Maternity health care in the United States is in a dire place, as outlined by a string of recent studies and reports.

An analysis published this month found one-third of the nation's counties do not have access to a hospital or birth center that offers obstetric care – essentially making these regions maternity care 'deserts'.

Meanwhile, the US Centers for Disease Control and Prevention (CDC) report more than 4 out of 5 women who died during pregnancy, or shortly thereafter, could have been saved with proper health care, according to data collected between 2017 and 2019.

Earlier this year, the CDC also reported that Black people are three times more likely to die from a pregnancy-related cause than White people – with variation in the quality of healthcare they receive, structural racism, implicit bias, and underlying chronic conditions contributing to the stark disparities.

Now, two epidemiologists from Harvard University T. H. Chan School of Public Health and Massachusetts General Hospital in Boston are highlighting an even larger cause of maternal death in the US, one that is shockingly overlooked.

In a recent editorial for the BMJ, Rebecca Lawn and Karestan Koenen point out that pregnant people and new mothers are more likely to be murdered than they are to die of pregnancy-related complications such as hypertensive disorders, hemorrhage, or sepsis – the three leading obstetric causes of maternal deaths.

These findings were initially published in Obstetrics & Gynecology in 2021, but given the recent media attention regarding the US maternal health system, Lawn and Koenen think the statistics are worth emphasizing again.

In 2022, another group of researchers found that most pregnancy-associated homicides (those which occurred during pregnancy or within one year of birth) were linked to intimate partner violence and firearms.

In the US between 2008 and 2019, firearms were used in 68 percent of pregnancy-related homicides, the nationwide data analysis showed.

"Preventing men's violence towards women, including gun violence, could save the lives of hundreds of women and their unborn children in the US every year," write Lawn and Koenen.

Violence against women is a global issue, but in the US, the availability of firearms appears to have made the problem much worse. Lawn and Koenen call it a "health emergency for pregnant women."

The two epidemiologists argue that more restrictions on firearms and better regulation of firearms are desperately needed to protect those who are pregnant. While the editorial does not acknowledge that transgender men and non-binary people can also become pregnant, violence against these groups occurs at staggering rates.

The recent and rapid unraveling of abortion care in many states of the US will, in all likelihood, make pregnancy-related homicide worse, the authors predict.

In abusive relationships, they explain, unintended or unwanted pregnancies have the potential to exacerbate the risk of homicide.

Black women are already three times more likely to be killed by a partner during or shortly after pregnancy compared to White or Hispanic women, and they are also more likely to suffer from restricted access to abortion services. Together, these two risk factors could prove extremely dangerous.

Trans people in the US also have relatively few options for terminating a pregnancy compared to other cohorts, due to a range of social, financial, and systemic factors.

"Research to identify risk factors for homicide in pregnancy is critical to prevention," the editorial argues.

"However, better quality data are needed for further analyses: recent studies have been limited by large amounts of missing data on the pregnancy status of women who have been killed. Detail on relationships and patterns of abuse leading to homicide during pregnancy and in the postpartum period is also minimal in large datasets."

As mounting evidence shows, pregnancy-associated homicide is one of the most preventable causes of maternal death in the US. It's high time it was taken seriously.

The editorial was published in the BMJ.