Nearly 15 years ago, as 20-year-old Emily Likins-Ehlers was navigating their entry into adulthood, they became pregnant by an abusive partner. It thrust Likins-Ehlers, whose pronouns are they/them, into what may have been one of the most dangerous points of their life, a period when birthing people are at high risk of violence, which can often become deadly. Homicide is among the leading causes of death among pregnant and postpartum people, surpassing obstetric-related causes such as sepsis or hemorrhaging.
But research shows that, although Likins-Ehlers was in a dangerous situation, they were also at one of the most critical moments for preventing this type of death.
As I reported in a feature story published last month, the firearm is at the core of the maternal homicide crisis; it is used in the majority of these violent deaths, often at the hands of intimate partners. Also at the center are Black women and young women, who are disproportionately likely to be victims. In my story, I shared the accounts of some of these women and their surviving families. Over the course of my reporting, there was one theme that I heard from epidemiologists, physicians, maternal care providers, and mothers: These deaths were preventable.
Strategies aimed at prevention include efforts to adjust how the health care system treats pregnancy care and patients, and more upstream issues, like addressing financial inequity or shifting cultural norms of abuse in childhood. Likins-Ehlers’ experience with pregnancy and reproductive justice inspired them to pursue another avenue: After ultimately deciding that their safest option was to have an abortion, as the risk of being tied to an abusive partner was too high, they became a doula, a type of pregnancy support worker that often works with people directly in their homes.
“I have a unique perspective on people’s families because I come into their homes and observe them in times when people aren’t normally observed, and notice where there are potential red flags and power imbalances,” said Likins-Ehlers, who now works in the Chicago area. “I’m more of a near-peer for most people than a provider would be and I’m not an authority figure, I’m more of a friend, so people tell me things that they would never tell, you know, a doctor or a nurse.”
One of the prevention strategies I heard about most frequently was intimate partner violence screenings by health care practitioners. Jacquelyn Campbell, a nursing professor at Johns Hopkins, was behind one of the first tools to help look for this type of risk. In 1985, Campbell introduced the Danger Assessment, a survey that inquired about factors like whether an abusive partner had a gun or a job. This type of tool was presented at a time when the American public was just beginning to understand the scope of intimate partner violence and retrospective studies showed the beginning of the increase in pregnancy-related homicides.
“The Danger Assessment was created with the help of abused women, to help women in those situations know if there is a high risk for homicide so they can use that information as they decide what to do moving forward,” Campbell told me. She further explained that intimate partner violence has been a long-standing issue that “we haven’t been entirely successful at [preventing]. We used the criminal justice approach which needed reform, but that was not enough, and the future iterations of things like the Violence Against Women Act started to include the health care system.”
Still, screening pregnant and post-partum patients for intimate partner violence has yet to be widely implemented. Research has found that nearly half of the women who experience intimate partner violence while pregnant or after giving birth are not screened for it. The results of the increased screening are promising, but there are still conversations about what uniform screening should look like.
Campbell said assessing violence or risk of violence should be a routine, confidential process with a health care provider who a patient has established a relationship with, which can exist without the fear that government agencies such as Child Protective Services will get involved.
“It’s important to ensure that this process is confidential and that we are not going to tell anybody that she doesn’t want to know. Our reason for asking is to help her get to whatever resources she needs or wants and that could be a social worker or someone else in the health care system,” Campbell said.
The published literature has suggested that physicians play a key role in screening efforts because pregnancy is a time when pregnant people should be coming into more frequent contact with the health care system. But experts say that there will have to be a shift in current practices to make that work.
“As health care providers, we are supposed to screen for intimate partner violence at least at the first prenatal visit and then throughout pregnancy when appropriate, but I do not know if we do the best job at this because as providers, we are uncomfortable with what we can provide them if that answer is yes,” said Dr. Veronica Gillispie-Bell, an OBGYN in Louisiana who has studied pregnancy-related violence. “All health care providers, not just OBGYNs, should be screening for intimate partner violence when they are noticing signs of physical trauma, and offering solutions like helping patients develop an escape plan or connecting them with community health workers and violence-based organizations.”
Gillispie-Bell emphasized, however, that a strategy rooted in assessment will take a communal-based approach to work.
“I’m a big proponent of doulas and midwives,” she said, “and for individuals being able to disclose things that they may not feel comfortable disclosing to me as the physician.”
Likins-Ehlers agrees. The relationship that a doula or midwife may have with pregnant and postpartum people can be more familiar than that of a physician. Research, particularly in Europe, has explored the role that these birthing agents could have in addressing intimate partner violence; compared to similar-income countries that have a more communal approach to birthing, the United States has the highest rate of pregnancy-related homicides. Doulas are trained to provide emotional and physical support; midwives are health care professionals who are additionally trained to deliver babies and provide prenatal care. Although they differ, both professions can work in or out of hospital settings, and both have been found to prevent maternal deaths from sepsis or hypertensive disorders.
If you have economic instability, you have difficulty with transportation, childcare, and maintaining a healthy diet, and you are more likely to be exposed to violence.
But outside of the health care system, experts say strategies that address systemic issues like sexism or financial inequity are also a part of the solution. These studies explore the ways that pregnancy is a unique period for violence, which could be exacerbated by the emotional and financial responsibilities of bringing a child into the world.
“On the Danger Assessment, unemployment is a risk factor for abuse escalating to homicide, so the flip side of that is providing and placing abusers with jobs,” said Campbell, the nurse who created one of the first assessments for domestic violence homicide.
Taking care of an infant can cost nearly $15,000 annually. States with greater income inequity have higher rates of perinatal homicides than states with more income equity. Scholars and physicians also note that financial pressures may connect to the reason why disproportionately Black and young women are at the highest risk for this type of violence. Some of the largest financial divides exist among young people and Black Americans.
“There are things that we need to think about from a systems and public policy standpoint to address the amount of violence that we see in Black and brown neighborhoods,” Gillispie-Bell said. “The federal minimum wage, which is $7.25, should be raised … because if you have economic instability, you have difficulty with transportation, childcare, and maintaining a healthy diet, and you are more likely to be exposed to violence.”
But those at the forefront of this work caution that expansion efforts should be centered around the needs of people at risk. Efforts like expanding Medicaid, which could make doula care more accessible, could also make it mandatory for doulas to report violence to agencies like Child Protective Services, which have proven not to be the most helpful.
“If we had a health care system in general that put people before profits, we would immediately see an improvement in all of this,” Likins-Ehlers said. “Also, if we had more female physicians and more Black women physicians, we would see more interventions on things like domestic violence, and overall better health outcomes for everyone, but that is also one of those complex issues that start at birth and what zip code that you are born into.”
There’s still more research — like studies focused on firearms and firearm access — needed to better understand how to prevent these deaths; that work is forthcoming. Research is also beginning to be published on the role that access to reproductive rights has on the rate of these homicides, a key aspect of the crisis in the wake of the 2022 Dobbs ruling which overturned Roe v. Wade.
For Campbell, who has been working to address intimate partner violence in a health-focused approach for more than 40 years, it isn’t just more research that’s needed. Addressing the crisis also needs stronger messaging.
“We have to be really careful of messaging around demonizing men or framing that abusers are terrible people incapable of change because that’s not true,” Campbell said. “The root causes of violence, whether against partners or anybody, we haven’t quite figured out yet.”
Funding Disclosure: This story was produced as a project for the USC Annenberg Center for Health Journalism’s 2024 National Fellowship, through the Dennis A. Hunt Fund for Health Journalism.
