America’s hidden firearm epidemic
India Kinamore should have been welcoming a new life into the world. At 26, she was nine months pregnant and due to give birth that very day. Instead, she was shot and killed by the father of her unborn child.
Eina Kwon was eight months pregnant with her second child when she was sitting in her car, and a stranger shot her. She and her unborn daughter both died.
India and Eina are only two examples of the hundreds of American women each year who are killed by homicide, primarily by firearms, before they give birth to their babies. Their deaths are noted, tallied and then subsumed into the quiet arithmetic of a crisis of firearm homicide during pregnancy that the United States has refused to name. Pregnancy is a time that society imagines to be protected; we’re supposed to stand up on the subway to let a pregnant woman rest her feet. Yet for many women, it is a period of heightened vulnerability to violence.
Pregnancy is widely understood as a primarily medical risk, one that modern health care systems are designed to manage — but not as a social risk. But violence (including homicide and suicide) and drug overdoses have now outpaced traditional medical causes of maternal mortality. And firearms are used in nearly 4 out of 5 homicides occurring during pregnancy. Because many of the pregnancy-related health risks and causes of death — including homicide, suicide and other violence-related harms — do not end with delivery, researchers often consider the full year after childbirth to capture risks that persist into the postpartum period. Research often uses “pregnancy” to encompass both periods.
There are several reasons why pregnancy may act as a risk factor for gun violence. Here we use the medical definition of pregnancy, which includes the time period of pregnancy, delivery and up to one year after birth. A substantial proportion of pregnancy-associated homicides occur in the context of intimate partner violence, which is also more common in pregnancy than conditions like preeclampsia or gestational diabetes. This is because for some women, pregnancy intensifies existing vulnerabilities, including increasing contact with partners or family members that heightens the risk of domestic violence. This may include financial dependence on the partner or conflict around the pregnancy itself. At the same time, it can be more difficult to leave unsafe environments when expecting a baby. And in the United States, where firearms are widely accessible, when a gun is present in an abusive relationship, the risk of a woman being killed increases fivefold.
So this is the paradox: In one of the most medically advanced countries in the world, pregnancy itself is associated with an increased risk of violent death among women, something advanced medical care can’t address. As a result, more U.S. women die during pregnancy (including the year postpartum) from violence than from bleeding, hypertension or infection. While policymakers debate maternal health in terms of access to prenatal care, hospital quality or postpartum support, bullets threaten maternal well-being as much as biology.
The numbers are stark.
Recent research suggests that, in the United States, pregnant or postpartum women are 35% more likely to be killed by firearms than women who are not pregnant. From 2018 to 2021, more than 400 pregnant or postpartum women were killed across 37 states — roughly 1 death every 4 days. During this time period, pregnancy-associated homicide rates rose in parallel with broader increases in firearm violence. More recent national data suggest that rates of violence, including homicide, have not meaningfully declined in the years since, underscoring the persistence of this risk.
The United States stands apart from peer countries. Globally, maternal deaths are most often from medical causes, such as obstetric complications. The United States is alone in our combination of high maternal mortality and high rates of firearm ownership, which are associated with increased rates of firearm homicide.
Who you are and where you live matters.
The burden of pregnancy-associated homicides falls hardest on young women 20-24 years old, with important disparities by race. Black women comprise 14% of women of childbearing age, but account for over 50% of pregnancy-associated firearm homicides. This disparity reflects broader structural conditions including economic marginalization, housing instability and higher exposure to community violence. Taken together, these systemic inequities increase the risks of violence and death for Black women during pregnancy.
Geography also plays a critical role. State-level variation in pregnancy-associated firearm homicide rates is staggering, with more than a tenfold difference between some states. These differences are unlikely to be random and instead likely reflect underlying differences in state context and policy priorities. States with higher firearm ownership are associated with higher rates of pregnancy-associated firearm homicide, while those with stronger protections against domestic violence are associated with lower rates. States that restrict reproductive health access are also correlated with higher rates of pregnancy-associated homicide, reflecting overlapping forms of vulnerability. For example, Louisiana, which has one of the highest firearm ownership rates and the most restrictive reproductive health access laws, also has the highest rate of pregnancy-associated firearm homicide. In other words, this is not simply a national problem but rather a reflection of individual state priorities.
Pregnancy is mainly thought of as a biological condition. In the United States, it is also a social one shaped by policy and by power. A Black woman in her 20s in Mississippi or Louisiana is not only more likely to die in childbirth from medical causes than her white peer in Massachusetts, she is also far more likely to be shot and killed while pregnant. These tragedies are often described as “unthinkable,” yet they are neither isolated nor unforeseeable; they are the predictable result of gaps in policy and enforcement.
Prevention will require policy, providers and public investment.
If homicide is the leading cause of death in pregnant and postpartum women, why does it remain almost invisible in the maternal health conversation? Part of the answer is in how the problem is framed. Mortality in pregnant and postpartum women is typically understood as a medical issue, solvable with better monitoring, earlier detection and improved clinical care. Violence, by contrast, is often treated as separate from health rather than as a core driver of mortality.
There are also systemic failures in how these deaths are counted. Maternal mortality data systems are fragmented and incomplete, pregnancy status is missed and firearm involvement is underreported. Without complete and reliable data, there is little accountability; without accountability, there is little urgency. Responsibility spans multiple systems: policymakers who set and enforce firearm laws and allocate community resources, public health agencies that track maternal deaths and health care systems that are often the first, and sometimes only, point of contact for women at risk.
We can help prevent these deaths if we’re honest about the challenge ahead.
Laws matter. Laws restricting firearm access for individuals subject to domestic violence restraining orders and those that ensure stronger background checks are associated with lower rates of firearm violence. However, these laws are unevenly implemented and often poorly enforced. In practice, this means that individuals known to pose a risk often gain or retain access to firearms during periods of heightened vulnerability of their partners.
Health care has a role to play. Routine screening for intimate partner violence can be incorporated into prenatal and postpartum care, creating opportunities to identify risk early. And screening should be paired with immediate access to support services, including social work, safety planning and referrals to community-based resources. Clinicians can counsel women and their partners on secure storage or temporary removal of firearms during periods of heightened risk. These interventions should not be about placing the burden on women to protect themselves but about using the health care system as a point of intervention.
Communities need investment. The risk of violence is shaped by the neighborhoods in which people live. Investments in safe housing, economic stability and community-based violence prevention programs can reduce exposure to violence before it escalates.
A maternal health crisis defined by guns
America is combating a maternal mortality crisis. This is not an unavoidable side effect of pregnancy. It is a reflection of policy choices — not only about health care, but about firearms and about how we invest in or abandon communities. Until we reckon with these facts and treat firearm violence as a maternal health emergency, we will continue to lose pregnant people like India, Eina and many others, as well as their babies.
