Violence As a Direct Cause of and Indirect Contributor to Maternal Death

Perinatal Homicide in the United States: A Systematic Literature Review

This review focused on literature from the United States evaluating homicide during the perinatal period. It was completed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventeen studies met the criteria for inclusion, including: describing prevalence and risk factors related to homicide deaths of pregnant or postpartum birthing individuals; being conducted in the United States; and being published in English 2007 or later. This review found that homicide is an important contributor to maternal mortality and is a leading cause of death during pregnancy and the postpartum period, especially if an individual is Black and under the age of 30. Future efforts must be made to standardize data collection efforts and resolve nuanced terminology that results in interpretation challenges. The United States should examine maternal deaths through the entirety of the perinatal period and fully invest in violence prevention efforts.

Societal Factors and Teen Dating Violence: a Scoping Review

Purpose of Review

This scoping review aims to identify quantitative research studies in the USA examining the association between societal factors and teen dating violence (TDV) victimization and/or perpetration.

Recent Findings

Nine articles examined a range of societal factors including gender norms and gender equality; cultural norms that support aggression towards others; income inequality; and laws and policies. Factors were measured in states, neighborhoods, schools, and classes. While findings varied, certain societal factors may be associated with TDV.

Summary

Findings highlight the relative lack of research examining associations between societal factors and TDV. This may be driven by limited data availability, complexity and cost of such research, and unclear definitions and measurement of societal factors. To decrease TDV and improve population-level adolescent health, more rigorous research is needed to inform the development of multilevel and structural interventions to address the outer layers of the social ecology.

Magnus J, Assefa N, Wordofa MA. The protocol for a cluster randomized controlled trial to evaluate couple-based violence prevention education and its ability to reduce intimate partner violence during pregnancy in Southwest Ethiopia

BACKGROUND

A significant proportion of women in Ethiopia suffer from violence by their intimate partner during pregnancy, which has adverse maternal and newborn outcomes. Couple-focused interventions are effective in reducing and/or controlling violence between women and their intimate partners. However, interventions addressing intimate partners of the victims are not well studied, particularly in the Ethiopian setting. This study aims to assess the effect of couple-based violence prevention education on intimate partner violence during pregnancy.

METHODS

We will use a cluster randomized controlled trial to evaluate the effectiveness of couple-based violence prevention education compared to routine care in reducing intimate partner violence during pregnancy. Sixteen kebeles will be randomly assigned to 8 interventions and 8 control groups. In the trial, 432 couples whose wife is pregnant will participate. Health extension workers (HEWs) will provide health education. Data will be collected at baseline and endline. All the collected data will be analyzed using Stata version 16.0 or SPSS version 25.0. We will use the McNemar test to assess the differences in outcomes of interest in both intervention and control groups before and after the intervention for categorical data. A paired t-test will be used to compare continuous outcome of interest in the intervention and the control groups after and before the intervention. The GEE (Generalized Estimating Equation), will be used to test the independent effect of the intervention on the outcome of the interest. Data analysis will be performed with an intention-to-treat analysis approach. During the analysis, the effect size, confidence interval, and p-value will be calculated. All tests will be two-sided, and statistical significance will be declared at p < 0.05.

DISCUSSION

We expect that the study will generate findings that can illuminate violence prevention strategies and practices in Ethiopia.

TRIAL REGISTRATION

It has been registered on ClinicalTrials.gov as NCT05856214 on May 4, 2023.

Health insurance coverage and experiences of intimate partner violence and postpartum abuse screening among rural US residents who gave birth 2016-2020

PURPOSE

Intimate partner violence (IPV) is elevated among rural residents and contributes to maternal morbidity and mortality. Postpartum health insurance expansion efforts could address multiple causes of maternal morbidity and mortality, including IPV. The objective of this study was to describe the relationship between perinatal health insurance, IPV, and postpartum abuse screening among rural US residents.

METHODS

Using 2016-2020 data on rural residents from the Pregnancy Risk Assessment Monitoring System, we assessed self-report of experiencing physical violence by an intimate partner and rates of abuse screening at postpartum visits. Health insurance at childbirth and postpartum was categorized as private, Medicaid, or uninsured. We also measured insurance transitions from childbirth to postpartum (continuous private, continuous Medicaid, Medicaid to private, and Medicaid to uninsured).

FINDINGS

IPV rates varied by health insurance status at childbirth, with the highest rates among Medicaid beneficiaries (7.7%), compared to those who were uninsured (1.6%) or privately insured (1.6%). When measured by insurance transitions, the highest IPV rates were reported by those with continuous Medicaid coverage (8.6%), followed by those who transitioned from Medicaid at childbirth to private insurance (5.3%) or no insurance (5.9%) postpartum. Nearly half (48.1%) of rural residents lacked postpartum abuse screening, with the highest proportion among rural residents who were uninsured at childbirth (66.1%) or postpartum (52.1%).

CONCLUSION

Rural residents who are insured by Medicaid before or after childbirth are at elevated risk for IPV. Medicaid policy efforts to improve maternal health should focus on improving detection and screening for IPV among rural residents.

Impact of sex, race, and social determinants of health on neonatal outcomes

Despite the global improvements in neonatal outcomes, mortality and morbidity rates among preterm infants are still unacceptably high. Therefore, it is crucial to thoroughly analyze the factors that affect these outcomes, including sex, race, and social determinants of health. By comprehending the influence of these factors, we can work towards reducing their impact and enhancing the quality of neonatal care. This review will summarize the available evidence on sex differences, racial differences, and social determinants of health related to neonates. This review will discuss sex differences in neonatal outcomes in part I and racial differences with social determinants of health in part II. Research has shown that sex differences begin to manifest in the early part of the pregnancy. Hence, we will explore this topic under two main categories: (1) Antenatal and (2) Postnatal sex differences. We will also discuss long-term outcome differences wherever the evidence is available. Multiple factors determine health outcomes during pregnancy and the newborn period. Apart from the genetic, biological, and sex-based differences that influence fetal and neonatal outcomes, racial and social factors influence the health and well-being of developing humans. Race categorizes humans based on shared physical or social qualities into groups generally considered distinct within a given society. Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. These factors can include a person's living conditions, access to healthy food, education, employment status, income level, and social support. Understanding these factors is essential in developing strategies to improve overall health outcomes in communities.

Rural/urban differences in rates and predictors of intimate partner violence and abuse screening among pregnant and postpartum United States residents

OBJECTIVE

To describe rates and predictors of perinatal intimate partner violence (IPV) and rates and predictors of not being screened for abuse among rural and urban IPV victims who gave birth.

DATA SOURCES AND STUDY SETTING

This analysis utilized 2016-2020 Pregnancy Risk Assessment Monitoring System (PRAMS) data from 45 states and three jurisdictions.

STUDY DESIGN

This is a retrospective, cross-sectional study using multistate survey data.

DATA COLLECTION/EXTRACTION METHODS

This analysis included 201,413 survey respondents who gave birth in 2016-2020 (n = 42,193 rural and 159,220 urban respondents). We used survey-weighted multivariable logistic regression models, stratified by rural/urban residence, to estimate adjusted predicted probabilities and 95% confidence intervals (CIs) for two outcomes: (1) self-reported experiences of IPV (physical violence by a current or former intimate partner) and (2) not receiving abuse screening at health care visits before, during, or after pregnancy.

PRINCIPAL FINDINGS

Rural residents had a higher prevalence of perinatal IPV (4.6%) than urban residents (3.2%). Rural respondents who were Medicaid beneficiaries, 18-35 years old, non-Hispanic white, Hispanic (English-speaking), or American Indian/Alaska Native had significantly higher predicted probabilities of experiencing perinatal IPV compared with their urban counterparts. Among respondents who experienced perinatal IPV, predicted probabilities of not receiving abuse screening were 21.3% for rural and 16.5% for urban residents. Predicted probabilities of not being screened for abuse were elevated for rural IPV victims who were Medicaid beneficiaries, 18-24 years old, or unmarried, compared to urban IPV victims with those same characteristics.

CONCLUSIONS

IPV is more common among rural birthing people, and rural IPV victims are at higher risk of not being screened for abuse compared with their urban peers. IPV prevention and support interventions are needed in rural communities and should focus on universal abuse screening during health care visits and targeted support for those at greatest risk of perinatal IPV.

Development and external validation of a pretrained deep learning model for the prediction of non-accidental trauma

Non-accidental trauma (NAT) is deadly and difficult to predict. Transformer models pretrained on large datasets have recently produced state of the art performance on diverse prediction tasks, but the optimal pretraining strategies for diagnostic predictions are not known. Here we report the development and external validation of Pretrained and Adapted BERT for Longitudinal Outcomes (PABLO), a transformer-based deep learning model with multitask clinical pretraining, to identify patients who will receive a diagnosis of NAT in the next year. We develop a clinical interface to visualize patient trajectories, model predictions, and individual risk factors. In two comprehensive statewide databases, approximately 1% of patients experience NAT within one year of prediction. PABLO predicts NAT events with area under the receiver operating characteristic curve (AUROC) of 0.844 (95% CI 0.838-0.851) in the California test set, and 0.849 (95% CI 0.846-0.851) on external validation in Florida, outperforming comparator models. Multitask pretraining significantly improves model performance. Attribution analysis shows substance use, psychiatric, and injury diagnoses, in the context of age and racial demographics, as influential predictors of NAT. As a clinical decision support system, PABLO can identify high-risk patients and patient-specific risk factors, which can be used to target secondary screening and preventive interventions at the point-of-care.

Research utility and limitations of textual data in the National Violent Death Reporting System: a scoping review and recommendations

BACKGROUND

Many studies of injury deaths rely on mortality data that contain limited contextual information about decedents. The National Violent Death Reporting System (NVDRS) is unique among such data systems in that each observation includes both quantitative variables and qualitative texts (called "narratives") abstracted from original source documents. These narratives provide rich data regarding salient circumstances that can be used to inform prevention efforts. This review provides a comprehensive summary of peer-reviewed research using NVDRS narratives over the past 20 years, including the limitations of these texts and provides recommendations on utilizing and improving narrative quality for researchers and practitioners.

MAIN BODY

Studies that used narratives to examine deaths related to suicide, homicide, undetermined intent, accidental firearm, or legal intervention were identified by a title/abstract screening, followed by a full-text review. The search was conducted on English-language, peer-reviewed literature and government reports published from 2002 to 2022 in PubMed, PsycInfo, Scopus, and Google Scholar. Abstracted elements focused on the methodologies used to analyze the narratives, including approaches to explore potential biases in these texts. Articles were abstracted independently by two reviewers, with disagreements resolved through consensus discussion. During the 20-year period, 111 articles used narratives. Two-thirds studied suicide (n = 48, 43%) and homicides (n = 25, 23%). Most studies analyzed the narratives using manual review (n = 81, 73%) and keyword searches (n = 9, 8%), with only 6 (5%) using machine learning tools. Narratives were mainly used for case finding (n = 49, 44%) and characterization of circumstances around deaths (n = 38, 34%). Common challenges included variability in the narratives and lack of relevant circumstantial details for case characterization.

CONCLUSION

Although the use of narratives has increased over time, these efforts would be enhanced by detailed abstraction of circumstances with greater salience to injury research and prevention. Moreover, researchers and practitioners would benefit from guidance on integrating narratives with quantitative variables and standardized approaches to address variability in the completeness and length of narratives. Such efforts will increase the reliability of findings and set the stage for more widespread applications of data science methods to these texts.

Screening for and Experiences of Intimate Partner Violence in the United States Before, During, and After Pregnancy, 2016-2019

Objectives. To measure rates of intimate partner violence (IPV) screening during the perinatal period among people experiencing physical violence in the United States. Methods. We used 2016-2019 Pregnancy Risk Assessment Monitoring System data (n = 158 338) to describe the incidence of physical IPV before or during pregnancy. We then assessed the prevalence of IPV screening before, during, or after pregnancy and predictors of receiving screening among those reporting violence. Results. Among the 3.5% (n = 6259) of respondents experiencing violence, 58.7%, 26.9%, and 48.3% were not screened before, during, or after pregnancy, respectively. Those reporting Medicaid or no insurance at birth, American Indian/Alaska Native people, and Spanish-speaking Hispanic people faced increased risk of not having a health care visit during which screening might occur. Among those attending a health care visit, privately insured people, rural residents, and non-Hispanic White respondents faced increased risk of not being screened. Conclusions. Among birthing people reporting physical IPV, nearly half were not screened for IPV before or after pregnancy. Public health efforts to improve maternal health must address both access to care and universal screening for IPV. (Am J Public Health. 2023;113(3):297-305. https://doi.org/10.2105/10.2105/AJPH.2022.307195).

The public health exposome and pregnancy-related mortality in the United States: a high-dimensional computational analysis

BACKGROUND

Racial inequities in maternal mortality in the U.S. continue to be stark.

METHODS

The 2015-2018, 4-year total population, county-level, pregnancy-related mortality ratio (PRM; deaths per 100,000 live births; National Center for Health Statistics (NCHS), restricted use mortality file) was linked with the Public Health Exposome (PHE). Using data reduction techniques, 1591 variables were extracted from over 62,000 variables for use in this analysis, providing information on the relationships between PRM and the social, health and health care, natural, and built environments. Graph theoretical algorithms and Bayesian analysis were applied to PHE/PRM linked data to identify latent networks.

RESULTS

PHE variables most strongly correlated with total population PRM were years of potential life lost and overall life expectancy. Population-level indicators of PRM were overall poverty, smoking, lack of exercise, heat, and lack of adequate access to food.

CONCLUSIONS

In this high-dimensional analysis, overall life expectancy, poverty indicators, and health behaviors were found to be the strongest predictors of pregnancy-related mortality. This provides strong evidence that maternal death is part of a broader constellation of both similar and unique health behaviors, social determinants and environmental exposures as other causes of death.

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

OBJECTIVE

To analyze differences in the demographic and social factors associated with pregnancy-associated violent deaths due to homicide compared with suicide by pregnancy timing.

METHODS

This was a retrospective cohort study using the Centers for Disease Control and Prevention's National Violent Death Reporting System from 2008 to 2019. We included females aged 15-44 years who died by suicide , defined as intentional self-harm, or homicide. Pregnancy-associated deaths were defined as those that occurred during or within 1 year of pregnancy.

RESULTS

Of 38,417 female victims aged 15-44 years identified in the data set, 10,411 had known pregnancy status; 1,300 of those deaths were pregnancy associated. Of all deaths with known pregnancy status, 3,203 were by homicide (30.8%) and 7,208 (69.2%) were by suicide. Pregnancy-associated homicide deaths made up 20.6% of all homicide deaths, and pregnancy-associated suicide deaths made up 8.8% of all suicide deaths. Individuals who died by homicide were younger (29.4±8.2 years vs 31.5±8.6 years), more likely to be single or never married (61.0% vs 50.0%), and had a higher proportion of associate's degree-level education or less as compared with individuals who died by suicide (28.1% vs 43.9%). 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. Having a mental health problem and any substance use were significantly more often associated with suicide deaths compared with homicide deaths (77.4% vs 7.2%, P <.001 for mental health, 33.3% vs 12.8%, P <.001 for substance use, respectively). Intimate partner violence was prevalent in both groups, although significantly higher in homicide deaths (57.3% vs 37.1%, P <.001). This pattern persisted when stratified by pregnancy status.

CONCLUSION

Mental health problems, substance use disorder, and intimate partner violence are preceding circumstances to pregnancy-associated suicide and homicide.

Income Inequality and Pregnancy-Associated Homicide in the US: A Longitudinal, State-Level Analysis

Pregnancy-associated homicide remains an understudied yet critical issue. Using restricted use mortality files provided by the National Center for Health Statistics and the National Violent Death Reporting System, annual state-level pregnancy-associated homicide ratios were estimated as the count of deaths divided by the number of live births. The exposure, the state Gini index, was categorized into tertiles to compare states by levels of income inequality. In the final adjusted longitudinal linear model, those who experienced the greatest amount of income inequality had a significant 1.28 per 100,000 homicide rate when compared to the lowest income inequality tertile.

Homicide During Pregnancy and the Postpartum Period in the United States, 2018-2019

OBJECTIVE

To estimate the national pregnancy-associated homicide mortality ratio, characterize pregnancy-associated homicide victims, and compare the risk of homicide in the perinatal period (pregnancy and up to 1 year postpartum) with risk among nonpregnant, nonpostpartum females aged 10-44 years.

METHODS

Data from the National Center for Health Statistics 2018 and 2019 mortality files were used to identify all female decedents aged 10-44 in the United States. These data were used to estimate 2-year pregnancy-associated homicide mortality ratios (deaths/100,000 live births) for comparison with homicide mortality among nonpregnant, nonpostpartum females (deaths/100,000 population) and to mortality ratios for direct maternal causes of death. We compared characteristics and estimated homicide mortality rate ratios and 95% CIs between pregnant or postpartum and nonpregnant, nonpostpartum victims for the total population and with stratification by race and ethnicity and age.

RESULTS

There were 3.62 homicides per 100,000 live births among females who were pregnant or within 1 year postpartum, 16% higher than homicide prevalence among nonpregnant and nonpostpartum females of reproductive age (3.12 deaths/100,000 population, P<.05). Homicide during pregnancy or within 42 days of the end of pregnancy exceeded all the leading causes of maternal mortality by more than twofold. Pregnancy was associated with a significantly elevated homicide risk in the Black population and among girls and younger women (age 10-24 years) across racial and ethnic subgroups.

CONCLUSION

Homicide is a leading cause of death during pregnancy and the postpartum period in the United States. Pregnancy and the postpartum period are times of elevated risk for homicide among all females of reproductive age.

Firearm Relinquishment Laws Associated With Substantial Reduction In Homicide Of Pregnant And Postpartum Women

Homicide is a leading cause of death among women who are pregnant and up to one year postpartum in the United States. Most incidents are perpetrated by an intimate partner with a firearm. Some states have implemented laws that prohibit firearm possession by perpetrators of domestic violence and, in some instances, include explicit statutory language mandating relinquishment of firearms once a person has become prohibited from possessing them. We examined the impact of these policies on state-level rates of homicide among pregnant and postpartum women during the period 2011-19. We found that state laws prohibiting possession of firearms and requiring relinquishment of firearms by people convicted of domestic violence-related misdemeanors were associated with substantial reductions in homicide of pregnant and postpartum women. State policy makers should consider further strengthening domestic violence-related firearm regulations and their enforcement to prevent homicide of pregnant and postpartum women.

Integrating National Violent Death Reporting System Data into Maternal Mortality Review Committees

Background: With the Maternal Mortality Review Information Application (MMRIA) data system, the Centers for Disease Control and Prevention (CDC), alongside Maternal Mortality Review Committees (MMRCs), are developing comprehensive and uniform data collection to eradicate preventable maternal deaths. However, MMRIA is primarily focused on pregnancy-related deaths, and not pregnancy-associated deaths. Currently, the National Violent Death Reporting System Restricted Access Data (NVDRS-RAD) on pregnancy-associated homicides and suicides are not included in MMRIA and by extension the work of most MMRCs. This study examined the NVDRS-RAD data from 2014 to 2017 and argues that the data for pregnancy-associated maternal deaths should be integrated into the work of MMRCs. Methods: A secondary data analysis of the NVDRS-RAD from 2014 to 2017 was conducted. Pregnancy-associated mortality was identified using data available within the NVDRS-RAD and categorized according to period of pregnancy and manner of death. Descriptive statistics and risk ratios were calculated. Chi-square tests were also calculated. Results: The results indicate that pregnancy and the postpartum period show increased risk for homicide and suicide. Pregnant women were found to be five times more likely to die by homicide than their nonpregnant peers who died by violent means. The relationships between periods of pregnancy and manner of death were all found to be significantly associated although the association was weak. Conclusions: Integrating National Violent Death Reporting System data on pregnancy-associated deaths into MMRIA would improve the efficacy of MMRCs and address the intertwined risk factors driving the racial disparities of the United States' maternal mortality rate.