Murder most foul

Medical researchers now believe that homicide, not medical complications, is the leading cause of pregnancy-associated death.

Published February 27, 2003 8:26PM (EST)

Laci Peterson was due to give birth to a baby boy -- her first child -- this month. Instead, the 27-year-old Modesto mother-to-be is presumed dead. Her body is missing; her husband, though not an official suspect in his wife's disappearance, is under intense scrutiny by detectives in the case. Weary volunteers, scouring land and water since Peterson's disappearance Christmas Eve, focused on the New Melones Reservoir last weekend. Police searched the Peterson home for the second time early last week, removing several bags of evidence. Any hope that Laci and her baby are alive has nearly evaporated. "When we're looking in places under water, we're looking for a body," reported Police Chief Roy Wasden.

There's much for a woman to fear when she's pregnant -- the "What to Expect When You're Expecting" books gingerly spell out the many medical hazards in chapters too frightening for some women to read: preeclampsia, miscarriage, stillbirth, stroke and hemorrhage are complications that American women, many of whom enjoy some of the best prenatal care in the world, are familiar with.

But what the pregnancy manuals don't mention is a chilling fact that has been buried in death statistics for many years: Murder is now believed to be responsible for more pregnancy-associated deaths in this country than any other single cause, including medical complications such as embolism or hemorrhaging.

For decades, the medical community has limited its definition of "pregnancy-related death" to fatal medical complications, and law enforcement has followed suit, failing to collect separate data on whether female homicide victims were pregnant. The absence of murder as a category of pregnancy-related -- or more accurately, pregnancy-associated death -- left a void where a significant medical and social concern had been brewing for years.

"We aren't doing a good job yet of surveillance of pregnancy-associated deaths," says Dr. Cara Krulewitch, an epidemiologist at the University of Maryland in Baltimore, who was among the first researchers to find a link between pregnancy and homicide. "The system isn't in place because pregnant women are supposed to be healthy.

"We don't expect them to die -- or be killed," she says, "but it's beginning to change -- there's a sense that the number of deaths may be significantly higher -- with a frightening number caused by homicide."

And as the numbers of pregnant women murdered every year are revealed, so, too, are their murderers. Homicide is the fourth leading cause of death among all American women of childbearing age; and one-third of all female murder victims each year are killed by an intimate partner. As pioneering medical researchers reexamine death reports of murdered women, looking for signs that the victim was pregnant, they are concluding that often, the killer of a pregnant woman is the partner or spouse of the mother-to-be.

"Why are pregnant women dying?" asks Rebecca Whiteman of the Family Violence Protection Fund in San Francisco. "Their partners are killing them."

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Historically, deaths defined as "pregnancy-related" were deaths caused by a medical complication of pregnancy, or deaths that occurred when pregnancy aggravated an existing health problem. Traumatic deaths of pregnant women -- deaths due to injury, accident or violence -- have generally not been systematically collected or examined. The result is an almost complete lack of accurate national statistics about the number of pregnant women murdered or the circumstances of their deaths. In the absence of those numbers, researchers have begun to compile data, often on a state-by-state basis, by recovering and then scrutinizing old death records and murder reports.

Cara Krulewitch, who is also a nurse and midwife, suspected for years that pregnancy-associated deaths -- a phrase that, unlike "pregnancy-related," includes deaths associated not just with medical complications in pregnancy but with trauma, including murder -- were underreported. In an initial study in the Journal of Midwifery and Women's Health, she took a look at death records in Washington, D.C., over an eight-year span. She was shocked by her discovery that 14 of 35, or 38 percent, of pregnant women who died in Washington from 1988 to 1996 were victims of homicide.

She also found that, during that same period, the Washington Center for Health Statistics reported only 21 of those pregnancy-related deaths, those who died from medical causes. The 13 homicide victims that Krulewitch found were reported simply as murder victims. Their pregnancy status wasn't noted on their death certificates.

"I was stunned by what I saw," says Krulewitch.

In a 2001 study published in the Journal of the American Medical Association, researchers in the Maryland Department of Health and Mental Hygiene found that between 1993 and 1998, homicide was responsible for more pregnancy-associated deaths in Maryland than any single medical cause, accounting for 20 percent of all pregnancy-associated deaths. Homicide accounted for twice as many deaths as the most common medical cause -- embolism.

More recently, in a study to be published in May in Child Maltreatment, a journal of the American Professional Society on the Abuse of Children, Krulewitch also focused on Maryland, attempting to calculate the risk for pregnant women in that state of being murdered during, or in the year after, a pregnancy. Looking at all female victims of murder in Maryland between 1994 and 1998, Krulewitch found that pregnant women were disproportionately represented. Comparing the percentage of women in the total female population who were pregnant to the percentage of murder victims who were pregnant, Krulewitch found that pregnant women were twice as likely to be murdered as non-pregnant women of the same age.

A 2002 study in the Journal of the American Medical Women's Association also found that homicide was the leading cause of pregnancy-associated deaths in Massachusetts from 1990 to 1999. They also determined that the rate of pregnancy-associated deaths -- not necessarily homicides -- was at least three times higher for African-American women, and all women younger than 25 and between the ages of 40 to 44.

In a similar study, researchers at Winston-Salem's Wake Forest University School of Medicine found that of 167 pregnancy-associated deaths in North Carolina from 1992 to 1994, 22 (13 percent) were a result of homicide. Women who accounted for half of the injury-related maternal deaths -- not necessarily homicides -- were known to have been abused or were suspected of being abused by either an intimate partner or an acquaintance. The study also indicated that more than one-fourth of them (26.8 percent) were known to have abused drugs and/or alcohol.

Other studies have found that trauma is the leading cause of death of pregnant women and that most trauma deaths -- defined as injury, accident or violence -- are due to murder. Researchers from Johns Hopkins University School of Hygiene and Public Health examined death certificates from the New York City Medical Examiner's Office, and found that among pregnant women who died of trauma in New York City from 1987 to 1991, 63 percent were murdered. Researchers there concluded that "homicide and other injuries are major contributors to maternal mortality and should be (but rarely are) included routinely in maternal mortality surveillance systems."

And figures collected from Chicago's Cook County Medical Examiner's Office revealed that 57 percent of pregnant women who died of trauma from 1986 to 1989 were murdered. A fourth of those women were shot to death, 13 percent were stabbed, and 13 percent were strangled. Suicide accounted for 9 percent of the trauma deaths.

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Even in the realm of heinous crimes, it's hard to imagine an act more horrifying than the killing of a pregnant woman. That the killer of a woman carrying a child is likely to be her intimate partner, perhaps the father of the child, is somehow even harder to accept -- except for those familiar with the nature of domestic violence in this country. Attacks on pregnant women, even those that result in death, are "sadly, not surprising, given the history of domestic violence," says Dr. Jeffrey Edelson, a professor at the University of Minnesota and a national expert on domestic violence.

Juley Fulcher, policy director for the National Coalition Against Domestic Violence in Washington and an attorney who used to represent battered women in court, many of them pregnant, agrees. "I can't tell you how many times those women were beaten while their abuser would say things like, 'I'm going to kick that baby out of you,'" she recalls.

Fulcher believes that hurting the fetus is the most effective way for a batterer to "get to" his wife or girlfriend. "It's what she cares about the most, and that's what abusers focus on," she says. "They are so obsessed with control and power that they will do anything. It's extraordinarily common for men to threaten to hurt or kill a woman's pets, or threaten or hurt the children."

Edelson believes that stress brought on by the pregnancy itself -- such as anxiety over finances -- can lead to increased violence. Or, he says, it may be triggered by simple jealousy. "Suddenly, attention is focused on the woman, and she may pay less attention to the man," he says. "Perhaps she's tired and doesn't make the kinds of dinner he likes, perhaps she doesn't want to have sex."

A pregnancy also tends to deprive abusers of the isolation they count on to be able to control and hurt their partners with impunity. Pregnant women have to leave the house often for checkups. "This can be threatening to an abusive spouse who may feel he's losing control over the situation and that his actions may come to light during an examination," said Lisa James of the Family Violence Prevention Fund.

Reflected in general research on abuse are indications that domestic violence is a frequent and increasingly common cause of maternal injury. Many women who experience violence during pregnancy have a history of reported abuse before pregnancy, though battery often begins -- or intensifies -- during pregnancy, experts say. James says pregnancy is often the point at which the emotionally or verbally abusive partner escalates to physical violence. Experts say once a victim is pregnant, beatings tend to change from general body blows to target the face and abdomen.

Sherrie, who asked that her last name not be used, was abused by a 17-year-old boyfriend who beat her badly while she was pregnant.

"I was young. I had zero experience. I didn't have anyone to talk to," she says. "I got caught up in everything he said -- that I was worthless, that no one else was going to like me. It was confusing. I kept trying to figure out what was going on in my head," says Sherrie, who now helps counsel victims of domestic violence.

"It got worse during the pregnancy. There was a point I really wanted to leave him."

But when Sherrie, 18 at the time and four months pregnant, left her boyfriend, he began to stalk her. He finally confronted her at a supermarket in their small Northern California hometown, and they argued as she shopped for groceries. Suddenly, he picked up a heavy bag of potatoes and slammed her in the back, knocking her to the floor.

"Everybody around us stopped and stared, but nobody helped me," recalled Sherrie. "I thought, 'Gosh, I'm in this alone."

She fled to her car, but her boyfriend wrestled the keys from her, grabbed her by the throat and lifted her off the ground. "My feet were dangling in the air," she says. "People watched us in the parking lot but no one helped. He threw me in the back of the car and drove off. He was crying and apologizing for hitting me. He said he didn't want me to leave."

He parked outside his parents' home, and disabled the engine so Sherrie couldn't drive off. But she fled on foot to a gas station, where an attendant hid her and called police.

Her boyfriend was initially charged with kidnapping and assault and served half of a three-year sentence. They continued to talk and see each other, but Sherrie's pregnancy and the birth of their daughter was the beginning of the end of their relationship. "I wanted to take care of her." Eventually, she decided, "This is what happened to me. It's not going to happen again."

There has been no public indication that Scott Peterson abused Laci Peterson. On the contrary, her family initially reported that Laci was happy in her marriage and thrilled at the prospect of adding a child to the family. But a month after his wife disappeared, Scott -- who says he was fishing the day Laci vanished -- admitted he was having an affair with a local woman at the time his wife vanished. Last month he sold off Laci's Land Rover, and referred to his wife in the past tense -- then quickly corrected himself -- in an ABC interview with Diane Sawyer.

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Researchers like Krulewitch, as well as domestic violence experts and activists, believe that the discovery and analysis of the homicide-pregnancy link through statistics could bring a new awareness in the medical community about the cause of death and injury associated with pregnancy. Up until now, medical literature has focused almost exclusively on medical complications related to pregnancy, such as high blood pressure and toxemia, that could be fatal.

In an editorial accompanying a recent study on the pregnancy-homicide link, Victoria Frye of the Center of Gender and Health Equity points out that traditionally ignored "social causes" as well as medical causes of maternal death provide important clues to solving pregnancy problems. She concludes: "Pregnancy-associated death represents a largely preventable source of premature mortality among young women in the United States and devastates the children, families, and communities left behind."

Many states already have begun to acknowledge the high incidence of murder in pregnancy-associated deaths by including a place on death certificates to indicate that the deceased was pregnant. It is meant to provide a way to more easily track the number of pregnant women murdered each year, but domestic violence experts say the paperwork is often ignored. Meanwhile, the FBI still doesn't isolate the number of pregnant women from the total number of homicide victims listed in annual crime statistics.

Besides pushing for data collection that accurately reflects the number of pregnant women murdered every year, domestic abuse organizations are asking for routine medical screening to help stem the tide of violence against pregnant women. "We find that violence represents more of a threat to pregnant women than diabetes, yet doctors screen routinely for diabetes, but not for abuse," said James.

The Centers for Disease Control and the American College of Obstetricians and Gynecologists also are pushing for increased screening, but Whiteman said in some cases it's a battle.

"There's too often this disconnect between medicine and behavior," says Whiteman. "You have a doctor who says, 'I'm an internist, I don't do that behavioral stuff.' But it's a key aspect of health."

Domestic abuse organizations are scrupulously avoiding any tactic that would establish or increase penalties for intentional harm to a fetus. Such a law played a role in the case of former NFL player Rae Carruth, who was convicted of hiring a hit man to kill his pregnant girlfriend in 1999 so he wouldn't have to pay child support. Cherica Adams, 24, was shot four times and died a month later. Her baby boy, Chancellor, survived the attack and is being raised by Adams' mother, who testified at Carruth's trial that Chancellor is developmentally disabled because of the shooting. Carruth was sentenced to 19 years in prison. A 10-month portion of the sentence was attributed to a finding that Carruth used "an instrument in attempting to harm an unborn child."

Such laws, domestic violence experts worry, can too easily be turned against the women they're supposed to protect, shifting focus from a mother to a fetus, and creating precedent for antiabortion laws in other areas.

"These laws tend to be promulgated by anti-abortionists that can easily do more harm than good," says Fulcher. Edelson calls the laws "cynical."

"The problem is we aren't doing enough adult to adult," he says. "The woman alone apparently isn't reason enough to prosecute. But if we protect the woman, the baby she's carrying is protected."

Ultimately, and sadly, the link between pregnancy and homicide is just one aspect -- perhaps the most frightening -- of domestic abuse in this country. An estimated 1,500 to 2,400 young women are killed each year by their intimate partners. Every 15 seconds in this country a woman is physically assaulted by her husband, boyfriend, or live-in partner, according to statistics from the U.S. Department of Justice. The agency also estimates that approximately 2.5 million women are abused annually, with as many as 50 percent of all women experiencing at least one episode of battering during their lifetime.

"There's all this talk about terrorism," says Whiteman of the Family Violence Protection Fund in San Francisco. "What people don't know or want to forget about is the violence in our own neighborhoods, in our homes."

This story has been corrected.

By Mary Papenfuss

Mary Papenfuss is a writer and editor in Paris.

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