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With a death rate for pregnant women that’s twice the U.S. average, Louisiana is one of the country’s most dangerous places to have a baby. Now, a new study on maternal mortality in the state includes another startling statistic: Homicide is among the leading causes of death.

study published Monday in JAMA Pediatrics by researchers from Tulane University and Louisiana State University found that women in Louisiana are more likely to be killed than to die from any single pregnancy-related condition.

Of the 119 pregnancy-related deaths in Louisiana from January 2016 through December 2017, 13.4% were homicides, or a rate of 12.9 deaths per 100,000 live births. In comparison, the rate for two common causes of maternal death, hypertensive disorders like preeclampsia and car crashes, were 3.2 and 10.5 per 100,000, respectively.

Aside from the broad category of “complications during delivery,” only diseases like cancer, HIV and respiratory illness outranked homicide.

Decades of research have shown that the chance a woman will be killed rises after she becomes pregnant, but the latest study points out that those deaths are not given the same attention as deaths that are directly related to giving birth. It demonstrates the need to address issues of violence against women in maternal care, according to study author Maeve Wallace, an assistant professor at Tulane.

“Maternal mortality reduction efforts should incorporate violence prevention strategies and recommendations to prevent future maternal deaths,” she said.

Researchers looked at all maternal deaths in Louisiana in 2016 and 2017 to understand the circumstances of the deaths. Maternal deaths are defined as anything occurring during pregnancy or in the year after birth. A homicide rate was calculated for those women and compared to Louisiana’s overall homicide rate for the same age group using data from the Centers for Disease Control and Prevention.

In comparison to women and girls in Louisiana of the same childbearing age who were not pregnant, the risk of homicide was twice as high in pregnant and postpartum women.

Experts say it’s unclear why that is so but that Louisiana’s high rate of violence against women may be a factor. In 2019, the state had the second-highest rate for men killing women, behind only Alaska.

“When there is already existing domestic violence, pregnancy can be a trigger for an abusive partner to commit more serious acts or homicide,” said Eva Lessinger, the director of programs at the New Orleans Family Justice Center and a member of Louisiana’s Pregnancy Associated Mortality Review Committee.

“It brings up a lot of jealousy, attachment issues, control — which is the heart of domestic violence. We have high rates of homicide and high rates of maternal mortality, so it doesn’t surprise me at all that we have high rates of maternal homicides,” she said.

Decades-old studies list homicide as the main threat to a pregnant woman’s life. In a Maryland study conducted between 1993 and 1998, researchers found that 20% of pregnancy deaths were homicides, making it the leading cause of death. Another study found that over 40% of maternal deaths from 1988 to 1996 in Washington, D.C., were homicides. A 10-year study of almost 45,000 women in Pennsylvania released in 2017 found that pregnant women are twice as likely to suffer from violent trauma as other women and are nearly twice as likely to die from it.

“Data from other states suggest that injury-related deaths like homicide or overdose do outnumber the causes we traditionally called pregnancy-related — for example, hypertension or bleeding. Louisiana is not alone in highlighting that trend,” said Dr. Pooja Mehta, clinical assistant professor of obstetrics and gynecology at LSU and another of the study’s authors.

This analysis does suggest that rates are higher in Louisiana, but data aren’t collected from each state or on a national level in a way that makes it easy to compare them.

Deaths from suicide, homicide and drug overdoses are often excluded from large analyses of maternal deaths because the circumstances are difficult to discern.

To meaningfully track homicide causes, health professionals would need access to much more data, Lessinger said.

“It’s the abusive partner who is the risk factor,” she said. “We need a lot more data around the relationship and person who is the cause of homicide in order to understand the risk levels. With obstetric causes, you just need that hospital record.”

The authors emphasized that every maternal death should be investigated, and that both the direct causes of mortality and injury-related deaths have links to social determinants of health.

“For so long these worlds have been separated,” said Lessinger. “People are waking up.”

The study says pregnancy is a critical time to reach women with violence prevention services because it’s when they are most likely to seek health care services. Obstetricians are supposed to screen pregnant women for domestic violence, but experts said more needs to be done.

“The fact that it still exists despite screening recommendations speaks to the need to think about broader, deeper-rooted causes,” said Wallace. That means considering things like access to quality education, safe housing, safe neighborhoods and healthy foods.

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