July 7, 2025 • 42 mins
Pregnancy should be a time of joy and anticipation, but for thousands of American women each year, it becomes the most dangerous period of their lives. In this eye-opening conversation with Professor Elizabeth Tobin-Tyler of Brown University, we explore the shocking reality that homicide is a leading cause of traumatic death for pregnant and postpartum women, accounting for 31% of maternal injury deaths.
Professor Tobin-Tyler draws on her unique background spanning both law and public health to explain how pregnancy often triggers escalating violence in abusive relationships. When an abuser's need for control meets the shifting attention and resources that accompany pregnancy, the results can be deadly—particularly for Black women, who die at five times the rate of white women from homicide during pregnancy.
We dive into the complex systems that fail pregnant survivors, from healthcare settings where brief appointments and the presence of abusers make disclosure difficult, to legal frameworks that inadequately protect women from armed abusers. The conversation explores innovative solutions like medical-legal partnerships that bring lawyers into healthcare settings to address both medical and social determinants of health simultaneously.
The ripple effects of this violence extend far beyond individual families. Children exposed to domestic violence face lifelong health consequences, creating an estimated $8 billion annual economic burden across healthcare, education, and criminal justice systems. Despite these staggering costs, funding for research and services continues to face cuts.
You'll come away from this conversation with a new understanding of how Medicaid access, firearm regulations, and community-based services can save lives, along with practical advice for supporting pregnant survivors in your own community. Professor Tobin-Tyler challenges us all to stop normalizing violence against women and to recognize pregnant women as valuable human beings in their own right—not just as vessels for their children.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
The subject matter of this podcast will address
difficult topics multiple formsof violence, and identity-based
discrimination and harassment.
We acknowledge that thiscontent may be difficult and
have listed specific contentwarnings in each episode
description to help create apositive, safe experience for
all listeners.
Speaker 2 (00:20):
In this country, 31 million crimes 31 million crimes
are reported every year.
That is one every second.
Out of that, every 24 minutesthere is a murder.
Every five minutes there is arape.
Every two to five minutes thereis a sexual assault.
Every nine seconds in thiscountry, a woman is assaulted by
someone who told her that heloved her, by someone who told
(00:41):
her it was her fault, by someonewho tries to tell the rest of
us it's none of our business andI am proud to stand here today
with each of you to call thatperpetrator a liar.
Speaker 1 (00:52):
Welcome to the podcast on crimes against women.
I'm Maria McMullin.
When abusers make the choice toexact violence onto their
pregnant partners, it is notjust the offender who has failed
mom and baby.
Oftentimes, it is also thesocial systems and institutions
that re-victimize thisvulnerable population due to
deficiencies such asunaffordable health care,
inequity of services, lack ofresources and funding,
(01:15):
structural racism or theinability to keep them safe.
Unfortunately, these deficitscan lead to the death of mother
and child.
To emphasis this point, theNational Partnership for Women
and Families report that eachyear, an estimated 324,000
pregnant people in the UnitedStates are battered by their
intimate partners.
Furthermore, they report that63% of female homicide victims
(01:37):
were killed by an intimatepartner in cases where the
victims knew the offender, ashomicide is a leading cause of
traumatic death for pregnant andpostpartum women.
It accounts for 31% of maternalinjury deaths.
Today we are excited to engagein a conversation with a
renowned lawyer and publichealth and policy professor who
has dedicated her research andteachings towards women's health
and intimate partner violenceand the legalities that surround
(02:00):
this epidemic.
Elizabeth Tobin Tyler is aprofessor of health services
policy and practice at BrownUniversity School of Public
Health.
She teaches in the areas ofreproductive rights and justice,
public health law and ethics,health policy and health justice
.
Her scholarship focuses onwomen's health, reproductive
justice, intimate partnerviolence, the structural and
(02:20):
legal determinants of healthequity and public health law and
policy.
Professor Tobin Tyler editedPoverty, health and Law Readings
and Cases for Medical-LegalPartnership and co-authored with
Joel Teitelbaum An Essentialsof Health Justice, law Policy
and Structural Change.
Her scholarship has beenpublished in multiple journals,
including the New EnglandJournal of Medicine, jama,
(02:41):
american Journal of PublicHealth, american Journal of
Preventative Medicine, theLancet Health Affairs, the
Journal of Health and HumanRights Journal of Legal Medicine
and the Journal of Law,medicine and Ethics.
She holds a BA and MA from theUniversity of Texas at Austin
and a JD from NortheasternUniversity School of Law.
She has been selected forseveral fellowships and honors,
(03:03):
including the Emerging Leadersin Health and Medicine Forum by
the National Academy of Medicine, as a Public Health Law
Education Faculty Fellow by theRobert Wood Johnson Foundation
and as a fellow at the LawHealth Justice Center at the
University of Technology inSydney, australia.
Professor Tobin Tyler, welcometo the show.
Thanks for having me.
Happy to be with you.
(03:23):
So we opened this episode withan overview of how pregnancy,
while supposed to be a joyfuland exciting experience, is also
, for some women, the mostdangerous, indicating that
homicide is the leading cause oftraumatic death for pregnant
and postpartum women.
It makes sense, then, that weshould look at this situation
from many angles, includingpublic health and policy.
(03:44):
So help us understand theintersection of maternal
lethality, public health andpolicy by starting with the work
you do at Brown University andthe impact your research and
work has on public health andpolicy.
Speaker 3 (03:57):
Sure.
So I am a professor of healthservices policy and practice at
the Brown School of PublicHealth.
I'm trained as a lawyer, whichis somewhat unusual in public
health, but my work reallyfocuses on the ways in which
laws and policies, both aswritten as well as how they're
implemented and enforced, affectpeople's health.
So a lot of my work centersaround reproductive health,
(04:20):
rights and justice.
I also do a lot of workfocusing more broadly on health
disparities and the ways inwhich laws and policies either
contribute to health disparitiesor can be used as tools to
prevent disparities.
So I'm really I've been sort offascinated for a long time
about the ways in which thelegacy of laws that directly
(04:40):
impact health, likediscrimination laws, may affect
people's health, but also theways in which laws that we don't
even think of as related tohealth may impact people's
health.
So you think about, you know,housing laws or laws
contributing to the builtenvironment and what
opportunities people have andwhat access they have.
So we know in public healththat that is significant to
(05:02):
contributing to people's healthgenerally and certainly to
population health outcomes andhealth disparities.
The focus of a lot of my worknow is on maternal and
reproductive health.
As I said, and because, given mywork around health disparities,
I've been particularlyinterested in understanding
maternal health disparities forblack women and understanding
(05:23):
why they die at rates two tothree times that of white women.
Their babies also die at ratesof two times that of white women
, and so you know thesedisparities are not natural,
they come from somewhere, and myunderstanding of the law and
policy and sort of policychoices is important, I think,
(05:43):
in trying to think through whatare interventions, both in terms
of using law as a tool toimprove these situations, but
also understanding thatsometimes laws have negative
implications and how can webetter understand that?
One of the things that I'vestudied in great detail is sort
of the role of social drivers ofhealth, so social experience
(06:04):
and the ways in which socialexperience affects health
outcomes.
There's reams and reams ofpublic health research,
understanding that our socialexperiences contribute in a
significant way to our health,even more than access to health
care.
So living in poverty,experiencing discrimination,
living in unstable and unsafehousing, all of these things
(06:24):
contribute vastly to theoutcomes that people experience
in terms of their health.
And so, when you kind ofcombine those questions with the
experiences of pregnancy,maternal health and particularly
for black mothers whoexperience a number of those
social drivers.
We really have to understandhealth and maternal health and
reproductive health in thisreally broad way of
(06:47):
understanding the importance ofsocial drivers.
Speaker 1 (06:50):
That's a large swath of information to cover and to
work on, and I suppose you havesome concentrations of your work
too that maybe we'll get into.
But, to your point, socialdeterminants of health,
non-medical drivers of health,are really important data points
to examine when we're trying toaffect change in communities
(07:11):
that are underserved orunderprivileged or less
advantaged.
Now, especially with maternalhealth, it's widely known that
there's a disparity as well inthe research done specifically
on women's health and medicaltreatment for women, and
maternal health may be even oneof the most underserved observed
(07:31):
areas, if you will.
So the continuation, then, ofmaternal health projects such as
the one engineered by theNational Institutes for Health
is probably very important andnecessary, right?
How would you say your work iscontributing to giving us a
better picture of what womenneed and how to affect more
positive outcomes?
Speaker 3 (07:53):
Yeah, I mean, I think , on the National Institutes of
Health, it's really important tounderstand both where we have
been and where we are going, andthe research that has been
funded under the NationalInstitutes with regard to
maternal health has been justcritical in understanding the
disparities that we're talkingabout and understanding the
outcomes that we're talkingabout.
(08:13):
Not only do we have racialdisparities in maternal health,
but we have worse outcomes thanevery other wealthy nation has
right in terms of maternal deathand maternal morbidity.
So being able to track thatover time at the population
level, but also to studyinterventions that might be
appropriate for addressing thoseproblems, is critical.
(08:33):
And one of the concerns that weall have right now, as NIH
funding is being cut or grantsare being stopped, is that we're
going to lose sight of just howto think about these problems,
not only to track the problemsbut to think about the
interventions that we might beable to bring to bear.
And I think we had, you know, anumber of really good
(08:54):
progressive ways of thinkingabout this under the Biden
administration, both in terms ofresearch but also in terms of
interventions that now have beenpulled back under the new
administration, and so you know,having good research is
critical.
One of the things that we'remost worried about and I've done
work using the Pregnancy RiskAssessment Monitoring System.
It's a CDC-based program thatstudies people during pregnancy.
(09:19):
It's a large survey that moststates administer and it gives
us great insight into the kindsof issues that pregnant women
experience, and that has nowbeen taken offline by this
administration, and many of usare deeply concerned that
without that research we won'tbe able to study things like how
many women express that theyare experiencing domestic
(09:39):
violence, for example, becausethat's a question in the survey.
So if we don't have thatinformation, it of course makes
it that much more difficult forus to intervene.
Speaker 1 (09:48):
Yeah, I can certainly see why.
So this is where we come tokind of the intersection of
medicine and law.
They are somewhat mutuallyexclusive concepts, but yet your
work consists of anintersection of those two things
.
How does law coexist in thehealthcare space?
Speaker 3 (10:05):
You know, I don't think they're mutually exclusive
.
What I've learned over mycareer is that law really is a
foundation for virtuallyeverything that we do in society
, but in particular medicine andpublic health.
So we may all be certainlyaware that law structures and
regulates the healthcare systemthat we all experience.
It regulates the ways in whichproviders interact with patients
(10:27):
.
It also regulates and a lot ofthis is constitutional law sort
of what can the government do,for example, during a pandemic,
and how does the governmentbalance the individual interests
of people against public healthneeds, right?
So law really frames a lot ofthose kinds of questions.
But what I became mostfascinated with and this was
(10:47):
when I was in law school back inthe 1990s was understanding the
way that law, as I talked abouta little bit earlier, really
structures our socialenvironment and our social
experience.
So I worked in the 1990s at thefirst medical legal partnership
in the country at Boston MedicalCenter, which was an
opportunity to have lawyers andclinicians actually partner
(11:08):
together to provide better carefor patients.
I was working in the pediatricunit at Boston Medical Center
and so we worked with a lot ofparticularly low-income mothers
and children who experienced allsorts of negative social
drivers, as we talked aboutbefore housing, lack of access
to basic needs, domesticviolence and what I came to see
(11:30):
was that legal advocacy andbeing able to understand how the
law interacts with people'sexperiences and how it drives
their health is really acritical component of the
connection between law andmedicine and public health
generally.
So I'll give you an examplethere was a specialized program
at the hospital that focused onchildren who were exposed to
(11:51):
domestic violence, and becausewe had this sort of team, which
included lawyers, we were ableto work with families, both
survivors and their children, toprovide not only medical care
and therapeutic care because, ofcourse, there's significant
trauma that's affecting both thesurvivor and her children but
also by having lawyers engaged,we could address things like
(12:13):
getting protective orders, butalso breaking down some of the
legal barriers that so many lowincome in particular, but people
experiencing domestic violencemight find around.
You know, if they are able toget out of the relationship, can
they access housing, whathappens with their employment, a
whole range of issues thatdrive their health or social
drivers of health, but they'realso barriers for people
(12:35):
experiencing violence, and so Iwas really taken with this
understanding of how lawyers canplay such a significant role in
the healthcare setting by usinglaw as a tool to actually
support people and ensure thatnot just the laws are written
correctly but that they'reenforced on behalf of people
that otherwise might not be ableto get what they need and to
(12:55):
survive.
So I found that a reallycompelling model, and that's
when I really began to see theconnections between law and
health.
Speaker 1 (13:03):
Yeah, it's brilliant.
Is it a model that's still inplace today?
Speaker 3 (13:06):
It is.
That was the first one in thecountry.
There's now about 450 medicallegal partnerships in different
health clinics and settings andhospitals across the country.
So that was really thebeginning, as I said, of the
movement, and I'm a huge fan ofsort of this team-based approach
, particularly in healthcare, tounderstanding that health
encompasses many, many differentsocial and structural legal
(13:28):
issues.
So if you have the appropriateteam, including lawyers, I think
you can have a significantimpact on people's health and
well-being.
Speaker 1 (13:35):
Yeah, I'm really excited to hear that and about
that type of a partnershipacross the country.
Now let's talk a little bitabout the domestic violence that
we've both kind of mentionedhere so far in our conversations
, because the CDC reports thatapproximately 40% of homicides
among persons known to bepregnant or within a year of
pregnancy are related tointimate partner violence.
(13:57):
Is it statistics like thesethat motivated you to sharpen
the focus on maternal health inparticular?
Speaker 3 (14:04):
Yeah, I mean I think I was, and I'll just say a
little bit about my backgroundwith domestic violence and sort
of how I began to connect thedots between domestic violence
and maternal health.
So when I was in college manyyears ago, in the 1980s, I
worked at a domestic violenceshelter in Austin, texas as a
volunteer and really came tounderstand the dynamics of
domestic violence and becamequite passionate about
(14:26):
addressing those issues.
So when I was in law school Iworked as a domestic violence
advocate in the district courtand provided services and
support to people seekingdomestic violence restraining
orders and that just gave meenormous insight into the way
that abusive relationshipsfunction and the legal barriers
and other kinds of barriers thatsurvivors experience.
(14:46):
I also did work in the AttorneyGeneral's office during law
school focused on the effects ofdomestic violence on children,
and we were doing statewidetraining for law enforcement and
healthcare providers aroundthose issues.
So I had this sort of passionand background in domestic
violence.
I'm also passionate aboutreproductive and maternal health
and so those two thingsobviously intersect.
(15:07):
But I will say when I firstlearned the statistics as you
just mentioned about, you knowhow many people experiencing
abusive relationships, domesticviolence, are killed during
pregnancy.
Speaker 2 (15:20):
I was astonished.
Speaker 3 (15:21):
You know, what we know now from the public health
literature is that pregnantpeople die from homicide at
rates higher than hemorrhage andpreeclampsia, which are often
the reason that people dieduring pregnancy.
And so when you think aboutthat and the fact that we really
don't talk about that, we don'tthink about interventions that
(15:41):
are going to prevent pregnantpeople from being killed during
pregnancy, you know it's prettyastonishing.
So what I started to look atwas, again, with this sort of
legal framework is what are someof the ways that we can address
that problem?
I also want to mention that inmy research and this is, you
know, public health researchothers have done.
black women die at five timesthe rate of white women from
(16:03):
homicide during pregnancy andyou know we think that much of
that has to do with the lack ofresources in many communities of
color for survivors and victims, but also a reluctance to call
the police in communities ofcolor, where police violence may
be prevalent.
And so, again, black women havemuch higher rates of maternal
mortality generally, but we alsoknow that they have
(16:26):
significantly higher rates dueto homicide.
So the ways in which pregnancyand domestic violence intersect
are actually complex, and thereare many different factors that
come into play.
One is reproductive coercion,meaning that an abuser may
sabotage birth control, maycontrol the ways in which his
partner is able to control herown fertility, preventing access
(16:49):
to abortion.
Other things like that is quiteprevalent in relationships
where there's abuse, so issexual violence, and so unwanted
pregnancy in thoserelationships can be quite
common.
So, sort of on the front end,if there's abuse there's more
likely an unwanted pregnancy.
But then, of course, oncesomebody becomes pregnant, we
(17:10):
know that the violence escalates.
We're not entirely sure whythat happens.
I think, understanding thedynamics of domestic violence,
it's likely a time where theabuser wants to maintain even
more control and uses power todo that and violence to do that.
And one thing that we havelearned in terms of access to
reproductive health care, whichis another part of this, is the
(17:32):
importance of access to abortionand birth control for survivors
.
Reports of reproductivecoercion actually doubled the
year after Dobbs.
So there seemed to be a sort ofmessaging around who gets to
make decisions aboutreproduction or fertility for
survivors of domestic violencethat some abusers took to heart,
(17:53):
and there seems to be anincrease in reproductive
coercion.
And then, finally, I'll justsay access to care and, in
particular, abortion.
There's a new study that justcame out from the National
Bureau of Economic Research thatfound that reports of domestic
violence increased between 7 and10% for women living in
counties with abortion bans orsevere restrictions after DOB.
(18:14):
So there is a linkage betweenaccess to reproductive health
care, reproductive decisionmaking and violence.
Again, untangling all the waysin which these things interact
is really critical for beingable to intervene.
Speaker 1 (18:28):
This is a highly complex situation.
It's hard to believe that we'regoing to cover this topic in
just the little time we have tospend together, because you've
raised so many important pointsfor us to think about and, like
you, I was astonished as well atthe incredibly high rate of
lethality for pregnant women,especially Black women.
It's just incredible to me thatwe could have these statistics
(18:52):
and not have more legislation inplace, more access to health
care in place to accommodatepregnant women, and have
screenings in place with OBGYNsand others who care for women
who are pregnant and postpartumto determine their safety at
home.
Does that exist?
Speaker 3 (19:09):
I'll start with sort of this, the circumstances under
which OBGYNs are working rightnow and other healthcare
providers.
I mean, I would say ourhealthcare system is in crisis
in many places and that has todo with a lack of primary care
providers in many places.
So just people being able toaccess care for OBGYNs because
of the Dobbs decision, and sothe working conditions for
(19:32):
OBGYNs, depending on the statethey live in and what that looks
like in terms of being able toprovide the standard of care.
You know, we know, that theworkforce of OBGYNs is shifting,
that many are leaving thestates that have restrictive
abortion policies, which thencreate, you know, maternal
health and reproductive healthcare deserts in those states.
They're working underconditions that are really,
(19:54):
really challenging.
But, even in states where therearen't abortion restrictions,
there are lots of pressures onOBGYNs and primary care
providers in terms of the numberof patients they need, to see
how they respond to their needs,the sort of 10-minute or
15-minute visit.
So when you think about that inthe context of working with
people that are experiencingviolence, and how complex that
(20:15):
can be, because, many survivorsmay be reluctant to reveal or
disclose what's happening tothem and you have a provider who
may not have the time to reallyengage, so I think there are
pressures there.
That being said, you know we doknow what best practices are
for healthcare providers,including OBGYNs, that are
really useful in trying toaddress the needs of people that
(20:38):
come in that are experiencingviolence.
I would say not even all OBGYNsare completely aware of the
fact that domestic violence mayescalate during pregnancy.
So being aware of that iscritical.
But you mentioned screening.
Certainly the best practice isthat all patients be asked about
violence and safety in the home.
I think it's not just a matterof checking a box, which
(21:01):
sometimes it may feel like forpeople when they're being
screened for a whole range ofthings, because there's more and
more screening in the medicalsetting now for a lot of
different issues, but a reallyengaged screening in the sense
of looking the person in the eyesetting now for a lot of
different issues, but a reallyengaged screening in the sense
of looking the person in the eye, really engaging them and
really giving them space andtime to respond is critical.
(21:22):
But again, that can bechallenging in the current
environment and certainly lackof judgment or being
non-judgmental about theresponse, is critical.
Certainly, talking to them ifthey do disclose about what they
want and what they see as theiroptions, and not sort of
imposing those are reallycritical.
I think the other thing thatOBGYN offices can and should do,
(21:45):
whether it's a hospital settingor a smaller clinical setting,
is to really know the resourcesin the community and to build
partnerships with domesticviolence advocates, because I
think a lot of clinicians may bereluctant to ask these
questions if they don't knowwhat to do if they get a
positive answer.
So being able to know inadvance if the person needs help
(22:05):
, who can I turn to to help themengage in safety planning,
because they may not be able toleave today, but we can help
them begin that journey ifthat's where they are.
So I think there are a lot ofways that OBGYNs can be really
critical here, as well as otherproviders that interact with
women generally, but pregnantpeople as well.
Speaker 1 (22:24):
Yeah, you write some very interesting ideas about how
to screen and who to screen andwhen to do it, as well as the
time that it takes to add thatinto an office visit.
There's another complicationthat we should probably talk
about when doing screenings inan OBGYN office, and that is
when the abuser accompanies thepregnant woman to her doctor's
appointments.
(22:44):
It's not uncommon for expectingparents to visit the OBGYN's
office together for the regularappointments.
There are so many of them, bothduring the pregnancy and then
immediately following delivery,so that complicates things.
What are your thoughts aroundhow to get around that kind of a
situation, especially if theOBGYN suspects there could be
(23:07):
some intimate partner violence?
Speaker 3 (23:09):
OBGYNs who are trained and sensitive to
domestic violence, and I wouldadd, that's another critical
feature here is being sure thatwe train the workforce both
OBGYNs and other primary careproviders, as well as others, to
understand how power andcontrol work in these
relationships, and I taught atthe medical school here at Brown
for nine years and we werereally trying to build out the
(23:30):
training for medical studentsand residents around these
issues.
Because if you don't understandthose dynamics then you're not
going to pick up on cues, likean abuser who may insist on
being in the room if the patientis being examined, for example.
And so I think providers whoare sensitive to these issues
and who are able to pick up onthose cues can respond in a few
(23:51):
different ways.
They can certainly just ask ifthey can have a private visit
with the patient.
It's better not to ask thepatient because the patient may
be feeling threatened by theabuser.
So if you say you know, are youcomfortable with him being here
, she's likely to say yes.
You can say things like this isa part of the exam that I
usually do in private with mypatient, so I'm going to ask you
(24:13):
to leave the room for a fewminutes while we do that and
then use that opportunity as thetime to talk to the patient, to
get a better understanding ofwhat's going on and to determine
if there's reason for concern.
Speaker 1 (24:24):
I don't know how they do it.
I'm trying to think about youknow all of your points with a
discussion about nurses.
You know if nursing schoolsalso have training and education
for nursing students or evencontinuing the education about
domestic violence?
Speaker 3 (24:41):
You know, I don't know sort of across the board
the answer to that question myexperience with nursing
education is that they actuallyare quite good on this.
Again, I don't know if that'strue of all nursing education,
but I would say I think that's acritical aspect of this, not
just in the OBGYN setting but inemergency care, for example, or
other places where providers,including nurses, might interact
(25:03):
with people who areexperiencing domestic violence,
really again being able to sensewhat's going on, but also
thinking carefully about how tointeract with the patient in a
way that's not going to endangerher or allow her abuser to
threaten her and not allow herto get the care that she needs.
Speaker 1 (25:18):
Beyond pregnancy.
Postpartum is an incrediblychallenging time in a lot of
ways, but can be so much so fordomestic violence survivors,
because the wife or partner isnow mom and attention is
diverted to the new baby andaway from her partner or her
husband.
That is an extremely dangeroustime for a woman Because if
(25:43):
she's already in an abusiverelationship, it can really fan
the flames for this abuser right, For example, if he's feeling
that he's not receiving theattention that he deserves, he's
(26:11):
likely to be more controlling,he's likely to be more violent.
Speaker 3 (26:14):
But it's also harder to leave when you have a child,
especially if that controllingbehavior has meant that the
finances are controlled by theabuser, access to transportation
, a whole range of differentaspects of abusive behavior, and
those do often escalate after ababy is born.
But also children are veryoften used as pawns in these
relationships.
(26:34):
If you take the child away fromme, I will hurt you or kill you
.
They're often used as pawns inany kind of divorce litigation
or restraining order settingright.
So it gets even that much morecomplicated for the survivor to
not only to try to leave butalso to just stay safe, because
things can escalate.
Speaker 1 (26:53):
Yeah, definitely a frightening time for mom and
baby and unfortunately thingscan continue to unravel from
there Because there's alsoconsequently there can be sick
babies or mental health problemsor postpartum maternal health
problems for mom.
So things can just kind ofbegin to accelerate and create
(27:16):
issues inside the home whichthen kind of spill over outside
the home.
There'll be problems at work,there will be problems at school
.
These problems will lendthemselves to societal problems
as well.
So let's talk about thatspillover and maybe you can
provide more insight to us froma public health perspective how
domestic violence for pregnantwomen creates kind of this
(27:39):
ripple effect across otherissues in society.
Speaker 3 (27:43):
We haven't really talked about this yet.
So let me sort of ground thisand individual health outcomes
for both survivors and theirchildren, and then we can talk
about how we think about that atthe population level.
So you know, the research isreally really clear that people
who experience domestic violenceas survivors have long term
health implications.
(28:03):
So we might think aboutinjuries, right, but there's
obviously other ways in whichexperiencing domestic violence
affects people's health.
So it affects their mentalhealth through trauma.
It makes it more likely thatthey may use substances to cope.
But also what we've learnedfrom the public health research
is that stress in and of itselfplays a major factor in people's
(28:23):
health, including things likechronic disease, hypertension,
gastrointestinal problems awhole range of body systems that
are affected by stress.
So if you think about what'sstressful, living in a violent,
controlling relationship isprobably number one on your list
.
So there are health concernsthat occur for the survivor
based on that experience ofviolence.
(28:43):
What I was learning in the1990s and really found
fascinating is that there's beengood research done also on
children who are exposed todomestic violence, not
necessarily harmed physicallythemselves, but when we look at
their long term outcomes again,trauma related stress and a
whole host of adult healthproblems that manifest from
(29:06):
living in that stressfulenvironment and being exposed to
that violence.
So what we call that in publichealth is adverse childhood
experiences.
That's the language that comesfrom a variety of studies that
have looked at specific types ofadverse experiences that
children have and domesticviolence exposure is clearly one
of them.
So understanding sort of againthe implications, not just for
(29:28):
what might be happening at themoment in that home, but the
long term exposure for childrenand trauma that's experienced by
the survivor and the childrencreate ripple effects in the
healthcare system like missedwork, children not being able to
concentrate in school andtherefore not being able to
achieve, and that affectingtheir long-term productivity and
(29:51):
ability to work and theiropportunity.
We also talked about socialdeterminants of health.
People that are in violentrelationships, particularly if
they do leave, are more likelyto be homeless more likely to
live in poverty.
All of these things escalatebased on the experience of
violence and have enormousimplications for our healthcare
system, for education system,for criminal justice system
(30:13):
potentially and some people whohave studied this have put the
cost per year at about $8billion for the United States.
So when you think about the,you know the ramifications of
this as a social problem.
It's quite stark.
Speaker 1 (30:30):
There is some interesting research out there
about that and to your point,that $8 billion.
It's said that every economicsector of our society is
impacted by domestic violenceand a dollar value can actually
be pinpointed to it.
To your point, loss of time atwork, loss of wages.
It impacts the health industry,every single one.
(30:51):
You can go in and find thedollar value for, and if nothing
else, it should be eye openingto people.
If the statistics aboutlethality don't frighten you,
you know, maybe it makes sense,more sense to you if you look at
the economic impact of domesticviolence.
What recommendations then doyou have for policymakers and
legislators that could improvethe lives or protect pregnant
(31:12):
women experiencing intimatepartner violence?
Speaker 3 (31:15):
Yeah, I mean, I think to your point.
It's astonishing to me thatit's such an unrecognized
problem, right, because the datais so clear, and so I think we
all are.
We all have an obligation totry to educate our policymakers
about this and to help them tobetter understand domestic
violence in general, but inparticular, how it affects
maternal health and healthduring pregnancy.
(31:37):
We're in the midst of a crisis,I would argue, around pregnancy
care, around maternal healthand around violence against
women, and when you bring all ofthose things together, they're
really overlapping public healthproblems, and so that can make
it feel overwhelming andcomplicated, but I think we can
think about different aspects ofthe problem and try to address
them that way.
(31:57):
So before I get to that, I'lljust say we're a little bit in
defensive mode at the momentwith much of this because of
budget cuts that are reallyreally could be significant in
terms of addressing the problemswe're talking about.
So right now, there are threatsthat there could be significant
cuts to the Office of ViolenceAgainst Women, which is a
primary federal agency thatprovides a lot of funding for
(32:20):
services for people that areexperiencing violence.
That comes on the heels of theVictims of Crime Act reductions,
which is also a major source offunding for domestic violence
programs, and, as we talkedabout earlier, a reduction in
funding for research aroundmaternal health and violence
prevention.
So right now we're in a placewhere we have to sort of play
(32:41):
defense in terms of trying toget these programs reinstated.
But beyond that, we need tothink proactively, and so, on
the one hand, we have thismaternal health crisis, and
there are ways to think aboutthat.
So there has been legislationproposed, I think every year for
the last several years, byRepresentative Lauren Underwood
and Representative Alma Adams.
(33:01):
It's called the Momnibus BillMomnibus Act, and it's a
multifaceted piece oflegislation that really looks at
the maternal health crisis andprovides major investments in
different programs that wouldsupport maternal health.
So that includes even fundingfor things that we would think
of as sort of social drivers ofhealth, like thinking about
access to housing and supportivecommunity-based services and
(33:25):
that kind of thing.
So you know, I think it's notthat we can't think of things to
do right.
There are ways to do this if wecan get the political will to
support that.
On the domestic violence side, Ithink we haven't really talked
about this yet, but one of theother ways of thinking,
particularly about reduction ofperinatal homicide, is the
relationship with gun violence.
More than half of the victimsof homicide during pregnancy are
(33:49):
killed with a firearm, and soyou know we have not done a good
job of ensuring that people whoare known to be domestic
abusers not access firearms.
There was a major Supreme Courtcase a couple of years ago, the
Rahimi case, where the questionwas whether the court was going
to maintain the ViolenceAgainst Women Act provision that
(34:09):
prohibits domestic abusersunder subject to restraining
orders from possessing firearms,and the court fortunately did
uphold the law.
The federal law, but that lawdepends significantly on state
enabling legislation and stateenforcement, and what we know is
that those laws are highlyunenforced not enforced to the
(34:29):
degree that they should be, andso we know that if there's a gun
in the home, a personexperiencing domestic violence
is five times as likely to bekilled with that gun.
So, you know, intersectionallyagain thinking about access to
firearms and what that means forhomicide, and then, I think,
generally just looking at theways in which we do or don't
enforce many of our domesticviolence provisions.
(34:51):
I mean, we have come a long wayin law enforcement and options
for things like restrainingorders, but there's a lot of
gaps in terms of how those lawsare enforced and whether victims
and survivors actually feellike they're going to be safe.
And then, of course, finally,we have to invest in
community-based services, andthen again that goes back to
(35:11):
some of the work that we need todo to restore what was already
there.
But even those funding sourcesthat were already there were not
enough.
So if somebody is living inthis kind of relationship, are
there resources in theircommunity that can help them to
get out of that relationship?
And we're a long ways from that.
Speaker 1 (35:27):
Yeah, it's really going to take all of us, and all
of us working together, totackle some of these major
overarching, intersecting issuesand not to pile on.
But health insurance andMedicaid reform are very urgent
and controversial topics at themoment, and they are directly
related to maternal mortality.
(35:47):
What role do Medicaid ormaternal health policies play in
either helping or hindering apregnant survivor's ability to
get out of a violent situation?
Speaker 3 (35:58):
Yeah, I mean we know from the research that access to
Medicaid is life-saving ingeneral but also, you know,
reduces maternal mortality.
It plays a huge role forsurvivors of domestic violence
in that if you do not haveaccess to health insurance, you
are not going to get health care.
Clearly, if you're low income,and one of the primary ways that
we can detect and intervene ondomestic violence is through
(36:19):
health care.
Somebody has to be able to getto the clinic in order for that
to happen.
But the other important aspectof Medicaid and I think this has
been really the positive workof many years is many Medicaid
funded programs, particularlyfederally qualified community
health centers where many lowincome people get their health
care, have really robustlyexpanded their models to address
(36:41):
social needs as part of healthcare social needs including
things like exposure to domesticviolence.
So they often have socialworkers, they sometimes have
lawyers through medical legalpartnerships.
They often have communityhealth workers who live in the
community, often with livedexperience that might have their
own experience of domesticviolence, who really are there
(37:01):
to be a support system.
And so Medicaid access, orhaving coverage through Medicaid
, provides access to servicesthat can be really critical in
supporting people that areexperiencing violence.
The other thing about it is thatpeople don't always realize
this, but 40% of the babies bornin this country are covered by
Medicaid, and for Black womenit's 65%.
(37:24):
So think about a point ofintervention and a point of
potential support.
If all of those women arereceiving care through Medicaid
during their pregnancy and atthe time of birth, that's a
great point of potential supportand intervention.
And again, we can talk about,as we did earlier, the ways in
which clinicians can play a rolein that.
(37:45):
But Medicaid provides thisamazing opportunity to do that.
I think the cuts that are beingproposed are potentially
devastating in terms of peoplebeing cut off of Medicaid.
Fortunately, I think the periodof pregnancy and postpartum
will likely still be covered forpeople, but these things don't
just start in pregnancy.
If people have access toMedicaid over a longer period of
(38:08):
their lifespan, opportunitiesfor prevention and intervention
can occur earlier andpotentially prevent an unwanted
pregnancy of someone who's in anabusive relationship or ensure
that they get the care that theyneed earlier.
So I'm concerned, I'm reallyconcerned about potential cuts
and I think you know Medicaidagain is a really critical
aspect of this.
Speaker 1 (38:27):
I think all women should be concerned about
potential cuts to Medicaid andother offices that you mentioned
, like the Office on ViolenceAgainst Women and lots of other
things, because these are goingto impact us.
They're going to impact ourchildren, whether they are girls
or boys, across the board.
So there's also a lot ofcontradictions in some of the
decision making going on aroundthese issues, such as denying
(38:50):
anyone the right to an abortion,with abortion bans in certain
places in this country, and thenalso demanding, in a sense,
that they carry a pregnancy toterm but not giving health
coverage potentially to care forthat pregnancy and then the
resulting baby.
So I don't understand the logicbehind some of the ideas right
(39:11):
now, but maybe it'll revealitself as we move forward.
Let's talk for a minute aboutprevention strategies that you
can share that would bebeneficial to implement and
actions that this audience cantake to support pregnant women
in dangerous situations.
Speaker 3 (39:26):
The first thing I would say to anyone who's
concerned about this in theircommunity or sphere, family
sphere is asking someone thatyou're concerned about if they
feel safe and supported duringtheir pregnancy.
We think of you started, Ithink, at the beginning of
pregnancy as this incrediblyhappy, joyful time.
For some people, that'scertainly true, but for many,
(39:46):
especially if they'reexperiencing abuse, they're
going to feel even more trappedand more hopeless during this
period Because, as we talkedabout, violence can escalate,
but also having a baby can makeit even more difficult to leave,
and so I think people areafraid often to raise these
questions.
But I think it's critical thatif someone is concerned or
suspects that this is happening,that they ask the person and
(40:08):
let them know that there issupport there, even if they're
not initially responsive to that.
We talked about firearms, Ithink you know, for clinicians
for, again, for anyone who'sconcerned, knowing and asking if
there are firearms in the homefor a pregnant woman is critical
, because we know from theresearch it's much more likely
that that firearm will be usedif it's in the home and that
(40:31):
raises the possibility ofhomicide.
I always stress this, you know.
I think it's really hardsometimes for all of us to
understand, if somebody'sexperiencing this kind of
relationship, why they make thechoices that they make, and it's
really critical that we notjudge, that we listen, that we
offer options and resources andmake it clear that we are always
(40:53):
there if the person needsanything, and let them make the
decisions and be empowered to dothat, because we can't always
understand exactly what they'refacing and why they're making
the decisions that they'remaking.
We have a tendency in thiscountry to ignore or not pay
attention to violence againstwomen in general.
We've kind of normalized it, Ithink in a way that means that
(41:14):
we sort of accept that we havethe statistics that we have and
it's not acceptable.
I think all of us need tounderstand those statistics,
talk about those statistics, payattention to what's happening
in our own community, advocatefor the people that we know are
experiencing this, and talkabout the importance of
protecting and supportingpregnant women and women in
(41:37):
general, and not only their baby.
They are valuable, importanthuman beings and they should be
a priority as much as otherpeople and even their children.
So that's how I would urgepeople to think about this issue
going forward.
Speaker 1 (41:50):
Yeah, absolutely Good advice.
Thank you for all of theinformation that you shared and
for the work you're doing forthis important population this
important moment in time in ourcountry.
I appreciate you being here.
Thank you for being on the showtoday.
Speaker 3 (42:03):
Thanks for having me.
I really enjoyed talking withyou.
Speaker 1 (42:05):
Thanks so much for listening.
Until next time, stay safe.
The Conference on CrimesAgainst Women Summit Beyond the
Bounds, designed to addressgender-based crimes specific to
coastal, resort and ruralcommunities, will be held
September 22nd and 23rd in SouthPadre Island, texas.
For more information and toregister, visit our website
conferencecaworg.
(42:26):
And save the date for the 2026Conference on Crimes Against
Women convening May 18th throughthe 21st 2026 in Dallas, texas,
and follow us on social mediaat National CCAW to get the
latest news and informationabout all upcoming events and
trainings, including virtual andin-person educational
opportunities, updates on theInstitute for Coordinated
(42:47):
Community Response and more.
The subject matter of this podcast will address
difficult topics multiple formsof violence, and identity-based
discrimination and harassment.
We acknowledge that thiscontent may be difficult and
have listed specific contentwarnings in each episode
description to help create apositive, safe experience for
all listeners.
Speaker 2 (00:20):
In this country, 31 million crimes 31 million crimes
are reported every year.
That is one every second.
Out of that, every 24 minutesthere is a murder.
Every five minutes there is arape.
Every two to five minutes thereis a sexual assault.
Every nine seconds in thiscountry, a woman is assaulted by
someone who told her that heloved her, by someone who told
(00:41):
her it was her fault, by someonewho tries to tell the rest of
us it's none of our business andI am proud to stand here today
with each of you to call thatperpetrator a liar.
Speaker 1 (00:52):
Welcome to the podcast on crimes against women.
I'm Maria McMullin.
When abusers make the choice toexact violence onto their
pregnant partners, it is notjust the offender who has failed
mom and baby.
Oftentimes, it is also thesocial systems and institutions
that re-victimize thisvulnerable population due to
deficiencies such asunaffordable health care,
inequity of services, lack ofresources and funding,
(01:15):
structural racism or theinability to keep them safe.
Unfortunately, these deficitscan lead to the death of mother
and child.
To emphasis this point, theNational Partnership for Women
and Families report that eachyear, an estimated 324,000
pregnant people in the UnitedStates are battered by their
intimate partners.
Furthermore, they report that63% of female homicide victims
(01:37):
were killed by an intimatepartner in cases where the
victims knew the offender, ashomicide is a leading cause of
traumatic death for pregnant andpostpartum women.
It accounts for 31% of maternalinjury deaths.
Today we are excited to engagein a conversation with a
renowned lawyer and publichealth and policy professor who
has dedicated her research andteachings towards women's health
and intimate partner violenceand the legalities that surround
(02:00):
this epidemic.
Elizabeth Tobin Tyler is aprofessor of health services
policy and practice at BrownUniversity School of Public
Health.
She teaches in the areas ofreproductive rights and justice,
public health law and ethics,health policy and health justice
.
Her scholarship focuses onwomen's health, reproductive
justice, intimate partnerviolence, the structural and
(02:20):
legal determinants of healthequity and public health law and
policy.
Professor Tobin Tyler editedPoverty, health and Law Readings
and Cases for Medical-LegalPartnership and co-authored with
Joel Teitelbaum An Essentialsof Health Justice, law Policy
and Structural Change.
Her scholarship has beenpublished in multiple journals,
including the New EnglandJournal of Medicine, jama,
(02:41):
american Journal of PublicHealth, american Journal of
Preventative Medicine, theLancet Health Affairs, the
Journal of Health and HumanRights Journal of Legal Medicine
and the Journal of Law,medicine and Ethics.
She holds a BA and MA from theUniversity of Texas at Austin
and a JD from NortheasternUniversity School of Law.
She has been selected forseveral fellowships and honors,
(03:03):
including the Emerging Leadersin Health and Medicine Forum by
the National Academy of Medicine, as a Public Health Law
Education Faculty Fellow by theRobert Wood Johnson Foundation
and as a fellow at the LawHealth Justice Center at the
University of Technology inSydney, australia.
Professor Tobin Tyler, welcometo the show.
Thanks for having me.
Happy to be with you.
(03:23):
So we opened this episode withan overview of how pregnancy,
while supposed to be a joyfuland exciting experience, is also
, for some women, the mostdangerous, indicating that
homicide is the leading cause oftraumatic death for pregnant
and postpartum women.
It makes sense, then, that weshould look at this situation
from many angles, includingpublic health and policy.
(03:44):
So help us understand theintersection of maternal
lethality, public health andpolicy by starting with the work
you do at Brown University andthe impact your research and
work has on public health andpolicy.
Speaker 3 (03:57):
Sure.
So I am a professor of healthservices policy and practice at
the Brown School of PublicHealth.
I'm trained as a lawyer, whichis somewhat unusual in public
health, but my work reallyfocuses on the ways in which
laws and policies, both aswritten as well as how they're
implemented and enforced, affectpeople's health.
So a lot of my work centersaround reproductive health,
(04:20):
rights and justice.
I also do a lot of workfocusing more broadly on health
disparities and the ways inwhich laws and policies either
contribute to health disparitiesor can be used as tools to
prevent disparities.
So I'm really I've been sort offascinated for a long time
about the ways in which thelegacy of laws that directly
(04:40):
impact health, likediscrimination laws, may affect
people's health, but also theways in which laws that we don't
even think of as related tohealth may impact people's
health.
So you think about, you know,housing laws or laws
contributing to the builtenvironment and what
opportunities people have andwhat access they have.
So we know in public healththat that is significant to
(05:02):
contributing to people's healthgenerally and certainly to
population health outcomes andhealth disparities.
The focus of a lot of my worknow is on maternal and
reproductive health.
As I said, and because, given mywork around health disparities,
I've been particularlyinterested in understanding
maternal health disparities forblack women and understanding
(05:23):
why they die at rates two tothree times that of white women.
Their babies also die at ratesof two times that of white women
, and so you know thesedisparities are not natural,
they come from somewhere, and myunderstanding of the law and
policy and sort of policychoices is important, I think,
(05:43):
in trying to think through whatare interventions, both in terms
of using law as a tool toimprove these situations, but
also understanding thatsometimes laws have negative
implications and how can webetter understand that?
One of the things that I'vestudied in great detail is sort
of the role of social drivers ofhealth, so social experience
(06:04):
and the ways in which socialexperience affects health
outcomes.
There's reams and reams ofpublic health research,
understanding that our socialexperiences contribute in a
significant way to our health,even more than access to health
care.
So living in poverty,experiencing discrimination,
living in unstable and unsafehousing, all of these things
(06:24):
contribute vastly to theoutcomes that people experience
in terms of their health.
And so, when you kind ofcombine those questions with the
experiences of pregnancy,maternal health and particularly
for black mothers whoexperience a number of those
social drivers.
We really have to understandhealth and maternal health and
reproductive health in thisreally broad way of
(06:47):
understanding the importance ofsocial drivers.
Speaker 1 (06:50):
That's a large swath of information to cover and to
work on, and I suppose you havesome concentrations of your work
too that maybe we'll get into.
But, to your point, socialdeterminants of health,
non-medical drivers of health,are really important data points
to examine when we're trying toaffect change in communities
(07:11):
that are underserved orunderprivileged or less
advantaged.
Now, especially with maternalhealth, it's widely known that
there's a disparity as well inthe research done specifically
on women's health and medicaltreatment for women, and
maternal health may be even oneof the most underserved observed
(07:31):
areas, if you will.
So the continuation, then, ofmaternal health projects such as
the one engineered by theNational Institutes for Health
is probably very important andnecessary, right?
How would you say your work iscontributing to giving us a
better picture of what womenneed and how to affect more
positive outcomes?
Speaker 3 (07:53):
Yeah, I mean, I think , on the National Institutes of
Health, it's really important tounderstand both where we have
been and where we are going, andthe research that has been
funded under the NationalInstitutes with regard to
maternal health has been justcritical in understanding the
disparities that we're talkingabout and understanding the
outcomes that we're talkingabout.
(08:13):
Not only do we have racialdisparities in maternal health,
but we have worse outcomes thanevery other wealthy nation has
right in terms of maternal deathand maternal morbidity.
So being able to track thatover time at the population
level, but also to studyinterventions that might be
appropriate for addressing thoseproblems, is critical.
(08:33):
And one of the concerns that weall have right now, as NIH
funding is being cut or grantsare being stopped, is that we're
going to lose sight of just howto think about these problems,
not only to track the problemsbut to think about the
interventions that we might beable to bring to bear.
And I think we had, you know, anumber of really good
(08:54):
progressive ways of thinkingabout this under the Biden
administration, both in terms ofresearch but also in terms of
interventions that now have beenpulled back under the new
administration, and so you know,having good research is
critical.
One of the things that we'remost worried about and I've done
work using the Pregnancy RiskAssessment Monitoring System.
It's a CDC-based program thatstudies people during pregnancy.
(09:19):
It's a large survey that moststates administer and it gives
us great insight into the kindsof issues that pregnant women
experience, and that has nowbeen taken offline by this
administration, and many of usare deeply concerned that
without that research we won'tbe able to study things like how
many women express that theyare experiencing domestic
(09:39):
violence, for example, becausethat's a question in the survey.
So if we don't have thatinformation, it of course makes
it that much more difficult forus to intervene.
Speaker 1 (09:48):
Yeah, I can certainly see why.
So this is where we come tokind of the intersection of
medicine and law.
They are somewhat mutuallyexclusive concepts, but yet your
work consists of anintersection of those two things
.
How does law coexist in thehealthcare space?
Speaker 3 (10:05):
You know, I don't think they're mutually exclusive
.
What I've learned over mycareer is that law really is a
foundation for virtuallyeverything that we do in society
, but in particular medicine andpublic health.
So we may all be certainlyaware that law structures and
regulates the healthcare systemthat we all experience.
It regulates the ways in whichproviders interact with patients
(10:27):
.
It also regulates and a lot ofthis is constitutional law sort
of what can the government do,for example, during a pandemic,
and how does the governmentbalance the individual interests
of people against public healthneeds, right?
So law really frames a lot ofthose kinds of questions.
But what I became mostfascinated with and this was
(10:47):
when I was in law school back inthe 1990s was understanding the
way that law, as I talked abouta little bit earlier, really
structures our socialenvironment and our social
experience.
So I worked in the 1990s at thefirst medical legal partnership
in the country at Boston MedicalCenter, which was an
opportunity to have lawyers andclinicians actually partner
(11:08):
together to provide better carefor patients.
I was working in the pediatricunit at Boston Medical Center
and so we worked with a lot ofparticularly low-income mothers
and children who experienced allsorts of negative social
drivers, as we talked aboutbefore housing, lack of access
to basic needs, domesticviolence and what I came to see
(11:30):
was that legal advocacy andbeing able to understand how the
law interacts with people'sexperiences and how it drives
their health is really acritical component of the
connection between law andmedicine and public health
generally.
So I'll give you an examplethere was a specialized program
at the hospital that focused onchildren who were exposed to
(11:51):
domestic violence, and becausewe had this sort of team, which
included lawyers, we were ableto work with families, both
survivors and their children, toprovide not only medical care
and therapeutic care because, ofcourse, there's significant
trauma that's affecting both thesurvivor and her children but
also by having lawyers engaged,we could address things like
(12:13):
getting protective orders, butalso breaking down some of the
legal barriers that so many lowincome in particular, but people
experiencing domestic violencemight find around.
You know, if they are able toget out of the relationship, can
they access housing, whathappens with their employment, a
whole range of issues thatdrive their health or social
drivers of health, but they'realso barriers for people
(12:35):
experiencing violence, and so Iwas really taken with this
understanding of how lawyers canplay such a significant role in
the healthcare setting by usinglaw as a tool to actually
support people and ensure thatnot just the laws are written
correctly but that they'reenforced on behalf of people
that otherwise might not be ableto get what they need and to
(12:55):
survive.
So I found that a reallycompelling model, and that's
when I really began to see theconnections between law and
health.
Speaker 1 (13:03):
Yeah, it's brilliant.
Is it a model that's still inplace today?
Speaker 3 (13:06):
It is.
That was the first one in thecountry.
There's now about 450 medicallegal partnerships in different
health clinics and settings andhospitals across the country.
So that was really thebeginning, as I said, of the
movement, and I'm a huge fan ofsort of this team-based approach
, particularly in healthcare, tounderstanding that health
encompasses many, many differentsocial and structural legal
(13:28):
issues.
So if you have the appropriateteam, including lawyers, I think
you can have a significantimpact on people's health and
well-being.
Speaker 1 (13:35):
Yeah, I'm really excited to hear that and about
that type of a partnershipacross the country.
Now let's talk a little bitabout the domestic violence that
we've both kind of mentionedhere so far in our conversations
, because the CDC reports thatapproximately 40% of homicides
among persons known to bepregnant or within a year of
pregnancy are related tointimate partner violence.
(13:57):
Is it statistics like thesethat motivated you to sharpen
the focus on maternal health inparticular?
Speaker 3 (14:04):
Yeah, I mean I think I was, and I'll just say a
little bit about my backgroundwith domestic violence and sort
of how I began to connect thedots between domestic violence
and maternal health.
So when I was in college manyyears ago, in the 1980s, I
worked at a domestic violenceshelter in Austin, texas as a
volunteer and really came tounderstand the dynamics of
domestic violence and becamequite passionate about
(14:26):
addressing those issues.
So when I was in law school Iworked as a domestic violence
advocate in the district courtand provided services and
support to people seekingdomestic violence restraining
orders and that just gave meenormous insight into the way
that abusive relationshipsfunction and the legal barriers
and other kinds of barriers thatsurvivors experience.
(14:46):
I also did work in the AttorneyGeneral's office during law
school focused on the effects ofdomestic violence on children,
and we were doing statewidetraining for law enforcement and
healthcare providers aroundthose issues.
So I had this sort of passionand background in domestic
violence.
I'm also passionate aboutreproductive and maternal health
and so those two thingsobviously intersect.
(15:07):
But I will say when I firstlearned the statistics as you
just mentioned about, you knowhow many people experiencing
abusive relationships, domesticviolence, are killed during
pregnancy.
Speaker 2 (15:20):
I was astonished.
Speaker 3 (15:21):
You know, what we know now from the public health
literature is that pregnantpeople die from homicide at
rates higher than hemorrhage andpreeclampsia, which are often
the reason that people dieduring pregnancy.
And so when you think aboutthat and the fact that we really
don't talk about that, we don'tthink about interventions that
(15:41):
are going to prevent pregnantpeople from being killed during
pregnancy, you know it's prettyastonishing.
So what I started to look atwas, again, with this sort of
legal framework is what are someof the ways that we can address
that problem?
I also want to mention that inmy research and this is, you
know, public health researchothers have done.
black women die at five timesthe rate of white women from
(16:03):
homicide during pregnancy andyou know we think that much of
that has to do with the lack ofresources in many communities of
color for survivors and victims, but also a reluctance to call
the police in communities ofcolor, where police violence may
be prevalent.
And so, again, black women havemuch higher rates of maternal
mortality generally, but we alsoknow that they have
(16:26):
significantly higher rates dueto homicide.
So the ways in which pregnancyand domestic violence intersect
are actually complex, and thereare many different factors that
come into play.
One is reproductive coercion,meaning that an abuser may
sabotage birth control, maycontrol the ways in which his
partner is able to control herown fertility, preventing access
(16:49):
to abortion.
Other things like that is quiteprevalent in relationships
where there's abuse, so issexual violence, and so unwanted
pregnancy in thoserelationships can be quite
common.
So, sort of on the front end,if there's abuse there's more
likely an unwanted pregnancy.
But then, of course, oncesomebody becomes pregnant, we
(17:10):
know that the violence escalates.
We're not entirely sure whythat happens.
I think, understanding thedynamics of domestic violence,
it's likely a time where theabuser wants to maintain even
more control and uses power todo that and violence to do that.
And one thing that we havelearned in terms of access to
reproductive health care, whichis another part of this, is the
(17:32):
importance of access to abortionand birth control for survivors
.
Reports of reproductivecoercion actually doubled the
year after Dobbs.
So there seemed to be a sort ofmessaging around who gets to
make decisions aboutreproduction or fertility for
survivors of domestic violencethat some abusers took to heart,
(17:53):
and there seems to be anincrease in reproductive
coercion.
And then, finally, I'll justsay access to care and, in
particular, abortion.
There's a new study that justcame out from the National
Bureau of Economic Research thatfound that reports of domestic
violence increased between 7 and10% for women living in
counties with abortion bans orsevere restrictions after DOB.
(18:14):
So there is a linkage betweenaccess to reproductive health
care, reproductive decisionmaking and violence.
Again, untangling all the waysin which these things interact
is really critical for beingable to intervene.
Speaker 1 (18:28):
This is a highly complex situation.
It's hard to believe that we'regoing to cover this topic in
just the little time we have tospend together, because you've
raised so many important pointsfor us to think about and, like
you, I was astonished as well atthe incredibly high rate of
lethality for pregnant women,especially Black women.
It's just incredible to me thatwe could have these statistics
(18:52):
and not have more legislation inplace, more access to health
care in place to accommodatepregnant women, and have
screenings in place with OBGYNsand others who care for women
who are pregnant and postpartumto determine their safety at
home.
Does that exist?
Speaker 3 (19:09):
I'll start with sort of this, the circumstances under
which OBGYNs are working rightnow and other healthcare
providers.
I mean, I would say ourhealthcare system is in crisis
in many places and that has todo with a lack of primary care
providers in many places.
So just people being able toaccess care for OBGYNs because
of the Dobbs decision, and sothe working conditions for
(19:32):
OBGYNs, depending on the statethey live in and what that looks
like in terms of being able toprovide the standard of care.
You know, we know, that theworkforce of OBGYNs is shifting,
that many are leaving thestates that have restrictive
abortion policies, which thencreate, you know, maternal
health and reproductive healthcare deserts in those states.
They're working underconditions that are really,
(19:54):
really challenging.
But, even in states where therearen't abortion restrictions,
there are lots of pressures onOBGYNs and primary care
providers in terms of the numberof patients they need, to see
how they respond to their needs,the sort of 10-minute or
15-minute visit.
So when you think about that inthe context of working with
people that are experiencingviolence, and how complex that
(20:15):
can be, because, many survivorsmay be reluctant to reveal or
disclose what's happening tothem and you have a provider who
may not have the time to reallyengage, so I think there are
pressures there.
That being said, you know we doknow what best practices are
for healthcare providers,including OBGYNs, that are
really useful in trying toaddress the needs of people that
(20:38):
come in that are experiencingviolence.
I would say not even all OBGYNsare completely aware of the
fact that domestic violence mayescalate during pregnancy.
So being aware of that iscritical.
But you mentioned screening.
Certainly the best practice isthat all patients be asked about
violence and safety in the home.
I think it's not just a matterof checking a box, which
(21:01):
sometimes it may feel like forpeople when they're being
screened for a whole range ofthings, because there's more and
more screening in the medicalsetting now for a lot of
different issues, but a reallyengaged screening in the sense
of looking the person in the eyesetting now for a lot of
different issues, but a reallyengaged screening in the sense
of looking the person in the eye, really engaging them and
really giving them space andtime to respond is critical.
(21:22):
But again, that can bechallenging in the current
environment and certainly lackof judgment or being
non-judgmental about theresponse, is critical.
Certainly, talking to them ifthey do disclose about what they
want and what they see as theiroptions, and not sort of
imposing those are reallycritical.
I think the other thing thatOBGYN offices can and should do,
(21:45):
whether it's a hospital settingor a smaller clinical setting,
is to really know the resourcesin the community and to build
partnerships with domesticviolence advocates, because I
think a lot of clinicians may bereluctant to ask these
questions if they don't knowwhat to do if they get a
positive answer.
So being able to know inadvance if the person needs help
(22:05):
, who can I turn to to help themengage in safety planning,
because they may not be able toleave today, but we can help
them begin that journey ifthat's where they are.
So I think there are a lot ofways that OBGYNs can be really
critical here, as well as otherproviders that interact with
women generally, but pregnantpeople as well.
Speaker 1 (22:24):
Yeah, you write some very interesting ideas about how
to screen and who to screen andwhen to do it, as well as the
time that it takes to add thatinto an office visit.
There's another complicationthat we should probably talk
about when doing screenings inan OBGYN office, and that is
when the abuser accompanies thepregnant woman to her doctor's
appointments.
(22:44):
It's not uncommon for expectingparents to visit the OBGYN's
office together for the regularappointments.
There are so many of them, bothduring the pregnancy and then
immediately following delivery,so that complicates things.
What are your thoughts aroundhow to get around that kind of a
situation, especially if theOBGYN suspects there could be
(23:07):
some intimate partner violence?
Speaker 3 (23:09):
OBGYNs who are trained and sensitive to
domestic violence, and I wouldadd, that's another critical
feature here is being sure thatwe train the workforce both
OBGYNs and other primary careproviders, as well as others, to
understand how power andcontrol work in these
relationships, and I taught atthe medical school here at Brown
for nine years and we werereally trying to build out the
(23:30):
training for medical studentsand residents around these
issues.
Because if you don't understandthose dynamics then you're not
going to pick up on cues, likean abuser who may insist on
being in the room if the patientis being examined, for example.
And so I think providers whoare sensitive to these issues
and who are able to pick up onthose cues can respond in a few
(23:51):
different ways.
They can certainly just ask ifthey can have a private visit
with the patient.
It's better not to ask thepatient because the patient may
be feeling threatened by theabuser.
So if you say you know, are youcomfortable with him being here
, she's likely to say yes.
You can say things like this isa part of the exam that I
usually do in private with mypatient, so I'm going to ask you
(24:13):
to leave the room for a fewminutes while we do that and
then use that opportunity as thetime to talk to the patient, to
get a better understanding ofwhat's going on and to determine
if there's reason for concern.
Speaker 1 (24:24):
I don't know how they do it.
I'm trying to think about youknow all of your points with a
discussion about nurses.
You know if nursing schoolsalso have training and education
for nursing students or evencontinuing the education about
domestic violence?
Speaker 3 (24:41):
You know, I don't know sort of across the board
the answer to that question myexperience with nursing
education is that they actuallyare quite good on this.
Again, I don't know if that'strue of all nursing education,
but I would say I think that's acritical aspect of this, not
just in the OBGYN setting but inemergency care, for example, or
other places where providers,including nurses, might interact
(25:03):
with people who areexperiencing domestic violence,
really again being able to sensewhat's going on, but also
thinking carefully about how tointeract with the patient in a
way that's not going to endangerher or allow her abuser to
threaten her and not allow herto get the care that she needs.
Speaker 1 (25:18):
Beyond pregnancy.
Postpartum is an incrediblychallenging time in a lot of
ways, but can be so much so fordomestic violence survivors,
because the wife or partner isnow mom and attention is
diverted to the new baby andaway from her partner or her
husband.
That is an extremely dangeroustime for a woman Because if
(25:43):
she's already in an abusiverelationship, it can really fan
the flames for this abuser right, For example, if he's feeling
that he's not receiving theattention that he deserves, he's
(26:11):
likely to be more controlling,he's likely to be more violent.
Speaker 3 (26:14):
But it's also harder to leave when you have a child,
especially if that controllingbehavior has meant that the
finances are controlled by theabuser, access to transportation
, a whole range of differentaspects of abusive behavior, and
those do often escalate after ababy is born.
But also children are veryoften used as pawns in these
relationships.
(26:34):
If you take the child away fromme, I will hurt you or kill you
.
They're often used as pawns inany kind of divorce litigation
or restraining order settingright.
So it gets even that much morecomplicated for the survivor to
not only to try to leave butalso to just stay safe, because
things can escalate.
Speaker 1 (26:53):
Yeah, definitely a frightening time for mom and
baby and unfortunately thingscan continue to unravel from
there Because there's alsoconsequently there can be sick
babies or mental health problemsor postpartum maternal health
problems for mom.
So things can just kind ofbegin to accelerate and create
(27:16):
issues inside the home whichthen kind of spill over outside
the home.
There'll be problems at work,there will be problems at school
.
These problems will lendthemselves to societal problems
as well.
So let's talk about thatspillover and maybe you can
provide more insight to us froma public health perspective how
domestic violence for pregnantwomen creates kind of this
(27:39):
ripple effect across otherissues in society.
Speaker 3 (27:43):
We haven't really talked about this yet.
So let me sort of ground thisand individual health outcomes
for both survivors and theirchildren, and then we can talk
about how we think about that atthe population level.
So you know, the research isreally really clear that people
who experience domestic violenceas survivors have long term
health implications.
(28:03):
So we might think aboutinjuries, right, but there's
obviously other ways in whichexperiencing domestic violence
affects people's health.
So it affects their mentalhealth through trauma.
It makes it more likely thatthey may use substances to cope.
But also what we've learnedfrom the public health research
is that stress in and of itselfplays a major factor in people's
(28:23):
health, including things likechronic disease, hypertension,
gastrointestinal problems awhole range of body systems that
are affected by stress.
So if you think about what'sstressful, living in a violent,
controlling relationship isprobably number one on your list
.
So there are health concernsthat occur for the survivor
based on that experience ofviolence.
(28:43):
What I was learning in the1990s and really found
fascinating is that there's beengood research done also on
children who are exposed todomestic violence, not
necessarily harmed physicallythemselves, but when we look at
their long term outcomes again,trauma related stress and a
whole host of adult healthproblems that manifest from
(29:06):
living in that stressfulenvironment and being exposed to
that violence.
So what we call that in publichealth is adverse childhood
experiences.
That's the language that comesfrom a variety of studies that
have looked at specific types ofadverse experiences that
children have and domesticviolence exposure is clearly one
of them.
So understanding sort of againthe implications, not just for
(29:28):
what might be happening at themoment in that home, but the
long term exposure for childrenand trauma that's experienced by
the survivor and the childrencreate ripple effects in the
healthcare system like missedwork, children not being able to
concentrate in school andtherefore not being able to
achieve, and that affectingtheir long-term productivity and
(29:51):
ability to work and theiropportunity.
We also talked about socialdeterminants of health.
People that are in violentrelationships, particularly if
they do leave, are more likelyto be homeless more likely to
live in poverty.
All of these things escalatebased on the experience of
violence and have enormousimplications for our healthcare
system, for education system,for criminal justice system
(30:13):
potentially and some people whohave studied this have put the
cost per year at about $8billion for the United States.
So when you think about the,you know the ramifications of
this as a social problem.
It's quite stark.
Speaker 1 (30:30):
There is some interesting research out there
about that and to your point,that $8 billion.
It's said that every economicsector of our society is
impacted by domestic violenceand a dollar value can actually
be pinpointed to it.
To your point, loss of time atwork, loss of wages.
It impacts the health industry,every single one.
(30:51):
You can go in and find thedollar value for, and if nothing
else, it should be eye openingto people.
If the statistics aboutlethality don't frighten you,
you know, maybe it makes sense,more sense to you if you look at
the economic impact of domesticviolence.
What recommendations then doyou have for policymakers and
legislators that could improvethe lives or protect pregnant
(31:12):
women experiencing intimatepartner violence?
Speaker 3 (31:15):
Yeah, I mean, I think to your point.
It's astonishing to me thatit's such an unrecognized
problem, right, because the datais so clear, and so I think we
all are.
We all have an obligation totry to educate our policymakers
about this and to help them tobetter understand domestic
violence in general, but inparticular, how it affects
maternal health and healthduring pregnancy.
(31:37):
We're in the midst of a crisis,I would argue, around pregnancy
care, around maternal healthand around violence against
women, and when you bring all ofthose things together, they're
really overlapping public healthproblems, and so that can make
it feel overwhelming andcomplicated, but I think we can
think about different aspects ofthe problem and try to address
them that way.
(31:57):
So before I get to that, I'lljust say we're a little bit in
defensive mode at the momentwith much of this because of
budget cuts that are reallyreally could be significant in
terms of addressing the problemswe're talking about.
So right now, there are threatsthat there could be significant
cuts to the Office of ViolenceAgainst Women, which is a
primary federal agency thatprovides a lot of funding for
(32:20):
services for people that areexperiencing violence.
That comes on the heels of theVictims of Crime Act reductions,
which is also a major source offunding for domestic violence
programs, and, as we talkedabout earlier, a reduction in
funding for research aroundmaternal health and violence
prevention.
So right now we're in a placewhere we have to sort of play
(32:41):
defense in terms of trying toget these programs reinstated.
But beyond that, we need tothink proactively, and so, on
the one hand, we have thismaternal health crisis, and
there are ways to think aboutthat.
So there has been legislationproposed, I think every year for
the last several years, byRepresentative Lauren Underwood
and Representative Alma Adams.
(33:01):
It's called the Momnibus BillMomnibus Act, and it's a
multifaceted piece oflegislation that really looks at
the maternal health crisis andprovides major investments in
different programs that wouldsupport maternal health.
So that includes even fundingfor things that we would think
of as sort of social drivers ofhealth, like thinking about
access to housing and supportivecommunity-based services and
(33:25):
that kind of thing.
So you know, I think it's notthat we can't think of things to
do right.
There are ways to do this if wecan get the political will to
support that.
On the domestic violence side, Ithink we haven't really talked
about this yet, but one of theother ways of thinking,
particularly about reduction ofperinatal homicide, is the
relationship with gun violence.
More than half of the victimsof homicide during pregnancy are
(33:49):
killed with a firearm, and soyou know we have not done a good
job of ensuring that people whoare known to be domestic
abusers not access firearms.
There was a major Supreme Courtcase a couple of years ago, the
Rahimi case, where the questionwas whether the court was going
to maintain the ViolenceAgainst Women Act provision that
(34:09):
prohibits domestic abusersunder subject to restraining
orders from possessing firearms,and the court fortunately did
uphold the law.
The federal law, but that lawdepends significantly on state
enabling legislation and stateenforcement, and what we know is
that those laws are highlyunenforced not enforced to the
(34:29):
degree that they should be, andso we know that if there's a gun
in the home, a personexperiencing domestic violence
is five times as likely to bekilled with that gun.
So, you know, intersectionallyagain thinking about access to
firearms and what that means forhomicide, and then, I think,
generally just looking at theways in which we do or don't
enforce many of our domesticviolence provisions.
(34:51):
I mean, we have come a long wayin law enforcement and options
for things like restrainingorders, but there's a lot of
gaps in terms of how those lawsare enforced and whether victims
and survivors actually feellike they're going to be safe.
And then, of course, finally,we have to invest in
community-based services, andthen again that goes back to
(35:11):
some of the work that we need todo to restore what was already
there.
But even those funding sourcesthat were already there were not
enough.
So if somebody is living inthis kind of relationship, are
there resources in theircommunity that can help them to
get out of that relationship?
And we're a long ways from that.
Speaker 1 (35:27):
Yeah, it's really going to take all of us, and all
of us working together, totackle some of these major
overarching, intersecting issuesand not to pile on.
But health insurance andMedicaid reform are very urgent
and controversial topics at themoment, and they are directly
related to maternal mortality.
(35:47):
What role do Medicaid ormaternal health policies play in
either helping or hindering apregnant survivor's ability to
get out of a violent situation?
Speaker 3 (35:58):
Yeah, I mean we know from the research that access to
Medicaid is life-saving ingeneral but also, you know,
reduces maternal mortality.
It plays a huge role forsurvivors of domestic violence
in that if you do not haveaccess to health insurance, you
are not going to get health care.
Clearly, if you're low income,and one of the primary ways that
we can detect and intervene ondomestic violence is through
(36:19):
health care.
Somebody has to be able to getto the clinic in order for that
to happen.
But the other important aspectof Medicaid and I think this has
been really the positive workof many years is many Medicaid
funded programs, particularlyfederally qualified community
health centers where many lowincome people get their health
care, have really robustlyexpanded their models to address
(36:41):
social needs as part of healthcare social needs including
things like exposure to domesticviolence.
So they often have socialworkers, they sometimes have
lawyers through medical legalpartnerships.
They often have communityhealth workers who live in the
community, often with livedexperience that might have their
own experience of domesticviolence, who really are there
(37:01):
to be a support system.
And so Medicaid access, orhaving coverage through Medicaid
, provides access to servicesthat can be really critical in
supporting people that areexperiencing violence.
The other thing about it is thatpeople don't always realize
this, but 40% of the babies bornin this country are covered by
Medicaid, and for Black womenit's 65%.
(37:24):
So think about a point ofintervention and a point of
potential support.
If all of those women arereceiving care through Medicaid
during their pregnancy and atthe time of birth, that's a
great point of potential supportand intervention.
And again, we can talk about,as we did earlier, the ways in
which clinicians can play a rolein that.
(37:45):
But Medicaid provides thisamazing opportunity to do that.
I think the cuts that are beingproposed are potentially
devastating in terms of peoplebeing cut off of Medicaid.
Fortunately, I think the periodof pregnancy and postpartum
will likely still be covered forpeople, but these things don't
just start in pregnancy.
If people have access toMedicaid over a longer period of
(38:08):
their lifespan, opportunitiesfor prevention and intervention
can occur earlier andpotentially prevent an unwanted
pregnancy of someone who's in anabusive relationship or ensure
that they get the care that theyneed earlier.
So I'm concerned, I'm reallyconcerned about potential cuts
and I think you know Medicaidagain is a really critical
aspect of this.
Speaker 1 (38:27):
I think all women should be concerned about
potential cuts to Medicaid andother offices that you mentioned
, like the Office on ViolenceAgainst Women and lots of other
things, because these are goingto impact us.
They're going to impact ourchildren, whether they are girls
or boys, across the board.
So there's also a lot ofcontradictions in some of the
decision making going on aroundthese issues, such as denying
(38:50):
anyone the right to an abortion,with abortion bans in certain
places in this country, and thenalso demanding, in a sense,
that they carry a pregnancy toterm but not giving health
coverage potentially to care forthat pregnancy and then the
resulting baby.
So I don't understand the logicbehind some of the ideas right
(39:11):
now, but maybe it'll revealitself as we move forward.
Let's talk for a minute aboutprevention strategies that you
can share that would bebeneficial to implement and
actions that this audience cantake to support pregnant women
in dangerous situations.
Speaker 3 (39:26):
The first thing I would say to anyone who's
concerned about this in theircommunity or sphere, family
sphere is asking someone thatyou're concerned about if they
feel safe and supported duringtheir pregnancy.
We think of you started, Ithink, at the beginning of
pregnancy as this incrediblyhappy, joyful time.
For some people, that'scertainly true, but for many,
(39:46):
especially if they'reexperiencing abuse, they're
going to feel even more trappedand more hopeless during this
period Because, as we talkedabout, violence can escalate,
but also having a baby can makeit even more difficult to leave,
and so I think people areafraid often to raise these
questions.
But I think it's critical thatif someone is concerned or
suspects that this is happening,that they ask the person and
(40:08):
let them know that there issupport there, even if they're
not initially responsive to that.
We talked about firearms, Ithink you know, for clinicians
for, again, for anyone who'sconcerned, knowing and asking if
there are firearms in the homefor a pregnant woman is critical
, because we know from theresearch it's much more likely
that that firearm will be usedif it's in the home and that
(40:31):
raises the possibility ofhomicide.
I always stress this, you know.
I think it's really hardsometimes for all of us to
understand, if somebody'sexperiencing this kind of
relationship, why they make thechoices that they make, and it's
really critical that we notjudge, that we listen, that we
offer options and resources andmake it clear that we are always
(40:53):
there if the person needsanything, and let them make the
decisions and be empowered to dothat, because we can't always
understand exactly what they'refacing and why they're making
the decisions that they'remaking.
We have a tendency in thiscountry to ignore or not pay
attention to violence againstwomen in general.
We've kind of normalized it, Ithink in a way that means that
(41:14):
we sort of accept that we havethe statistics that we have and
it's not acceptable.
I think all of us need tounderstand those statistics,
talk about those statistics, payattention to what's happening
in our own community, advocatefor the people that we know are
experiencing this, and talkabout the importance of
protecting and supportingpregnant women and women in
(41:37):
general, and not only their baby.
They are valuable, importanthuman beings and they should be
a priority as much as otherpeople and even their children.
So that's how I would urgepeople to think about this issue
going forward.
Speaker 1 (41:50):
Yeah, absolutely Good advice.
Thank you for all of theinformation that you shared and
for the work you're doing forthis important population this
important moment in time in ourcountry.
I appreciate you being here.
Thank you for being on the showtoday.
Speaker 3 (42:03):
Thanks for having me.
I really enjoyed talking withyou.
Speaker 1 (42:05):
Thanks so much for listening.
Until next time, stay safe.
The Conference on CrimesAgainst Women Summit Beyond the
Bounds, designed to addressgender-based crimes specific to
coastal, resort and ruralcommunities, will be held
September 22nd and 23rd in SouthPadre Island, texas.
For more information and toregister, visit our website
conferencecaworg.
(42:26):
And save the date for the 2026Conference on Crimes Against
Women convening May 18th throughthe 21st 2026 in Dallas, texas,
and follow us on social mediaat National CCAW to get the
latest news and informationabout all upcoming events and
trainings, including virtual andin-person educational
opportunities, updates on theInstitute for Coordinated
(42:47):
Community Response and more.
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