6 and the lack of pregnancy status and fetal outcome
variables in most injury, trauma and violence surveillance systems, keeps the
impact and understanding of the magnitude and patterns of these events on the
fetus, and the children who survive, hidden from view. I strongly concur with
the author’s recommendation to encourage more linkage of maternal and fetal
death certificates with autopsy records and police reports. In addition, in
order to garner a more accurate picture of both maternal and fetal mortality and
morbidity related to injury and violence, that recommendation should be extended
to include more linkage of birth and fetal death certificates with other
important sources of maternal injury and violence data such as police reports,
crash reports (motor vehicle crashes are the leading cause of maternal injury
death and hospitalizations in the U.S., as a whole), emergency department and
hospital discharge data, and trauma registries. It is through this broader
perspective that the true impact of injury and trauma to pregnant women will be
measured.
Harold B. Weiss MPH, PhD
Director and Associate Professor
Center for Injury Research and Control
University of Pittsburgh
1Chang, J.; Berg, C. J.; Saltzman, L. E., and Herndon, J. Homicide: a leading
cause of injury deaths among pregnant and postpartum women in the United States,
1991-1999. Am J Public Health. 2005 Mar; 95(3):471-7.
2Nannini, A.; Weiss, J.; Goldstein, R., and Fogerty, S. Pregnancy-associated
mortality at the end of the twentieth century: Massachusetts, 1990-1999. J Am
Med Women's Assoc. 2002 Summer; 57(3):140-3.
3Horon I, Cheng D. Enhanced surveillance for pregnancy-associated mortality-
Maryland, 1993-1998. JAMA. 2001;285:1455-1459.
4Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: Final data for 2002.
National vital statistics reports; vol 53 no 5. Hyattsville, Maryland: National
Center for Health Statistics. 2004.
5Ikossi, D. G.; Lazar, A. A.; Morabito, D.; Fildes, J., and Knudson, M. M.
Profile of mothers at risk: an analysis of injury and pregnancy loss in 1,195
trauma patients. J Am Coll Surg. 2005 Jan; 200(1):49-56.
6Weiss HB, Songer TJ, Fabio A: Fetal deaths related to maternal injury. JAMA
2001;286:1863-8.
HAWAII PRAMS DATA
25 February 2005
Elizabeth B. Apana, Hawaii WIC Contract Specialist
I am completing research utilizing Hawaii PRAMS data on the amount of
information and/or education given to women either prenatally or
postpartum by health care providers on intimate partner violence. I was
pleased to see your article and there was a front page article on it in
the Honolulu Advertiser on February 23, 2005.
I worked in the field of intimate partner violence for six years and
have a MPH.
My oldest daughter died at the young age of twenty-six years of an
arteriovenous malformation which was the result of abuse by my partner
while I was pregnant. Injuries in utero which cause death later are even
harder to track, but nonetheless are homicide due to intimate partner
violence.
Thank you for bringing this uncomfortable truth out in the open.
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Injury and Violence Among Prregnant Women: What About the Baby
