The United States has one of the highest maternal mortality rates in the developed world — and it’s getting worse. The rate is higher than in countries like Egypt and Romania. While medical complications such as hemorrhage and infection have traditionally been blamed, new research points to an unexpected and deeply troubling cause: violence.

According to a new study, homicide and suicide are the leading causes of maternal death in the US. Yet, these deaths are often excluded from official maternal mortality statistics.

“Many people are surprised when they hear that violence is the leading cause of death in pregnancy,” says the study’s lead author Hooman Azad, MD, MPH, a fourth-year resident in the Department of Obstetrics & Gynecology at New York’s Columbia University Irving Medical Center.

Azad and colleagues carried out the most comprehensive review of maternal deaths. They reviewed CDC data from 2005 to 2022, while previous studies looked at either state-level data or data from multiple databases, which can be inconsistent.

Over this period, there were 20,421 pregnant deaths. Out of those, 11% were due to homicide and suicide. Specifically, 6.6% were homicides and 4.4% were suicides. Over half of these involved firearms.

This rate is much, much higher than for non-pregnant women. Researchers suggest that, in light of this, violent fatalities should also be considered in the maternal mortality rate.

“Right now, the definition of maternal mortality does not include death by homicide. I’m not sure this is correct — being pregnant or postpartum significantly increases the risk of death by homicide, and more pregnant women die of violence than any individual medical cause. Part of the reason violence is not recognized as the leading cause of death during pregnancy is because we don’t include homicide and suicide in the definition of maternal mortality.”

Big racial disparities

Like many health crises in the US, this issue disproportionately affects Black women. The study found that young Black mothers (ages 18-24) experience homicide at nearly four times the national average.

Another big disparity came with gun legislation. States that enacted firearm legislation had a 20-30% reduction in maternal firearm deaths. This is unsurprising and goes in line with previous research showing that firearm legislation reduces homicides and suicides.

Ultimately, this is yet another health crisis flying right in front of our faces, yet it remains largely overlooked in policy discussions and public awareness.

“There’s a misconception that most maternal deaths happen in hospitals or healthcare settings, and that’s simply not the case,” says another study author Mary D’Alton, MD, from the Columbia University Irving Medical Center. D’Alton also serves as director of services at the Sloane Hospital for Women at New York-Presbyterian. “We need more education about this serious national issue so we can begin to take steps to address it as clinicians as well as at the policy level.”

The abstract was published in the January 2025 issue of Pregnancy.