John Krugge

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Kable was distributing two Grove imprints, Black Cat and Zebra, both consisting of paperback erotica and wanted more titles and threatened to drop Grove if more titles were not forthcoming. The original plan for the Venus Library was to reissue vintage and often clandestine erotic literature from the s and s.

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The books were decently designed and of reasonable quality, and evoked the spirit of earlier literary book reprint series. Titles were published in both hard and softcovers. Hardcover series numbers were prefaced with an X, softcover with a V. The six initial titles included:.

The series was, in look and content, just too conservative. The series continued to consist of reprints of mostly low-grade pornographic novels with soft-porn photographic covers. Jackets are common to the series, with a simple, stylish design. Therefore, without having appropriate terminology and definitions, current information systems cannot accurately count this type of death. Aside from these three worldwide working definitions, there are two additional ones that are used only in the United States by the Centers for Diseases Control and Prevention CDC : "pregnancy-associated death" and "pregnancy-related death" The CDC "pregnancy-associated death" definition corresponds to the ICD "pregnancy-related death" definition, but the CDC "pregnancy-associated death" definition has two periods of observations: one within 42 days after the end of pregnancy, and the other between 43 and days after pregnancy termination.

In any case, while the CDC definitions do allow the surveillance system in the United States to more completely identify all deaths related to pregnancy, these definitions do not specify what a maternal death due to domestic violence is, nor can the information system count this type of death. Maternal mortality surveillance systems have provided inputs to enhance national statistical reports, and now most countries know what their leading causes of maternal death are.

Maternal deaths are mainly due to direct obstetric causes 16 e. However, it is clear that these are the causes that are most frequently measured. Correspondingly, health agencies have been called on to emphasize increasing access to care for obstetrical complications Nonetheless, the importance and usefulness of the maternal mortality ratio is well known. Most countries use this indicator as a measurement of progress in terms of social development, the state of health services and systems, the health status of women, and even as a measure of social justice since the majority of maternal deaths are concentrated among the poorest communities In most developed countries, maternal mortality is very low.

However, deaths of pregnant women due to violence do occur, and abused pregnant women may be more likely to be murdered than nonabused ones. Researchers have found in some areas of the United States that among pregnant women, deaths due to external causes of injury including homicides are more frequent than are deaths due to any other specific medical condition Another study found that for women abused during pregnancy the risk of being murdered or suffering an attempted murder was three times as high as it was for nonabused pregnant women 5.


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Data such as these indicate the need to develop a more inclusive definition of maternal mortality, including allowing for the assessment of the contribution of domestic violence. We believe that maternal mortality measurement is not sufficiently gender-sensitive. That is because the formula for the maternal mortality ratio was not originally created to take into account deaths of pregnant women due to gender-based violence. However, the ratio could be modified to consider those deaths. Generating accurate data on maternal deaths due to domestic violence would require the public health community to discuss the conceptual framework for data collection and management, the logistical needs for making it possible for information and surveillance systems to process the data, and, most importantly, the policy implications of data interpretation that would allow the development of appropriate interventions.

Domestic violence as a health problem or as a condition of ill health does not correspond to a physiopathological definition of disease. Consequently, "domestic violence" is not specified in ICD Domestic violence is essentially a behavioral problem, as are alcoholism and drug consumption.

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ICD does make it possible to code and attribute mortality for alcoholism as a behavioral ailment codes F ICD does provide codes for deaths due to several types of abuse and to specific perpetrators under the category of external causes of injury codes Y06, Y07 , which may make it possible to identify a limited number of deaths due to domestic violence.

To establish a cause of death there have to be clear mechanisms of causation. In the case of domestic violence, Peterson et al. In debating whether a maternal death due to domestic violence should be counted as an indirect obstetric cause, it is important to first discuss why most deaths of pregnant women due to, for example, diabetes mellitus or chronic hypertension are classified as being due to indirect obstetric causes. These diseases can start during pregnancy or can be aggravated by the pregnancy. If a pregnant woman dies due to these diseases, it is often assumed that obstetrical care would not have prevented her death.

Actual avoidance of this fatality would have been possible only if the woman had never gotten pregnant. So, how much different is the reasoning in these cases from the reasoning with deaths due to domestic violence? Domestic violence can also begin during or be aggravated by pregnancy 20 , as happens with many diseases.

More data are needed to explain whether changes in the patterns of violence e. However, some reported cases of murder associated with the existence of a pregnancy highlight the fact that this issue deserves more discussion. For example, in a homicide involving "honor killing," a woman is murdered to repair or prevent the "damage" that her pregnancy could cause to the reputation of her partner or family In such a case, avoidance of the death would have been possible only by preventing the pregnancy.

Consequently, if it were possible to establish that domestic violence and a death during pregnancy were causally related and this could be in the strict sense that the killing was motivated by the pregnancy , shouldn't this maternal death be counted as being due to domestic violence? This consideration would probably not apply to other forms of violent death, or to death due to injuries such as snakebites or accidents in general. The intention to commit gender-based violence toward the woman and her pregnancy is unlikely to exist in accidents per se.

Therefore, for most cases of maternal death that are possibly due to domestic violence, it is important to consider the specific circumstances of each case. This is what maternal mortality committees generally do for each maternal death that takes place in a health institution.

Maternal mortality has been the subject of epidemiological surveillance for several decades, especially in developed countries. Problems with underreporting and misclassification persist, but they have stimulated the development of new techniques to estimate maternal mortality ratios, thus facilitating comparisons of patterns and trends among countries and regions At present, despite the growing global interest in measuring violent deaths of pregnant women, neither the official figures usually produced by a country's surveillance system nor the adjusted estimates of maternal mortality such as those developed by the World Health Organization reflect the impact of domestic violence on maternal mortality.

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Expanding the definition of maternal death to include death due to domestic violence as a direct or indirect obstetric cause and making the subsequent adjustment in the maternal mortality ratio would pose challenges in identifying, registering, and reporting this type of death. Initial efforts to develop and strengthen the maternal mortality surveillance systems in Latin America and the Caribbean have already provided information that is allowing the identification of maternal deaths due to violence in general and gender-based violence in particular.

The information systems in many of the countries of the Region of the Americas are not fully developed. The surveillance cycle is an ongoing process of identifying cases, collecting data, analyzing the data, recommending actions, evaluating outcomes, and refining recommendations Understanding surveillance as a cycle increases the possibilities for continuous improvement in the information system.

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Having high-quality information from a high-quality surveillance system enables managers, policymakers, and health care providers at various levels of the health system not only to identify deaths and to collect and analyze data, but also to strengthen the decision-making process so as to formulate recommendations and actions that will improve health outcomes. Future steps to improve data collection should involve building on the best practices of countries in the Americas. These steps should also involve further analysis of data collection issues that are specific to the inclusion of violence in the maternal mortality ratio.

One concern is that it may be difficult to confirm a woman's pregnancy status.

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This involves more than discussion and agreement among epidemiologists and health program managers about indicating pregnancy status on a death certificate or in a database either by adding a box on a form or setting a code for a database. Forensic autopsy that includes the exploration of the uterine content has been useful in detecting early pregnancies 24 , but this method is not widely available in many countries of the Americas.

A second data-collection issue is that it may be difficult to determine if domestic violence is the cause of death. There may be daunting ethical and safety concerns as well as challenges in ensuring the reliability of the information. Fearing social stigma or being afraid for their own safety, many persons who know about the events associated with the death of a pregnant woman may be unwilling to disclose that information.

Whenever possible, courts, the police, and health institutions should work collaboratively on domestic violence research that takes a public health perspective. These kinds of partnerships have already proved successful in several cities in the United States A "verbal autopsy" can be used outside of a medical facility to rebuild the events surrounding the death of a woman due to domestic violence 23, For data processing there are some tools that are already available and others that are being developed.

With the ICECI it is possible to identify the type of relationship between the victim and the perpetrator. Nevertheless, with both the ICD and the ICECI it is impossible to identify all deaths of pregnant women, simply because pregnancy status is not coded since pregnancy is obviously not a disease. The monitoring of maternal deaths due to domestic violence should be done through epidemiological surveillance systems. However, expanding and improving the systems so as to generate maternal mortality estimates that are accurate and that include deaths due specifically to domestic violence will require sustained political will, resources, and commitment to action.

There are other approaches that can be useful for monitoring maternal deaths due to domestic violence, such as developing periodic ad hoc research. This approach could involve incorporating measurement of domestic violence into existing research or into future studies that use the Reproductive Age Mortality Study RAMOS methodology, which utilizes multiple sources of information in investigating all deaths among women of childbearing age 15, Furthermore, with the RAMOS methodology, the appropriateness of a definition of maternal death due to domestic violence can be tested, not only in the definition's conceptual aspects but also in its usefulness for data management processes and decision-making.

Universal screening for domestic violence among pregnant women in both developed and developing countries could be another way to prospectively explore morbidity and mortality for women and newborns, as well as the appropriateness of certain interventions. It is not known if the current maternal mortality figures are concealing greater differences than are now indicated between developed countries and developing countries in the number of maternal deaths and in the number of such deaths caused by domestic violence.

Obtaining information on maternal mortality due to domestic violence can help build understanding of the level of gender inequality that exists in countries. This information can also help ensure that the maternal mortality ratio accurately represents what it frequently is used as, that is, an indicator of various dimensions of social development. An ongoing WHO multicountry study on the prevalence of domestic violence 27 will provide additional key information to better understand the health consequences that that violence has for women. PAHO research on domestic violence in Latin America and the Caribbean has been instrumental in setting intervention priorities, identifying the numerous individual and societal factors around domestic violence, and identifying the "critical path" that women who are victims of domestic violence follow as they seek help PAHO is now conducting research to assess the extent of the relationship between domestic violence and maternal and perinatal health Investing in research on this issue is essential to guiding and supporting countries in their efforts to review and improve their models of care intended to have healthy women, healthy families, and healthy communities existing within a framework of gender equality.

We would like to also thank Angela Bayer and Rachel Kaufman for their time in reviewing this paper.

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Henry Espinoza thanks Ana Langer, from the Population Council in Mexico, for motivating him to work in this research area. United Nations, Division for the Advancement of Women. Version 1.

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Volume 1: tabular lists. World Health Organization. International statistical classification of diseases and related health problems, tenth revision. Geneva: WHO; Ronsmans C, Khlat M. Adolescence and risk of violent death during pregnancy in Matlab, Bangladesh [letter]. Abuse during pregnancy and femicide: urgent implications for women's health. Obstet Gynecol. Economic Commission for Latin America and the Caribbean. Eliminating gender-based violence, ensuring equality.

Suicide during pregnancy and its neglect as a component of maternal mortality. Int J Gynaecol Obstet. Developing community-based strategies to decrease maternal morbidity and mortality due to unsafe abortion: pre-intervention report. East Afr Med J. Salud Publica Mex. Forthcoming United Nations. Declaration on the elimination of violence against women [Internet site].