Podcast on Crimes Against Women
The Conference on Crimes Against Women (CCAW) is thrilled the announce the Podcast on Crimes Against Women (PCAW). Continuing with our fourth season, the PCAW releases new episodes every Monday. The PCAW serves as an extension of the information and topics presented at the annual Conference, providing in-depth dialogue, fresh perspectives, and relevant updates by experts in the fields of victim advocacy, criminal justice, medicine, and more. This podcast’s format hopes to create a space for topical conversations aimed to engage and educate community members on the issue of violence against women, how it impacts our daily lives, and how we can work together to create lasting cultural and systemic change.
Podcast on Crimes Against Women
Homicide is a leading cause of maternal death, and we're not talking about it enough.
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.
The subject matter of this podcast will address difficult topics multiple forms of violence, and identity-based discrimination and harassment. We acknowledge that this content may be difficult and have listed specific content warnings in each episode description to help create a positive, safe experience for all listeners.
Speaker 2:In this country, 31 million crimes 31 million crimes are reported every year. That is one every second. Out of that, every 24 minutes there is a murder. Every five minutes there is a rape. Every two to five minutes there is a sexual assault. Every nine seconds in this country, a woman is assaulted by someone who told her that he loved her, by someone who told her it was her fault, by someone who tries to tell the rest of us it's none of our business and I am proud to stand here today with each of you to call that perpetrator a liar.
Speaker 1:Welcome to the podcast on crimes against women. I'm Maria McMullin. When abusers make the choice to exact violence onto their pregnant partners, it is not just the offender who has failed mom and baby. Oftentimes, it is also the social systems and institutions that re-victimize this vulnerable population due to deficiencies such as unaffordable health care, inequity of services, lack of resources and funding, structural racism or the inability to keep them safe. Unfortunately, these deficits can lead to the death of mother and child. To emphasis this point, the National Partnership for Women and Families report that each year, an estimated 324,000 pregnant people in the United States are battered by their intimate partners. Furthermore, they report that 63% of female homicide victims were killed by an intimate partner in cases where the victims knew the offender, as homicide is a leading cause of traumatic death for pregnant and postpartum women. It accounts for 31% of maternal injury deaths. Today we are excited to engage in a conversation with a renowned lawyer and public health and policy professor who has dedicated her research and teachings towards women's health and intimate partner violence and the legalities that surround this epidemic.
Speaker 1:Elizabeth Tobin Tyler is a professor of health services policy and practice at Brown University School of Public Health. She teaches in the areas of reproductive rights and justice, public health law and ethics, health policy and health justice. Her scholarship focuses on women's health, reproductive justice, intimate partner violence, the structural and legal determinants of health equity and public health law and policy. Professor Tobin Tyler edited Poverty, health and Law Readings and Cases for Medical-Legal Partnership and co-authored with Joel Teitelbaum An Essentials of Health Justice, law Policy and Structural Change. Her scholarship has been published in multiple journals, including the New England Journal of Medicine, jama, american Journal of Public Health, american Journal of Preventative Medicine, the Lancet Health Affairs, the Journal of Health and Human Rights Journal of Legal Medicine and the Journal of Law, medicine and Ethics. She holds a BA and MA from the University of Texas at Austin and a JD from Northeastern University School of Law. She has been selected for several fellowships and honors, including the Emerging Leaders in Health and Medicine Forum by the National Academy of Medicine, as a Public Health Law Education Faculty Fellow by the Robert Wood Johnson Foundation and as a fellow at the Law Health Justice Center at the University of Technology in Sydney, australia.
Speaker 1:Professor Tobin Tyler, welcome to the show. Thanks for having me. Happy to be with you. So we opened this episode with an overview of how pregnancy, while supposed to be a joyful and exciting experience, is also, for some women, the most dangerous, indicating that homicide is the leading cause of traumatic death for pregnant and postpartum women. It makes sense, then, that we should look at this situation from many angles, including public health and policy. So help us understand the intersection of maternal lethality, public health and policy by starting with the work you do at Brown University and the impact your research and work has on public health and policy.
Speaker 3:Sure. So I am a professor of health services policy and practice at the Brown School of Public Health. I'm trained as a lawyer, which is somewhat unusual in public health, but my work really focuses on the ways in which laws and policies, both as written as well as how they're implemented and enforced, affect people's health. So a lot of my work centers around reproductive health, rights and justice. I also do a lot of work focusing more broadly on health disparities and the ways in which laws and policies either contribute to health disparities or can be used as tools to prevent disparities. So I'm really I've been sort of fascinated for a long time about the ways in which the legacy of laws that directly impact health, like discrimination laws, may affect people's health, but also the ways in which laws that we don't even think of as related to health may impact people's health. So you think about, you know, housing laws or laws contributing to the built environment and what opportunities people have and what access they have. So we know in public health that that is significant to contributing to people's health generally and certainly to population health outcomes and health disparities.
Speaker 3:The focus of a lot of my work now is on maternal and reproductive health.
Speaker 3:As I said, and because, given my work around health disparities, I've been particularly interested in understanding maternal health disparities for black women and understanding why they die at rates two to three times that of white women.
Speaker 3:Their babies also die at rates of two times that of white women, and so you know these disparities are not natural, they come from somewhere, and my understanding of the law and policy and sort of policy choices is important, I think, in trying to think through what are interventions, both in terms of using law as a tool to improve these situations, but also understanding that sometimes laws have negative implications and how can we better understand that?
Speaker 3:One of the things that I've studied in great detail is sort of the role of social drivers of health, so social experience and the ways in which social experience affects health outcomes. There's reams and reams of public health research, understanding that our social experiences 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 unsafe housing, all of these things contribute vastly to the outcomes that people experience in terms of their health. And so, when you kind of combine those questions with the experiences of pregnancy, maternal health and particularly for black mothers who experience a number of those social drivers. We really have to understand health and maternal health and reproductive health in this really broad way of understanding the importance of social drivers.
Speaker 1:That's a large swath of information to cover and to work on, and I suppose you have some concentrations of your work too that maybe we'll get into. But, to your point, social determinants of health, non-medical drivers of health, are really important data points to examine when we're trying to affect change in communities that are underserved or underprivileged or less advantaged. Now, especially with maternal health, it's widely known that there's a disparity as well in the research done specifically on women's health and medical treatment for women, and maternal health may be even one of the most underserved observed areas, if you will. So the continuation, then, of maternal health projects such as the one engineered by the National Institutes for Health is probably very important and necessary, right? How would you say your work is contributing to giving us a better picture of what women need and how to affect more positive outcomes?
Speaker 3:Yeah, I mean, I think, on the National Institutes of Health, it's really important to understand both where we have been and where we are going, and the research that has been funded under the National Institutes with regard to maternal health has been just critical in understanding the disparities that we're talking about and understanding the outcomes that we're talking about. Not only do we have racial disparities in maternal health, but we have worse outcomes than every other wealthy nation has right in terms of maternal death and maternal morbidity. So being able to track that over time at the population level, but also to study interventions that might be appropriate for addressing those problems, is critical. And one of the concerns that we all have right now, as NIH funding is being cut or grants are being stopped, is that we're going to lose sight of just how to think about these problems, not only to track the problems but to think about the interventions that we might be able to bring to bear. And I think we had, you know, a number of really good progressive ways of thinking about this under the Biden administration, both in terms of research but also in terms of interventions that now have been pulled back under the new administration, and so you know, having good research is critical.
Speaker 3:One of the things that we're most worried about and I've done work using the Pregnancy Risk Assessment Monitoring System. It's a CDC-based program that studies people during pregnancy. It's a large survey that most states administer and it gives us great insight into the kinds of issues that pregnant women experience, and that has now been taken offline by this administration, and many of us are deeply concerned that without that research we won't be able to study things like how many women express that they are experiencing domestic violence, for example, because that's a question in the survey. So if we don't have that information, it of course makes it that much more difficult for us to intervene.
Speaker 1:Yeah, I can certainly see why. So this is where we come to kind of the intersection of medicine and law. They are somewhat mutually exclusive concepts, but yet your work consists of an intersection of those two things. How does law coexist in the healthcare space?
Speaker 3:You know, I don't think they're mutually exclusive. What I've learned over my career is that law really is a foundation for virtually everything that we do in society, but in particular medicine and public health. So we may all be certainly aware that law structures and regulates the healthcare system that we all experience. It regulates the ways in which providers interact with patients. It also regulates and a lot of this is constitutional law sort of what can the government do, for example, during a pandemic, and how does the government balance the individual interests of people against public health needs, right? So law really frames a lot of those kinds of questions.
Speaker 3:But what I became most fascinated with and this was when I was in law school back in the 1990s was understanding the way that law, as I talked about a little bit earlier, really structures our social environment and our social experience.
Speaker 3:So I worked in the 1990s at the first medical legal partnership in the country at Boston Medical Center, which was an opportunity to have lawyers and clinicians actually partner together to provide better care for patients.
Speaker 3:I was working in the pediatric unit at Boston Medical Center and so we worked with a lot of particularly low-income mothers and children who experienced all sorts of negative social drivers, as we talked about before housing, lack of access to basic needs, domestic violence and what I came to see was that legal advocacy and being able to understand how the law interacts with people's experiences and how it drives their health is really a critical component of the connection between law and medicine and public health generally.
Speaker 3:So I'll give you an example there was a specialized program at the hospital that focused on children who were exposed to domestic violence, and because we had this sort of team, which included lawyers, we were able to work with families, both survivors and their children, to provide not only medical care and therapeutic care because, of course, there's significant trauma that's affecting both the survivor and her children but also by having lawyers engaged, we could address things like getting protective orders, but also breaking down some of the legal barriers that so many low income in particular, but people experiencing domestic violence might find around.
Speaker 3:You know, if they are able to get out of the relationship, can they access housing, what happens with their employment, a whole range of issues that drive their health or social drivers of health, but they're also barriers for people experiencing violence, and so I was really taken with this understanding of how lawyers can play such a significant role in the healthcare setting by using law as a tool to actually support people and ensure that not just the laws are written correctly but that they're enforced on behalf of people that otherwise might not be able to get what they need and to survive. So I found that a really compelling model, and that's when I really began to see the connections between law and health.
Speaker 1:Yeah, it's brilliant. Is it a model that's still in place today?
Speaker 3:It is. That was the first one in the country. There's now about 450 medical legal partnerships in different health clinics and settings and hospitals across the country. So that was really the beginning, as I said, of the movement, and I'm a huge fan of sort of this team-based approach, particularly in healthcare, to understanding that health encompasses many, many different social and structural legal issues. So if you have the appropriate team, including lawyers, I think you can have a significant impact on people's health and well-being.
Speaker 1:Yeah, I'm really excited to hear that and about that type of a partnership across the country. Now let's talk a little bit about the domestic violence that we've both kind of mentioned here so far in our conversations, because the CDC reports that approximately 40% of homicides among persons known to be pregnant or within a year of pregnancy are related to intimate partner violence. Is it statistics like these that motivated you to sharpen the focus on maternal health in particular?
Speaker 3:Yeah, I mean I think I was, and I'll just say a little bit about my background with domestic violence and sort of how I began to connect the dots between domestic violence and maternal health.
Speaker 3:So when I was in college many years ago, in the 1980s, I worked at a domestic violence shelter in Austin, texas as a volunteer and really came to understand the dynamics of domestic violence and became quite passionate about addressing those issues. So when I was in law school I worked as a domestic violence advocate in the district court and provided services and support to people seeking domestic violence restraining orders and that just gave me enormous insight into the way that abusive relationships function and the legal barriers and other kinds of barriers that survivors experience. I also did work in the Attorney General's office during law school focused on the effects of domestic violence on children, and we were doing statewide training for law enforcement and healthcare providers around those issues. So I had this sort of passion and background in domestic violence. I'm also passionate about reproductive and maternal health and so those two things obviously intersect. But I will say when I first learned the statistics as you just mentioned about, you know how many people experiencing abusive relationships, domestic violence, are killed during pregnancy.
Speaker 2:I was astonished.
Speaker 3:You know, what we know now from the public health literature is that pregnant people die from homicide at rates higher than hemorrhage and preeclampsia, which are often the reason that people die during pregnancy. And so when you think about that and the fact that we really don't talk about that, we don't think about interventions that are going to prevent pregnant people from being killed during pregnancy, you know it's pretty astonishing. So what I started to look at was, again, with this sort of legal framework is what are some of the ways that we can address that problem? I also want to mention that in my research and this is, you know, public health research others have done.
Speaker 3:black women die at five times the rate of white women from homicide during pregnancy and you know we think that much of that has to do with the lack of resources in many communities of color for survivors and victims, but also a reluctance to call the police in communities of color, where police violence may be prevalent.
Speaker 3:And so, again, black women have much higher rates of maternal mortality generally, but we also know that they have significantly higher rates due to homicide. So the ways in which pregnancy and domestic violence intersect are actually complex, and there are many different factors that come into play. One is reproductive coercion, meaning that an abuser may sabotage birth control, may control the ways in which his partner is able to control her own fertility, preventing access to abortion. Other things like that is quite prevalent in relationships where there's abuse, so is sexual violence, and so unwanted pregnancy in those relationships 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, once somebody becomes pregnant, we know that the violence escalates. We're not entirely sure why that happens. I think, understanding the dynamics of domestic violence, it's likely a time where the abuser wants to maintain even more control and uses power to do that and violence to do that.
Speaker 3:And one thing that we have learned in terms of access to reproductive health care, which is another part of this, is the importance of access to abortion and birth control for survivors. Reports of reproductive coercion actually doubled the year after Dobbs. So there seemed to be a sort of messaging around who gets to make decisions about reproduction or fertility for survivors of domestic violence that some abusers took to heart, and there seems to be an increase in reproductive coercion. And then, finally, I'll just say access to care and, in particular, abortion. There's a new study that just came out from the National Bureau of Economic Research that found that reports of domestic violence increased between 7 and 10% for women living in counties with abortion bans or severe restrictions after DOB. So there is a linkage between access to reproductive health care, reproductive decision making and violence. Again, untangling all the ways in which these things interact is really critical for being able to intervene.
Speaker 1:This is a highly complex situation. It's hard to believe that we're going to cover this topic in just the little time we have to spend together, because you've raised so many important points for us to think about and, like you, I was astonished as well at the incredibly high rate of lethality for pregnant women, especially Black women. It's just incredible to me that we could have these statistics and not have more legislation in place, more access to health care in place to accommodate pregnant women, and have screenings in place with OBGYNs and others who care for women who are pregnant and postpartum to determine their safety at home. Does that exist?
Speaker 3:I'll start with sort of this, the circumstances under which OBGYNs are working right now and other healthcare providers. I mean, I would say our healthcare system is in crisis in many places and that has to do with a lack of primary care providers in many places. So just people being able to access care for OBGYNs because of the Dobbs decision, and so the working conditions for OBGYNs, depending on the state they live in and what that looks like in terms of being able to provide the standard of care. You know, we know, that the workforce of OBGYNs is shifting, that many are leaving the states that have restrictive abortion policies, which then create, you know, maternal health and reproductive health care deserts in those states. They're working under conditions that are really, really challenging.
Speaker 3:But, even in states where there aren't abortion restrictions, there are lots of pressures on OBGYNs and primary care providers in terms of the number of patients they need, to see how they respond to their needs, the sort of 10-minute or 15-minute visit.
Speaker 3:So when you think about that in the context of working with people that are experiencing violence, and how complex that can be, because, many survivors may be reluctant to reveal or disclose what's happening to them and you have a provider who may not have the time to really engage, so I think there are pressures there. That being said, you know we do know what best practices are for healthcare providers, including OBGYNs, that are really useful in trying to address the needs of people that come in that are experiencing violence. I would say not even all OBGYNs are completely aware of the fact that domestic violence may escalate during pregnancy. So being aware of that is critical. But you mentioned screening. Certainly the best practice is that all patients be asked about violence and safety in the home.
Speaker 3:I think it's not just a matter of checking a box, which sometimes it may feel like for people when they're being screened for a whole range of things, because there's more and more screening in the medical setting now for a lot of different issues, but a really engaged screening in the sense of looking the person in the eye setting now for a lot of different issues, but a really engaged screening in the sense of looking the person in the eye, really engaging them and really giving them space and time to respond is critical.
Speaker 3:But again, that can be challenging in the current environment and certainly lack of judgment or being non-judgmental about the response, is critical. Certainly, talking to them if they do disclose about what they want and what they see as their options, and not sort of imposing those are really critical. I think the other thing that OBGYN offices can and should do, whether it's a hospital setting or a smaller clinical setting, is to really know the resources in the community and to build partnerships with domestic violence advocates, because I think a lot of clinicians may be reluctant to ask these questions if they don't know what to do if they get a positive answer. So being able to know in advance if the person needs help, who can I turn to to help them engage in safety planning, because they may not be able to leave today, but we can help them begin that journey if that's where they are. So I think there are a lot of ways that OBGYNs can be really critical here, as well as other providers that interact with women generally, but pregnant people as well.
Speaker 1:Yeah, you write some very interesting ideas about how to screen and who to screen and when to do it, as well as the time that it takes to add that into an office visit. There's another complication that we should probably talk about when doing screenings in an OBGYN office, and that is when the abuser accompanies the pregnant woman to her doctor's appointments. It's not uncommon for expecting parents to visit the OBGYN's office together for the regular appointments. There are so many of them, both during the pregnancy and then immediately following delivery, so that complicates things. What are your thoughts around how to get around that kind of a situation, especially if the OBGYN suspects there could be some intimate partner violence?
Speaker 3:OBGYNs who are trained and sensitive to domestic violence, and I would add, that's another critical feature here is being sure that we train the workforce both OBGYNs and other primary care providers, as well as others, to understand how power and control work in these relationships, and I taught at the medical school here at Brown for nine years and we were really trying to build out the training for medical students and residents around these issues. Because if you don't understand those dynamics then you're not going to pick up on cues, like an abuser who may insist on being in the room if the patient is being examined, for example. And so I think providers who are sensitive to these issues and who are able to pick up on those cues can respond in a few different ways. They can certainly just ask if they can have a private visit with the patient. It's better not to ask the patient because the patient may be feeling threatened by the abuser. So if you say you know, are you comfortable with him being here, she's likely to say yes.
Speaker 3:You can say things like this is a part of the exam that I usually do in private with my patient, so I'm going to ask you to leave the room for a few minutes while we do that and then use that opportunity as the time to talk to the patient, to get a better understanding of what's going on and to determine if there's reason for concern.
Speaker 1:I don't know how they do it. I'm trying to think about you know all of your points with a discussion about nurses. You know if nursing schools also have training and education for nursing students or even continuing the education about domestic violence?
Speaker 3:You know, I don't know sort of across the board the answer to that question my experience with nursing education is that they actually are quite good on this. Again, I don't know if that's true of all nursing education, but I would say I think that's a critical aspect of this, not just in the OBGYN setting but in emergency care, for example, or other places where providers, including nurses, might interact with people who are experiencing domestic violence, really again being able to sense what's going on, but also thinking carefully about how to interact with the patient in a way that's not going to endanger her or allow her abuser to threaten her and not allow her to get the care that she needs.
Speaker 1:Beyond pregnancy. Postpartum is an incredibly challenging time in a lot of ways, but can be so much so for domestic violence survivors, because the wife or partner is now mom and attention is diverted to the new baby and away from her partner or her husband. That is an extremely dangerous time for a woman Because if she's already in an abusive relationship, it can really fan the flames for this abuser right, For example, if he's feeling that he's not receiving the attention that he deserves, he's likely to be more controlling, he's likely to be more violent.
Speaker 3:But it's also harder to leave when you have a child, especially if that controlling behavior has meant that the finances are controlled by the abuser, access to transportation, a whole range of different aspects of abusive behavior, and those do often escalate after a baby is born. But also children are very often used as pawns in these relationships. If you take the child away from me, I will hurt you or kill you. They're often used as pawns in any kind of divorce litigation or restraining order setting right. So it gets even that much more complicated for the survivor to not only to try to leave but also to just stay safe, because things can escalate.
Speaker 1:Yeah, definitely a frightening time for mom and baby and unfortunately things can continue to unravel from there Because there's also consequently there can be sick babies or mental health problems or postpartum maternal health problems for mom. So things can just kind of begin to accelerate and create issues inside the home which then kind of spill over outside the home. There'll be problems at work, there will be problems at school. These problems will lend themselves to societal problems as well. So let's talk about that spillover and maybe you can provide more insight to us from a public health perspective how domestic violence for pregnant women creates kind of this ripple effect across other issues in society.
Speaker 3:We haven't really talked about this yet. So let me sort of ground this and individual health outcomes for both survivors and their children, and then we can talk about how we think about that at the population level. So you know, the research is really really clear that people who experience domestic violence as survivors have long term health implications. So we might think about injuries, right, but there's obviously other ways in which experiencing domestic violence affects people's health. So it affects their mental health through trauma. It makes it more likely that they may use substances to cope. But also what we've learned from the public health research is that stress in and of itself plays a major factor in people's health, including things like chronic disease, hypertension, gastrointestinal problems a whole range of body systems that are affected by stress. So if you think about what's stressful, living in a violent, controlling relationship is probably number one on your list.
Speaker 3:So there are health concerns that occur for the survivor based on that experience of violence. What I was learning in the 1990s and really found fascinating is that there's been good research done also on children who are exposed to domestic violence, not necessarily harmed physically themselves, but when we look at their long term outcomes again, trauma related stress and a whole host of adult health problems that manifest from living in that stressful environment and being exposed to that violence. So what we call that in public health is adverse childhood experiences. That's the language that comes from a variety of studies that have looked at specific types of adverse experiences that children have and domestic violence exposure is clearly one of them. So understanding sort of again the implications, not just for what might be happening at the moment in that home, but the long term exposure for children and trauma that's experienced by the survivor and the children create ripple effects in the healthcare system like missed work, children not being able to concentrate in school and therefore not being able to achieve, and that affecting their long-term productivity and ability to work and their opportunity.
Speaker 3:We also talked about social determinants of health. People that are in violent relationships, particularly if they do leave, are more likely to be homeless more likely to live in poverty. All of these things escalate based on the experience of violence and have enormous implications for our healthcare system, for education system, for criminal justice system potentially and some people who have studied this have put the cost per year at about $8 billion 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:There is some interesting research out there about that and to your point, that $8 billion. It's said that every economic sector of our society is impacted by domestic violence and a dollar value can actually be pinpointed to it. To your point, loss of time at work, loss of wages. It impacts the health industry, every single one. You can go in and find the dollar value for, and if nothing else, it should be eye opening to people. If the statistics about lethality don't frighten you, you know, maybe it makes sense, more sense to you if you look at the economic impact of domestic violence. What recommendations then do you have for policymakers and legislators that could improve the lives or protect pregnant women experiencing intimate partner violence?
Speaker 3:Yeah, I mean, I think to your point. It's astonishing to me that it's such an unrecognized problem, right, because the data is so clear, and so I think we all are. We all have an obligation to try to educate our policymakers about this and to help them to better understand domestic violence in general, but in particular, how it affects maternal health and health during pregnancy. We're in the midst of a crisis, I would argue, around pregnancy care, around maternal health and around violence against women, and when you bring all of those things together, they're really overlapping public health problems, and so that can make it feel overwhelming and complicated, but I think we can think about different aspects of the problem and try to address them that way. So before I get to that, I'll just say we're a little bit in defensive mode at the moment with much of this because of budget cuts that are really really could be significant in terms of addressing the problems we're talking about. So right now, there are threats that there could be significant cuts to the Office of Violence Against Women, which is a primary federal agency that provides a lot of funding for services for people that are experiencing violence. That comes on the heels of the Victims of Crime Act reductions, which is also a major source of funding for domestic violence programs, and, as we talked about earlier, a reduction in funding for research around maternal health and violence prevention. So right now we're in a place where we have to sort of play defense in terms of trying to get these programs reinstated.
Speaker 3:But beyond that, we need to think proactively, and so, on the one hand, we have this maternal health crisis, and there are ways to think about that. So there has been legislation proposed, I think every year for the last several years, by Representative Lauren Underwood and Representative Alma Adams. It's called the Momnibus Bill Momnibus Act, and it's a multifaceted piece of legislation that really looks at the maternal health crisis and provides major investments in different programs that would support maternal health. So that includes even funding for things that we would think of as sort of social drivers of health, like thinking about access to housing and supportive community-based services and that kind of thing. So you know, I think it's not that we can't think of things to do right. There are ways to do this if we can get the political will to support that.
Speaker 3:On the domestic violence side, I think we haven't really talked about this yet, but one of the other ways of thinking, particularly about reduction of perinatal homicide, is the relationship with gun violence. More than half of the victims of homicide during pregnancy are killed with a firearm, and so you know we have not done a good job of ensuring that people who are known to be domestic abusers not access firearms. There was a major Supreme Court case a couple of years ago, the Rahimi case, where the question was whether the court was going to maintain the Violence Against Women Act provision that prohibits domestic abusers under subject to restraining orders from possessing firearms, and the court fortunately did uphold the law.
Speaker 3:The federal law, but that law depends significantly on state enabling legislation and state enforcement, and what we know is that those laws are highly unenforced not enforced to the degree that they should be, and so we know that if there's a gun in the home, a person experiencing domestic violence is five times as likely to be killed with that gun.
Speaker 3:So, you know, intersectionally again thinking about access to firearms and what that means for homicide, and then, I think, generally just looking at the ways in which we do or don't enforce many of our domestic violence provisions. I mean, we have come a long way in law enforcement and options for things like restraining orders, but there's a lot of gaps in terms of how those laws are enforced and whether victims and survivors actually feel like they're going to be safe. And then, of course, finally, we have to invest in community-based services, and then again that goes back to some of the work that we need to do to restore what was already there. But even those funding sources that were already there were not enough. So if somebody is living in this kind of relationship, are there resources in their community that can help them to get out of that relationship? And we're a long ways from that.
Speaker 1:Yeah, it's really going to take all of us, and all of us working together, to tackle some of these major overarching, intersecting issues and not to pile on. But health insurance and Medicaid reform are very urgent and controversial topics at the moment, and they are directly related to maternal mortality. What role do Medicaid or maternal health policies play in either helping or hindering a pregnant survivor's ability to get out of a violent situation?
Speaker 3:Yeah, I mean we know from the research that access to Medicaid is life-saving in general but also, you know, reduces maternal mortality. It plays a huge role for survivors of domestic violence in that if you do not have access 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 on domestic violence is through health care. Somebody has to be able to get to the clinic in order for that to happen. But the other important aspect of Medicaid and I think this has been really the positive work of many years is many Medicaid funded programs, particularly federally qualified community health centers where many low income people get their health care, have really robustly expanded their models to address social needs as part of health care social needs including things like exposure to domestic violence. So they often have social workers, they sometimes have lawyers through medical legal partnerships. They often have community health workers who live in the community, often with lived experience that might have their own experience of domestic violence, who really are there to be a support system. And so Medicaid access, or having coverage through Medicaid, provides access to services that can be really critical in supporting people that are experiencing violence.
Speaker 3:The other thing about it is that people don't always realize this, but 40% of the babies born in this country are covered by Medicaid, and for Black women it's 65%. So think about a point of intervention and a point of potential support. If all of those women are receiving care through Medicaid during their pregnancy and at the time of birth, that's a great point of potential support and intervention. And again, we can talk about, as we did earlier, the ways in which clinicians can play a role in that. But Medicaid provides this amazing opportunity to do that.
Speaker 3:I think the cuts that are being proposed are potentially devastating in terms of people being cut off of Medicaid. Fortunately, I think the period of pregnancy and postpartum will likely still be covered for people, but these things don't just start in pregnancy. If people have access to Medicaid over a longer period of their lifespan, opportunities for prevention and intervention can occur earlier and potentially prevent an unwanted pregnancy of someone who's in an abusive relationship or ensure that they get the care that they need earlier. So I'm concerned, I'm really concerned about potential cuts and I think you know Medicaid again is a really critical aspect of this.
Speaker 1:I think all women should be concerned about potential cuts to Medicaid and other offices that you mentioned, like the Office on Violence Against Women and lots of other things, because these are going to impact us. They're going to impact our children, whether they are girls or boys, across the board. So there's also a lot of contradictions in some of the decision making going on around these issues, such as denying anyone the right to an abortion, with abortion bans in certain places in this country, and then also demanding, in a sense, that they carry a pregnancy to term but not giving health coverage potentially to care for that pregnancy and then the resulting baby. So I don't understand the logic behind some of the ideas right now, but maybe it'll reveal itself as we move forward. Let's talk for a minute about prevention strategies that you can share that would be beneficial to implement and actions that this audience can take to support pregnant women in dangerous situations.
Speaker 3:The first thing I would say to anyone who's concerned about this in their community or sphere, family sphere is asking someone that you're concerned about if they feel safe and supported during their pregnancy. We think of you started, I think, at the beginning of pregnancy as this incredibly happy, joyful time. For some people, that's certainly true, but for many, especially if they're experiencing abuse, they're going to feel even more trapped and more hopeless during this period Because, as we talked about, violence can escalate, but also having a baby can make it even more difficult to leave, and so I think people are afraid often to raise these questions. But I think it's critical that if someone is concerned or suspects that this is happening, that they ask the person and let them know that there is support there, even if they're not initially responsive to that. We talked about firearms, I think you know, for clinicians for, again, for anyone who's concerned, knowing and asking if there are firearms in the home for a pregnant woman is critical, because we know from the research it's much more likely that that firearm will be used if it's in the home and that raises the possibility of homicide. I always stress this, you know.
Speaker 3:I think it's really hard sometimes for all of us to understand, if somebody's experiencing this kind of relationship, why they make the choices that they make, and it's really critical that we not judge, that we listen, that we offer options and resources and make it clear that we are always there if the person needs anything, and let them make the decisions and be empowered to do that, because we can't always understand exactly what they're facing and why they're making the decisions that they're making.
Speaker 3:We have a tendency in this country to ignore or not pay attention to violence against women in general. We've kind of normalized it, I think in a way that means that we sort of accept that we have the statistics that we have and it's not acceptable. I think all of us need to understand those statistics, talk about those statistics, pay attention to what's happening in our own community, advocate for the people that we know are experiencing this, and talk about the importance of protecting and supporting pregnant women and women in general, and not only their baby. They are valuable, important human beings and they should be a priority as much as other people and even their children. So that's how I would urge people to think about this issue going forward.
Speaker 1:Yeah, absolutely Good advice. Thank you for all of the information that you shared and for the work you're doing for this important population this important moment in time in our country. I appreciate you being here. Thank you for being on the show today.
Speaker 3:Thanks for having me. I really enjoyed talking with you.
Speaker 1:Thanks so much for listening. Until next time, stay safe. The Conference on Crimes Against Women Summit Beyond the Bounds, designed to address gender-based crimes specific to coastal, resort and rural communities, will be held September 22nd and 23rd in South Padre Island, texas. For more information and to register, visit our website conferencecaworg. And save the date for the 2026 Conference on Crimes Against Women convening May 18th through the 21st 2026 in Dallas, texas, and follow us on social media at National CCAW to get the latest news and information about all upcoming events and trainings, including virtual and in-person educational opportunities, updates on the Institute for Coordinated Community Response and more.