Death by pregnancy: Why are so many moms-to-be dying?

So they launched a study to explore all occurrences of death during pregnancy, not just those directly related to obstetric complications—which was how the National Center for Health Statistics defined "maternal death" at the time.

The further they probed, the more they checked and rechecked, the more undeniable it became: These women weren't dying only of traditional causes like thromboembolism; they were being killed. Shot. Strangled. Beaten to death. By husbands, boyfriends, lovers. By the fathers of their unborn children.

Horon and Cheng's findings, published in the March 21, 2001, issue of the Journal of the American Medical Association, revealed that homicide was in fact the leading cause of mortality during pregnancy and the first postpartum year, accounting for one out of five deaths. Simultaneously, a study in the Journal of Midwifery & Women's Health found that an astounding 43 percent of maternal deaths over eight years in Washington, D.C., were homicides. Compounding the problem: Nearly half of those cases were not included in D.C.'s Center for Health Statistics. In essence, they were invisible. The D.C. study's chilling title was "Hidden from View."

The medical community was stunned. How could this be happening under everyone's radar? More important, why was it happening at all? But the numbers didn't generate headlines until nearly two years later, when a pregnant Laci Peterson disappeared on Christmas Eve 2002. Her body was found the following April in San Francisco Bay, and her husband, Scott, was arrested for murdering her and their unborn son, Conner. The cold-blooded nature of his crime generated exponentially more press than the studies had, in part because it seemed so aberrant. Operative word: seemed. Experts who were carrying out research spurred by the 2001 findings knew better.

While the Peterson case held the stage, those very findings were written up by a few media outlets—including a three-part series in The Washington Post in 2004. Once Peterson received a death sentence in early 2005, though, interest in other, less-prominent maternal murders subsided.

Why wasn't there more outrage? Jenny Davidson, CEO and executive director of Stand Up Placer, a battered women's safe house in Auburn, California, feels the reason is twofold. Studies document how we become desensitized to violence against women because our popular culture is literally saturated with it. Secondly, we have an "it couldn't happen to me" resistance to hearing about men killing their partners. And, says Davidson, "we frequently hold victims more accountable than we do perpetrators."

Meanwhile, research continued, some of it suggesting that even the disturbing 2001 numbers might vastly underrepresent the problem. Because studies differ in demographics, tools, and methods, a meta-analysis of intimate-partner violence, or IPV, during pregnancy—a major risk factor for maternal homicide—found estimates ranging from 1 percent to an astonishing 50 percent. One researcher recently called IPV during pregnancy "a health and safety issue of epidemic proportions." Adding frustration to fear: Methods for recording maternal deaths are incomplete and vary from state to state.

Then this spring, a rigorous, decadelong study of traumatic injuries among women of childbearing age was presented at the annual meeting of the American College of Obstetrics and Gynecology. It found that pregnant women are more likely to suffer violent trauma—and are twice as likely to die after trauma—than nonpregnant women. So despite years of calls for more research, education, and intervention on this problem, after thousands more women carrying unborn children died at the hands of their partners, essentially no progress had been made since 2001. The paper was presented on May 6, one week before Mother's Day.

SEEDS OF TROUBLE

It often starts with a belittling comment, maybe a shove during an argument. Later, a veiled threat... and then a threat acted upon. Of the 1.5 million women sexually or physically assaulted by an intimate partner in 2015, 324,000 were pregnant when attacked, or about 21 percent, according to the National Coalition Against Domestic Violence. IPV and murder are closely linked because abuse tends to escalate. Isolated "incidents" can become more frequent—and pregnancy can change the equation for the worse, making IPV more likely, not less. Estimates of the percentage of women assaulted during pregnancy by a partner who said he had never done it before range from 16 to 25.

Even in the upbeat context of fertility and pregnancy tracking app community boards, stories of assault surface. Often headlining their posts with phrases like "Is this abuse?" Women describe emotional and physical battery by their partners. "I'm afraid to bring anything up to my husband about things that are bothering me," writes one woman who is four months pregnant. "He never hears what I have to say till after he's done screaming at me, throwing stuff, or hitting... I just fear he will one day hurt our baby because he doesn't know how to control his anger." Another asks, tellingly, "Do you believe if a man hits you once he'll do it again?"

Why do these assaults happen—and lead so often to murder? Research has begun to illuminate the who and how of maternal death. Both IPV and partner homicide during pregnancy cross ethnic, racial, and socioeconomic lines. As for the manner of death, gunshot is most common, but anecdotal evidence shows a variety of methods, from stabbing to strangling.

Certain types of pregnancies make violence more likely too. Women with "mistimed" pregnancies—the couple planned to have children, but later—suffer IPV at more than twice the rate of those with planned pregnancies. Even more dire is when a pregnancy is "unwanted" by the father; those women are victims of IPV at three times the rate of those carrying a child both parents want and have planned for. At Scott Peterson's trial, his sister-in-law testified that when she asked him about his impending fatherhood, he looked at her and said, "I was kinda hoping for infertility."

Take the case of Karen*, described by a counselor from a shelter. She was lying in bed with a man she was seeing and casually admitted she "might be late." They discussed what they might decide to do about it. And then something flipped. The man, who had never been abusive before, began brutally hitting her around her genitals, even shoving his hand violently into her vagina, seemingly trying to end the pregnancy. She drifted in and out of consciousness as the savage beating continued. After the man left her to die, she crawled to a phone and called a friend, who took her to the hospital.

There, like many victims of IPV, she lied, telling doctors she had fallen. She had a shattered pelvis and was hospitalized for months. Karen left using a walker, told she could never have children. She kept this toxic secret for two years, until going to a safe house for battered women to tell her story. She went not to take action—the man was long gone—but for support from people who understood. Her experience shocked even the seen-it-all workers at the safe house. But Karen was also lucky, in a way: She escaped with her life.

Many others have not. Even as we went to press, the body of a 31-year-old teacher in Maryland had just been found in a shallow grave; her boyfriend has been charged with her murder. According to family and police, she was four months pregnant with his child.

WHY MEN KILL THEIR OWN

Many men feel anxious about impending parenthood, but few become violent. The majority of those who do are already abusive—though typically only toward their partners, and most don't have a criminal record. That can make them hidden time bombs waiting to go off. In addition to worries about money or commitment issues, there can be other triggers as well, says Cheng. "Sometimes the man feels jealous of the attention the baby is getting, or will get, or he feels that he is losing control of his freedom."

For certain men, those emotions can make pregnancy feel like a crisis. In general, batterers tend to be controlling and possessive, according to domestic-violence pioneer Susan Hanks, Ph.D. They seek total mastery over not just their partner's life, but their own, she told a documentary filmmaker in 1998. The twist is that often these men are abnormally dependent on women and threatened by any move toward independence their partner might make. In their eyes, a pregnancy gives the woman more power and autonomy. Not only is she now in command of a large part of his future—he might have a child to support—but in nurturing another life, she appears to be taking a step away from him and toward her own wishes and goals. In reality, of course, she has actually become more dependent on him: Physically, she feels vulnerable, and financially, she's looking at two decades of raising a child.

Many abusers, however, also come to realize that a pregnancy means "he's got her," says James Dugo, Ph.D., a psychologist in Des Plaines, Illinois. Dugo has worked for 40 years counseling what he estimates to be more than 8,000 men who battered their partners. "The stakes are higher for the mother. It's not likely she'll report the father of her unborn child, let alone put him in jail." Having heard the same story from so many men, Dugo adds bluntly: "They know what they can get away with." But what might make a man unexpectedly "snap," as Karen's boyfriend did? There is still no crystal ball, Dugo says. "Violent men share certain factors—including growing up in an abusive household and having low self-esteem—but plenty of men have those traits and don't become batterers, and we don't know why. A lot more research is needed."

THE WOMEN WHO STAY

For every woman like Karen, whose attack did come out of the blue, there are many who had been abused but chose to remain with their partners and lie about the cause of their injuries. From the outside, this can seem inexplicable. However difficult it is to disengage from such a relationship, wouldn't a pregnancy provide added impetus for a woman to leave, to protect herself and her unborn child? As with men, the answers are complicated and layered.

Emily* lived through violence during pregnancy not once but six times, with each of her children. The first assault occurred on her wedding night, when her new husband beat her in their honeymoon suite. "I was in total denial and shock," she says. When she became pregnant, Emily hoped it would change things and the "incidents" would stop now that her husband was becoming a father. He made an effort to avoid her stomach when he hit her, and she convinced herself that the pregnancy gave her some crumb of control.

Now, looking back, Emily describes her mindset as "brainwashed. You're traumatized—you cling to the idea of that perfect little world, and you want so badly to remain a family." She finally left the marriage out of fear for her life and now works at a safe house for battered women and their children, where she often hears the same words from those who come seeking shelter.

Researchers who study "battered woman syndrome" call that mixture of denial, trauma, and loss of control "learned helplessness." The term originated in studies in which dogs were randomly given electrical shocks inside their cages yet didn't try to escape even when the cage doors were left open. Researchers theorized that the dogs' experience of unpredictable pain essentially rewired their brains so that they felt helpless to change their condition. Experts who study abuse think that similar brain modifications occur when women are assaulted over time: Nothing they do cures their pain, and they feel incapable of changing anything—or of leaving.

Now combine that possible shift in brain chemistry with the usual aspects of pregnancy, says Chivas Mays, a housing manager at the Stand Up Placer women's shelter. "The hormones, the fatigue, the stress, and wanting to have faith in the father of your child—it becomes more understandable why so many women are reluctant to leave."

Mays, who herself was physically and sexually assaulted by the father of her unborn child, also believed (as many abused pregnant women do) that becoming a parent would change him. Then there is the shame and embarrassment factor, she adds. Many pregnant women who are assaulted ask themselves, "What kind of a mother would let this happen to her?" And worry about sharing custody with their abusive partner if they reveal the truth. What's more, trying to escape may put their life in even greater danger. The majority of IPV homicides occur when women try to leave, or succeed in leaving, their abuser. It can seem as if there's no way to escape.

A SHADOW EPIDEMIC

With these kinds of numbers, how is it that the scope of this intimate violence remains so hard to tease out, except in isolated studies of one particular area and period of time? One big reason is that there is no clear nationwide method for reporting maternal homicides. States vary in the way deaths of both mother and fetus are recorded, as well as in the kinds of information included. Until 2003, the U.S. Standard Death Certificate issued by the National Center for Health Statistics did not ask whether a woman was pregnant when she died. In that year, partly as a result of the Peterson case, the center added a check-box for pregnancy status. At first only four states used it in place of their own versions; by 2009 that number had risen to 25. As of this year, all 50 states' forms have a space to note pregnancy, but some are included under "other circumstances" and therefore still difficult to tally electronically.

Adding to the confusion are studies that show many doctors and medical examiners don't bother to mark the pregnancy status box when the cause of death is other than obvious "maternal causes" like hemorrhages. And 77 percent of the deaths occur in the first 20 weeks, when a fetal death certificate is not required. So while a woman who dies from, say, gestational diabetes is clearly a "maternal death," getting a picture of all deaths during pregnancy entails cross-checking medical examiners' reports (an autopsy after a lethal gunshot) with doctors' records, death certificates, and other sources.

That lack of numbers makes it hard to change health policy to prevent IPV by, for example, requiring that doctors at trauma centers ask about IPV when a patient is pregnant (studies continue to show this is done only in a minority of cases). It's a catch-22: Evidence is needed to enforce change, but when many women hide IPV and the database of maternal homicide is incomplete, that evidence is elusive.

HOPE GROWS

There are bright spots in this grim landscape. Cheng notes that there have been inroads in IPV awareness among the medical community, as more doctors learn how to uncover signs of IPV—often by just asking the right questions. Some experts point out that pregnancy is actually an optimal time for physicians to identify violence in a relationship, because a pregnant woman is seeing health-care providers more frequently (commonly 12 to 13 prenatal visits) and building a trusting rapport with them.

We're also learning more about how to ask questions. Simply asking a woman if she has been "abused" is not only vague but can seem judgmental. Studies show that when women are probed about specific behaviors—Does your partner talk down to you? Does he control your finances, or your contact with friends or family? Has he ever hit you?—a more accurate picture emerges. One study found that 38 percent of women changed their answer about abuse from "no" to "yes" when follow-up questions about particular acts were asked. Such interventions may help ferret out partners who have been emotionally, but not yet physically, abusive.

Cheng urges medical schools to incorporate IPV training into the regular curriculum, and "while that is starting, we have a long way to go," she says. "Doctors, and especially obstetricians, have a unique opportunity to help women have safe relationships and pregnancies. We need to educate our patients about resources they can turn to if there are problems." With that knowledge—and the growing research on maternal death-by-partner—perhaps many more women and their unborn children can survive and thrive.

HOW TO GET HELP

If you worry that you, or a friend or family member, may be caught up in a potentially dangerous relationship, here's where to start.

"IS IT ABUSE?"Many women aren't clear on what constitutes abuse. Go to getdomesticviolencehelp.com to access the HITS screening Tool, a simple five-question test that aids you in evaluating the dynamics in your relationship—and whether to seek help.

A WAY OUTInformation on the website of the national coalition against domestic violence (ncadv.org) can walk you through the process of leaving an abusive relationship, including dealing with police and lawyers and finding a safe house. The group also has a national hotline for confidential advice: 1-800-799-SAFE.

*Names and identifying characteristics have been changed.