Guns, Drugs, and Despair: New Data, New Perspectives on Maternal Death Risks

The leading threat to a pregnant woman’s life in America is not a hemorrhage in the delivery room or a clot in her blood. It is a bullet, an overdose, or her own hand.A study published this year in the New England Journal of Medicine has upended one of the most foundational assumptions in obstetric medicine. Researchers at Columbia University Irving Medical Center analyzed all deaths among pregnant and postpartum women in the United States from 2018 to 2023, identifying 7,901 deaths across the six years.Unintentional drug overdose and violence — homicide and suicide combined — now account for more than one-fourth of all maternal deaths in the country, nearly equaling the combined toll of cardiovascular disease, infection, hypertension, and hemorrhage.Drug overdose was the single leading cause of maternal death, claiming 1,152 lives at a rate of 5.2 deaths per 100,000 live births. Violence — homicide or suicide by any means — accounted for 866 deaths at a rate of 3.9 per 100,000. Of those, homicide claimed 593 lives; suicide, 273.“The NEJM piece builds on data that has been well studied and well known in the field for years,” Director of Communications at the Society for Maternal-Fetal Medicine Greg Phillips tells the New York Sun. “The nation’s high rates of maternal death are driven, in part, by mental health issues and injury deaths, including suicide and homicide.”So, why has it taken this long for America to reckon with the fact that the most dangerous moment in a mother’s life may not be on the delivery table, but in the months after she leaves it?Exclusion By DefinitionThe classic framework taught in medical, public health, and obstetrical training has long held that the leading causes of maternal death in the United States are cardiovascular disease, hypertension, hemorrhage, and infection. That framework now appears incomplete.Part of the problem, researchers argue, is by design. The official definition of maternal mortality — drawn from the World Health Organization and used by the CDC’s National Center for Health Statistics — explicitly excludes deaths caused by intentional and unintentional injury, poisoning, and drug overdose. Under that definition, a woman who dies by suicide while suffering from postpartum depression does not count as a maternal death. Violence is not an anomaly being missed; it is a category being excluded.Lead study author Dr. Hooman Azad of Columbia University told the Society for Maternal-Fetal Medicine: “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.”Behind the homicides, one factor is nearly constant. Of 637 maternal homicides identified across 47 states from 2018 to 2022, firearms accounted for 78 percent of deaths, and 51 percent were linked to intimate partner violence.A separate study by researchers at Harvard Medical School and Boston Children’s Hospital, published in JAMA Network Open in November 2025, found that from 2018 to 2021, pregnant women experienced a 37 percent higher firearm homicide rate than nonpregnant women, and that for every one percent increase in state-level firearm ownership, firearm homicides of pregnant women rose by 8 percent.New Tracking, New DataA key turning point in understanding the full scope of the categorial problem came through a seemingly mundane bureaucratic change.“It was not until 2017 that all states in the United States had adopted the current version of the death certificate,” Professor of Public Health at the University of Texas at San Antonio Jeffrey Howard tells the Sun.“This is important because it was … this revised version that made it possible to track deaths of mothers who died from causes other than obstetric causes,” he explains. “The change was called the pregnancy checkbox, and it created a mechanism to identify women who died while pregnant or within one year of delivery.”Before universal adoption of that checkbox — first introduced in the 2003 revision of the United States Standard Certificate of Death — there was no reliable national system for flagging whether a woman who died of a gunshot wound, an overdose, or suicide had recently given birth.The data collection itself is also relatively new.“The CDC and others have not been analyzing this data for all that long,” Adrienne Griffen, the executive director of the Maternal Mental Health Leadership Alliance, tells the Sun. “It’s really just been the last ten years or so that they’ve gotten better at collecting the data.”The most recent data from the CDC’s state-based Maternal Mortality Review Committees, considered the gold standard precisely because they review deaths for the full year postpartum and include violent deaths, reinforces the NEJM findings.According to that data, mental health conditions are now the underlying cause of 27.7 percent of pregnancy-related deaths, up from 23 percent in the prior reporting period. Of those deaths, 45 percent were determined to be suicides, and 51 percent were overdoses or poisoning. Significantly, 37.8 percent of all pregnancy-associated deaths occur late in the postpartum year, between 43 and 365 days after delivery — a window that standard maternal mortality definitions entirely miss.A System That Wasn’t Built for ThisThe conventional prenatal care model — blood pressure checks, glucose tests, fetal monitoring — was designed to manage the medical complications of pregnancy. It was not constructed to detect a woman being beaten at home, identify opioid dependency, or flag suicidal ideation in a postpartum patient with no mental health referral pathway.Less than 20 percent of women are currently screened for maternal mental health disorders, despite those conditions driving an enormous share of these deaths. More than 80 percent of maternal deaths in the United States are preventable, including the more than one in four maternal fatalities attributable to mental health disorders.These deaths are not a new phenomenon — what is new is the willingness to count them. “Homicide, suicide, and overdose have been leading causes of death among pregnant and postpartum women for many, many years,” Associate Professor at the University of Arizona College of Public Health Maeve Wallace tells the Sun. “There is research dating back at least two decades that finds that those violent causes of death exceed mortality due to the leading obstetric causes of death.”The gap between what the system was designed to catch and what is actually killing women has never been more apparent.“Our maternal health system has historically been designed around clinical complications that occur in hospitals or shortly after delivery,” perinatal epidemiologist and assistant professor at Penn State College of Medicine Kristin Sznajder tells the Sun. “That framework misses deaths rooted in behavioral health conditions, substance use, and violence.”A critical step, Dr. Sznajder argues, would be “strengthening prenatal and postpartum care as a coordinated support system that meaningfully connects women to behavioral healthcare, substance use treatment, and violence prevention resources, and ongoing support across the perinatal period.”That requires changes that go well beyond the exam room, including some that remain politically contentious.“The most important changes are those that occur outside the clinic and address the larger problems of gun violence and substance use,” physician and epidemiologist Jay Varma tells the Sun. “Physicians can make a difference by counseling patients about substance use and ensuring they get treated. Even though it is controversial in some states, physicians are also legally allowed to counsel patients about firearm safety, especially reminding them that guns should be stored unloaded and separate from ammunition.”Between 2016 and 2023, mothers reported a nearly 64 percent increase in fair-to-poor mental health — a trend that, according to a Columbia University study published in JAMA Internal Medicine, began years before the pandemic and cuts across nearly every socioeconomic group. The infrastructure to meet that demand has not kept pace.The consulting room itself is an underused intervention point.“You’re at your obstetrician’s office every month, then every two weeks — you’re a captive audience,” Ms. Griffen explains. “We should be talking to you every single time: ‘How are you doing?’ We need to shift more of the responsibility onto providers to normalize it. And we need more resources.”The scale of the problem, experts stress, demands a response that matches it. “I believe the problem is societal in scope and prenatal and postpartum care alone will not resolve these issues,” Dr. Howard says. “We have to understand the factors contributing to violence and drug use better.”For those who have spent careers trying to shift that reality, there is both frustration at how long it has taken and cautious hope about where the field is heading.“If we really wanted to do better, this should start in medical school,” says Ms. Griffen. “Everybody should be trained on mental health conditions in general. And if you’re going into obstetrics or pediatrics or psychiatry or family practice, you should have specific training on maternal mental health conditions. “In another 20 years, this will hopefully be like gestational diabetes — every mother is screened, everybody knows what to do, there’s no question. It’s just part of obstetric care.”

Guns, Drugs, and Despair: New Data, New Perspectives on Maternal Death Risks

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