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."

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