- Email: [email protected]
Violent deaths of pregnant women in Egyptian governorates of Cairo and Giza
Accepted Manuscript Violent deaths of pregnant women in Egyptian governorates of Cairo and Giza Nadia A. Kotb, Samah F. Ibrahim PII:
S1752-928X(18)30520-1
DOI:
10.1016/j.jflm.2018.09.003
Reference:
YJFLM 1714
To appear in:
Journal of Forensic and Legal Medicine
Received Date: 18 February 2018 Revised Date:
13 August 2018
Accepted Date: 5 September 2018
Please cite this article as: Kotb NA, Ibrahim SF, Violent deaths of pregnant women in Egyptian governorates of Cairo and Giza, Journal of Forensic and Legal Medicine (2018), doi: 10.1016/ j.jflm.2018.09.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Violent Deaths of Pregnant Women in Egyptian Governorates of Cairo and Giza 1
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Nadia A. Kotb1, Samah F. Ibrahim1.2 Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Cairo University 2
Faculty of Medicine, Princess Nourah Bint-Abdulrahman University.
Samah F. Ibrahim
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Assistant professor at Forensic Medicine and Clinical Toxicology departement -Faculty of Medicine-Cairo University
Email: [email protected]
Nadia A. Kotb
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Assistant professor at Faculty of Medicine, Princess Nourah Bint-Abdulrahman University
Professor at Forensic Medicine and Clinical Toxicology departement -Faculty of Medicine-Cairo University
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Email:[email protected]
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Abstract
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Violent Deaths of Pregnant Women in Egyptian Governorates of Cairo and Giza
Background: Pregnancy-associated deaths are a widely recognized phenomenon, that warrants in-depth investigation. Of the 319 suspicious
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deaths of adult women (>20 years) autopsied during 2011-2012, in the Cairo and Giza governorates, 37 (11.7%) women were pregnant at the time of the autopsy. This paper analyzes the corresponding demographic data, autopsy
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findings, and toxicological screening. The results reveal that the number of deaths of pregnant women were higher in 2012 than in 2011. In addition, the number of cases from Giza exceeded those from Cairo (62.2% and 37.8%, respectively). Most cases involved married women (62.2%) in the third trimester of pregnancy (67.5%). Most deaths were predominantly un-
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intentional (51.4%) attributed to peri-partum complications. Homicidal deaths contributed to 43% of cases, and the husband was the suspect perpetrator in 37.5% of cases. Only two cases were associated with
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substance abuse. Conclusion: the paper concludes that this analysis may inform future strategies to protect pregnant women from the hazards of
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violence and labor that threaten their lives. Keywords: forensic medicine, deaths, pregnant women, violence, Egypt
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Background The term “pregnancy-associated deaths” refers to death resulting from complications or events initiated or aggravated by pregnancy. Pregnancy
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may initiate aggression or depression that stimulates violence and in many cases may end in the death of pregnant women (Kavanaugh & Miller, 2012). Pregnant women who are exposed to health or social problems
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domestic violence, anxiety, and substance abuse are more vulnerable to hazards that lead to death during pregnancy or delivery (Richardson & Feder, 1996). Martin et al. (1996) found that violence victims were more
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likely to use multiple substances than non-victims, and such incidences increased during pregnancy. The global prevalence of violence during pregnancy varied from 0.9-20%, and increased during the third trimester (7.4-20%) (Gazmararian, 1996). The prevalence of battery during pregnancy was estimated by Rasmussen and Knudsen (1996) to vary from
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1-10%, and increased in a fourth of domestic violence cases. In the United States, abuse during pregnancy affected 3-11% of adult women (Ballard et al., 1998).
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The current study aims to reveal the prevalence of pregnancyassociated deaths in the Egyptian community and the risk factors that
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contribute to death during pregnancy. Methodology
To study the pregnancy-associated deaths of the Cairo and Giza
governorates, all pregnant women who died during pregnancy in suspicious circumstances from 2011-2012 were chosen as the sample of this study. The study was conducted at the Zeinhom Morgue-Forensic Medicine Authority
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of the Ministry of Justice, which serves the Cairo and Giza governorates. The relevant demographic data, autopsy findings and toxicology screening results were collected from their archives.
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Results
Of the 317 adult women autopsied in the Zeinhom Morgue, 37 were pregnant at the time of death. All were between 30-40 years of age. More
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than half of the cases were from Giza (62.2%). The number of 2012 cases was higher than 2011 cases Figure (1). Sixty-two percent of the cases were
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married and 16.2% were single Figure (2).
Approximately half of the cases (48.6%) were un-intentional deaths, and 43% of the cases were homicidal deaths Table (1). Un-intentional and homicidal cases were higher in Giza than in Cairo (62.2% and 37.8%, respectively), and the only suicidal death (by burning) occurred in Giza
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Figure (3). Moreover, the number of cases increased for each trimester of pregnancy. Most cases (67.5%) occured during the third trimester Table (1) and Figure (4).
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The husband was the perpetrator in 37.5% of cases, followed by the brother 12.5% of the victims Figure (5).
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Regarding the cause of death, 37.5% of cases were killed with sharp
weapons. Blunt weapons were used in 12.5% of cases. Violent asphyxia was detected in 31.3% of cases, followed by smothering (12.5%), throttling (12.5%), and strangulation (6.3%). Dry burn (12.5%) and illegal abortion (6.3%) were the causes of the remaining deaths Table (2). Toxicological analysis proved that two cases from Giza tested positive for ethyl alcohol and cannabis.
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Half of the un-intentional pregnant women’s deaths were the result of caesarian section complications. Peri-operative hemorrhage was the underlying cause of 33.3%) of the cases. Amniotic pulmonary embolism was
was reported in one case Figure (6). Discussion
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the cause of death in 11% of the cases. Un-intentional falling from height
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Violence against women is a worldwide public health problem and human rights concern (Pereira et al., 2013). A review of the literature
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indicates the prevalence of violence during pregnancy (Rasmussen & Knudsen, 1996).
The present study aimed to assess the prevelance of violence as a cause of
maternal mortality in our community as compared to other
countries. This study was conducted based on the autopsies of adult who
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were pregnant at the time of death. Of 317 autopsied women, 37 were pregnant (11.7%). This prevalence is higher than that reported by Abrahams et al. (2013) in South Africa, but lower than that of Dannenberg
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et al. (1995) in New York City (39%). The current study found that there were more autopsied pregnant
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women in 2012 than in 2011 (62.2% and 37.8%, respectively), which reflects a rise in violence against pregnant Egyptian women. This findings contrasts with what was observed by Abrahams et al. (2013) in South Africa, where the incidence of femicide in 2009 was lower than in 1999. Also, the present study showed that the number of autopsied pregnant women was higher in the Giza governorate (62.2%) than the Cairo governorate (37.8%). A similar result was reported in the U.S., where abuse
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during pregnancy increased up to 38% among low-income teenage mothers (Heise & Garcia Moreno, 2002). The majority of the studied pregnant victims were married (62.2%).
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For many women, the family circle is their most violent and harmful environment (Carcedo, 2009). This finding concurs with Mazza et al. (1996), who stated that over a quarter of women in relationships had been
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victims of physical or emotional abuse by their partners.
The present study also showed that homicidal deaths accounted for
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40.5% of the studied pregnant women, while un-intentional deaths were reported for more than half of cases (51.4%). Most were from the Giza governorate, which may indicate more aggression and maltreatment of lowincome pregnant women. The single case of reported suicide also occurred in the Giza governorate. These results coincide with that of violent maternal
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deaths in the U.S. state of Illinois, where homicide, suicide and, substanceabuse related deaths accounted for nearly one fourth of pregnancy-associated deaths from 2002-2013 (Koch & Geller, 2017).
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In the current study, the incidence of violence by homicide, suicide, or un-intention, increased over the course of gestation, and was most prevalent
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during the third trimester (67.5%). This result concurs with that of Ibrahim et al. (2015), who identified signs of violence in 44.1% of pregnant women with high incidence of adverse pregnancy outcomes and death. Similarly, Gazmararian (1996) found that the prevalence of violence during pregnancy varied from 0.9-20.1%, with a higher prevalence of violence during the third trimester (7.4-20.1%).
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The husband was the suspected perpetrator was in 37.5% of these homicide cases, and the victim’s brother or father had lower incidences (12.5% and 6.3%, respectively). The World’s Women Report (2015) stated
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that about one third of women worldwide have experienced violence, and intimate partners are the most common offenders. Such trends peak during women’s reproductive years in both developed and undeveloped countries. In the most extreme cases, this violence can lead to death. About two thirds
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of the victims of intimate partner crimes and family-related homicides were women.
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According to the European Union Agency for Fundamental Rights (2014), most violence ocuurs within intimate relationships. Similar findings were reported by Unal et al. (2016) in Istanbul, Turkey, where the husband was the perpetrator in 20.1% of 537 autopsied women victims and the intimate partner comprised 52.3% of the identified perpetrators. Similarly,
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an Indian study of 400 villages found that 16% of deaths during pregnancy were the result of partner violence (Ganatra et al., 1995). Fleming et al. (2015) attributed the 100% incidence of male offenders-gender norms and
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social constructions of masculinity that make men more likely than women to perpetrate interpersonal violence.
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In the current study, sharp weapons constituted 37.5% of the
intentional deaths of pregnant women, followed by violent asphyxia (31.3%) and blunt weapons (12.5%). Two (12.5%) cases showed signs of burns and illegal abortion was the underlying cause of one case (6.3%). In contrast to this Egyptian study, the Illinois results from 2008-2013 showed that the most common form of homicide of pregnant women was gunshot wounds
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(50%) and 40% were the result of domestic violence (Koch & Geller, 2017). Un-intentional deaths contributed to 48.6% of cases in the present
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study, which indicates the high susceptibility of pregnant women to die during pregnancy or labour due to pre-existing or incidental pathological conditions. It is worth noting that battery during pregnancy is a significant
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contributing factor. These results concur with Kavanaugh & Miller (2012) who found that among women in Virginia who died while pregnant or within a year of pregnancy, homicide contributed to only 8% of cases, and
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suicide to 7% of cases. Other pathological conditions were more common, including cardiovascular disorder (15.1%), amniotic pulmonary embolism (12.5%), cardiomyopathy (12.5%), and hemorrhage in (9.3%). Only two Egyptian cases’ toxicological analysis tested positive for
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either alcohol or cannabinoids. Drug abuse increases the risk of male violence (Keller, 1996), and women who experience violence are more susceptible
to
depression,
anxiety
and
pregnancy
complications
(Richardson & Feder, 1996). Martin et al. (1996) found that 31% of
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violence.
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women who used one or more substances during pregnancy were victims of
The Egyptian government has set many different rules to protect
women against violence and ensure their participation in everyday life. The most significant laws are the Egyptian Constitution of 2014 and the Criminal Code of 1937 with its amendments (Reda, 2017). Crimes against women in Egypt are divided into two groups: misdemeanors and felonies. Misdemeanors are usually punished by fines
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and short-term jail time. Felonies’ punishing law includes different degrees of the crime, and perpetrators will be punished by longer jail time (Reda, 2017) or will face the death penalty, if their victim died (Khaled, 2017).
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United States’ laws consider the fetus as being a person and have more harsh penalties if the woman is murdered while pregnant (National Right to Life Committee, 2016) (Legislatures, 2016). Furthermore, North
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Carolina Senate has set a legislation that would create a separate criminal offense for the death of a fetus when the mother is murdered (North
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Carolina Coalition Against Domestic Violence, 2011). Conclusion
Deaths due to violence during pregnancy are prevalent in the Cairo and Giza governorates. Violence is more prevalent in rural and low-income communities (i.e. Giza) and increases during pregnancy especially during
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the third trimester. The most frequent pregnancy-related deaths was homicide. In addition, the husband was the main perpetrator. Half of the homicidal cases were caused by sharp and blunt weapons. Un-intentional
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pregnant women deaths accounted for about half of these cases, often the result of a lack of medical care during pregnancy or labour.
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Recommendations
Similar studies are necessary in additional governorates to verify the
nature of this violence, reveal its precipitating risk factors, and develop a strategy to combat the violence. National campaigns against violence are needed to raise the public awareness of the impact of interpersonal violence on personal safety, especially that of pregnant women. References
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1. Abrahams N, Mathews S, Martin L, Lombard C, Jewkes R. Intimate Partner Femicide in South Africa in 1999 and 2009. PLoS Medicine. 2013;10(4):e1001412. https://doi.org/10.1371/journal.pmed.1001412
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2. Ballard T, Saltzman L, Gazmararian J, Spitz A, Lazorick S, Marks J. Violence during pregnancy: measurement issues. American Journal of Public Health. 1998;88(2):274-276. Doi 10.2105/ajph.88.2.274
3. Carcedo A. Femicide in Central America 2000–2006. In strengthening
SC
understanding of femicide. [Seattle, WA etc.]. Widyono M. (editor): Program for appropriate technology in health (PATH) : with WHO; Available
M AN U
2009.
at
https://www.path.org/publications/files/GVR_femicide_rpt.pdf 4. Dannenberg A, Carter D, Lawson H, Ashton D, Dorfman S, Graham E. Homicide and other injuries as causes of maternal death in New York City, 1987 through 1991. American Journal of Obstetrics and 1995;172(5):1557-1564.
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Gynecology.
Doi
10.1016/0002-
9378(95)90496-4
5. European Union Agency for Fundamental Rights (2014): Violence women:
an
EU-wide
survey.
Available
at
EP
against
file:///C:/Users/Administrator/Downloads/fra-2014-vaw-survey-main-
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results_en.pdf
6. Fleming P, Gruskin S, Rojo F, Dworkin S. Men's violence against women and men are inter-related: Recommendations for simultaneous intervention.
Social
Science
&
Medicine.
2015;146:249-256.
https://doi.org/10.1016/j.socscimed.2015.10.021 7. Ganatra BR, Coyaji KJ, Rao VN. Too far, too little, too late: a community-based case-control study of maternal mortality in rural
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west Maharashtra, India. Bull World Health Organ. 1998;76(6):591-8. PMID:10191555. Doi 10.1007/bf02723662. 8. Gazmararian J. Prevalence of violence against pregnant women.
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JAMA: The Journal of the American Medical Association. 1996;275(24):1915-1920.Doi 10.1001/jama.275.24.1915
9. Heise L, Garcia Moreno C. Violence by intimate partners. In: Krug EG et al., eds. World report on violence and health. Geneva, World Organization,
2002:87–121.
Available
SC
Health
at
http://apps.who.int/iris/bitstream/10665/77432/1/WHO_RHR_12.36_
M AN U
eng.pdf
10. Ibrahim ZM, Ahmed WAS, El-Hamid SA, Hagras AM. Intimate partner violence among Egyptian pregnant women: incidence, risk factors, and adverse maternal and fetal outcomes. Clinical and Experimental Obstetrics & Gynecology. June (2015). 42(2):212-9.
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doi: 10.12891/ceog1829.2015
11. Kavanaugh V, Miller F. The Contribution of Violence to PregnancyRelated Deaths in Virginia. Journal of Obstetric, Gynecologic & Nursing.
2012;41:S138-S139.Doi
10.1111/j.1552-
EP
Neonatal
6909.2012.01362_29.x
AC C
12. Keller LE. Invisible victims: battered women in psychiatric and medical
emergency
rooms.
Bull
Menninger
Clin.
1996
Winter;60(1):1-21. Review. PMID: 8742669.
13. Khaled F. Egyptian Laws Punishing Rape Insufficiently Help Victims of Violence. Available at https://theglobepost.com/2018/02/18/egyptsexual-violence-law/, Feb 18, 2018. Retrieved 7 August 2018.
14. Koch AR, Geller SE. Addressing maternal deaths due to violence: the Illinois
experience.
Am
J
Obstet
Gynecol.
2017
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Nov;2017(5):556.e1-556.e6. doi: 10.1016/j.ajog.2017.08.005. Epub 2017 Aug 24. PMID: 28844823. 15. Legislatures, National Conference of State. "Fetal Homicide State
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Laws". www.ncsl.org. Retrieved 6 October 2016. 16. Martin SL, English KT, Clark KA, Cilenti D, Kupper LL. Violence and substance use among North Carolina pregnant women. Am J Public Health. 1996 Jul; 86(7):991-8. Doi 10.2105/ajph.86.7. 991.
SC
PMID: 8669524
17. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional
M AN U
violence against women: a general practice-based prevalence study. Med J Aust. 1996 Jan 1;164(1):14-7.PMID: 8559088 18. National Right to Life Committee."State Homicide Laws That Recognize Unborn Victims". www.nrlc.org. Retrieved 6 October 2016.
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19. North Carolina Coalition Against Domestic Violence. "NCCADV Position Statement: Fetal Murder Legislation" (PDF). Retrieved 31 March 2011.
EP
20. Pereira A, Vieira D, Magalhães T. Fatal intimate partner violence against women in Portugal: A forensic medical national study. Journal Forensic
and
Legal
Medicine.
2013;
20(8):1099-
AC C
of
1107.https://doi.org/10.1016/j.jflm.2013.09.015.
21. Rasmussen KL, Knudsen HJ. Violence towards pregnant women. Ugeskr Laeger. 1996 Apr 22; 158(17):2373-6. Review. Danish. PMID:8685989
22. Reda L. Violence Against Women: Egyptian laws, policies in place. Available at https://www.egypttoday.com/Article/2/34864/Violence-
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Against-Women-Egyptian-laws-policies-in-place.
1
Dec
2017.
Retrieved 7 August 2019. 23. Richardson J, Feder G. Domestic violence: a hidden problem for
PMID: 8703527
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general practice. Br J Gen Pract. 1996 Apr;46(405):239-42. Review.
24. The world’s women report (2015). Violence against women, united nation.
Available
at
SC
https://unstats.un.org/unsd/gender/downloads/WorldsWomen2015_ch apter6_t.pdf
M AN U
25. Unal E, Koc S, Unal V, Akcan R, Javan G. Violence against women: A series of autopsy studies from Istanbul, Turkey. Journal of Forensic and
Legal
Medicine.
2016;40:42-46.
https://doi.org/10.1016/j.jflm.2015.11.025
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Acknowledgement
This study was supported by Dr/Hisham Abd El-Hamid, the chair of Egyptian Medico-Legal Authority of the Ministry of Justice in Cairo, Egypt. The authors gratefully acknowledge the staff team working in Zeinhom
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Mortuary staff, who assisted the data collection of this work.
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Homicide
Suicide
Un-intentional
Undetermined
Number (%)
4 6 6 16(43.3%)
1 1(2.7%)
1 17 18(48.6%)
1 1 2(5.4%)
5(13.5%) 7(19%) 25(67.5%) 37(100%)
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*significant P value is <0.05
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Manner of death Trimester First Second Third Number (%)
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Table 1: Distribution of the Cause of Death for Autopsied Pregnant Women and Trimester of Pregnancy at the Time of Death
P-value 0.02*
Table (2): Cause of Death for Autopsied Pregnant Women in Egyptian Governorates Sharp injuries
Blunt injuries
Asphyxia Smothering Strangulation
Burn
Illegal abortion
Number (%)
P-value
Throttling
1 5 6(37.5%)
2 2(12.5%)
2 2(12.5%)
2 2(12.5%)
2 2(12.5%)
1 1(6.3%)
6(37.5%) 10 (62.5%) 16(100%)
0.05*
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*significant P value is <0.05
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Cause of death Governorate Cairo Giza Total (%)
1 1(6.3%)
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14 cases in 2011
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23 cases in 2012
35%
Cairo
43% 57%
Giza
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65%
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Non-significant difference (P-value =0.4)
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Figure 1: Residential Distribution of Autopsied Pregnant Women.
37.5%
33%
22%
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22%
12.5%
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CAIRO 2011
34%
36.5%
22% 12.5%
CAIRO 2012
Married (23 cases)
67%
GIZA 2011
Single (6 cases)
GIZA2012
Unknown (8 cases)
Non-significant difference (P-value =0.1)
Figure 2: Marital status of autopsied pregnant women. .
Cairo Giza
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100%
62.50%
56%
0 HOMICIDE (16 CASES)
SUICIDE (1 CASE)
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44%
37.5%
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100%
UN-INTENTIONAL (18 CASES) Cairo
UNDETERMINED (2 CASES)
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Giza
0
Non-significant difference (P-value =0.1)
Figure 3: Distribution of Autopsied Pregnant Women According to the Manner of Death and Governorate.
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.
13.5% FIRST
67.5%
19%
SECOND
THIRD
Significant difference (P-value =0.02)
Figure 4: Distribution of Autopsied Pregnant Women According to the Period of Gestation at the Time of Autopsy.
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33%
100%
33.3% 33.3%
33%
16.7%
HUSBAND (6 CASES)
BROTHER (2 CASE)
Cairo 2011 (2 cases)
FATHER (1 CASE)
Cairo 2012 (4 cases)
16.7%
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16.7%
FOREIGNER (1 CASE)
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16.7%
100%
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100%
Giza 2011 (4 cases)
UNDETERMINED (6 CASES)
Giza 2012 (6 cases)
Non-significant difference (P-value =0.5)
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Figure 5: Suspected Perpetrator in Homicidal (intentional) Deaths of Pregnant Women.
1
Fall from height (1 case)
1
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Amniotic pulmonary embolism (2 cases)
2
Post-partum hemorrhage (5 cases)
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1 3
1
Ante-partum hemorrhage (1 case)
4
Caesarian section’ complications (9 cases) 0
Cairo
1
2
5 3
4
5
6
7
8
9
Giza
Non-significant difference (P-value =0.7)
Figure (6): Distribution of Autopsied Un-intentional Pregnant Women Deaths According to the Causes of Death.
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1. The number of pregnancy-associated deaths over a 2-years period was around 37 cases. 2. All were between 30-40 years of age with known identity.
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3. Approximately half of the cases were un-intentional deaths.
4. The husband was the main perpetrator in the homicidal deaths.
The incidence of violence increased over the course of gestation.
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5.
S1752-928X(18)30520-1
DOI:
10.1016/j.jflm.2018.09.003
Reference:
YJFLM 1714
To appear in:
Journal of Forensic and Legal Medicine
Received Date: 18 February 2018 Revised Date:
13 August 2018
Accepted Date: 5 September 2018
Please cite this article as: Kotb NA, Ibrahim SF, Violent deaths of pregnant women in Egyptian governorates of Cairo and Giza, Journal of Forensic and Legal Medicine (2018), doi: 10.1016/ j.jflm.2018.09.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Violent Deaths of Pregnant Women in Egyptian Governorates of Cairo and Giza 1
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Nadia A. Kotb1, Samah F. Ibrahim1.2 Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Cairo University 2
Faculty of Medicine, Princess Nourah Bint-Abdulrahman University.
Samah F. Ibrahim
SC
Assistant professor at Forensic Medicine and Clinical Toxicology departement -Faculty of Medicine-Cairo University
Email: [email protected]
Nadia A. Kotb
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Assistant professor at Faculty of Medicine, Princess Nourah Bint-Abdulrahman University
Professor at Forensic Medicine and Clinical Toxicology departement -Faculty of Medicine-Cairo University
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Email:[email protected]
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Abstract
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Violent Deaths of Pregnant Women in Egyptian Governorates of Cairo and Giza
Background: Pregnancy-associated deaths are a widely recognized phenomenon, that warrants in-depth investigation. Of the 319 suspicious
SC
deaths of adult women (>20 years) autopsied during 2011-2012, in the Cairo and Giza governorates, 37 (11.7%) women were pregnant at the time of the autopsy. This paper analyzes the corresponding demographic data, autopsy
M AN U
findings, and toxicological screening. The results reveal that the number of deaths of pregnant women were higher in 2012 than in 2011. In addition, the number of cases from Giza exceeded those from Cairo (62.2% and 37.8%, respectively). Most cases involved married women (62.2%) in the third trimester of pregnancy (67.5%). Most deaths were predominantly un-
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intentional (51.4%) attributed to peri-partum complications. Homicidal deaths contributed to 43% of cases, and the husband was the suspect perpetrator in 37.5% of cases. Only two cases were associated with
EP
substance abuse. Conclusion: the paper concludes that this analysis may inform future strategies to protect pregnant women from the hazards of
AC C
violence and labor that threaten their lives. Keywords: forensic medicine, deaths, pregnant women, violence, Egypt
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Background The term “pregnancy-associated deaths” refers to death resulting from complications or events initiated or aggravated by pregnancy. Pregnancy
RI PT
may initiate aggression or depression that stimulates violence and in many cases may end in the death of pregnant women (Kavanaugh & Miller, 2012). Pregnant women who are exposed to health or social problems
SC
domestic violence, anxiety, and substance abuse are more vulnerable to hazards that lead to death during pregnancy or delivery (Richardson & Feder, 1996). Martin et al. (1996) found that violence victims were more
M AN U
likely to use multiple substances than non-victims, and such incidences increased during pregnancy. The global prevalence of violence during pregnancy varied from 0.9-20%, and increased during the third trimester (7.4-20%) (Gazmararian, 1996). The prevalence of battery during pregnancy was estimated by Rasmussen and Knudsen (1996) to vary from
TE D
1-10%, and increased in a fourth of domestic violence cases. In the United States, abuse during pregnancy affected 3-11% of adult women (Ballard et al., 1998).
EP
The current study aims to reveal the prevalence of pregnancyassociated deaths in the Egyptian community and the risk factors that
AC C
contribute to death during pregnancy. Methodology
To study the pregnancy-associated deaths of the Cairo and Giza
governorates, all pregnant women who died during pregnancy in suspicious circumstances from 2011-2012 were chosen as the sample of this study. The study was conducted at the Zeinhom Morgue-Forensic Medicine Authority
ACCEPTED MANUSCRIPT
of the Ministry of Justice, which serves the Cairo and Giza governorates. The relevant demographic data, autopsy findings and toxicology screening results were collected from their archives.
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Results
Of the 317 adult women autopsied in the Zeinhom Morgue, 37 were pregnant at the time of death. All were between 30-40 years of age. More
SC
than half of the cases were from Giza (62.2%). The number of 2012 cases was higher than 2011 cases Figure (1). Sixty-two percent of the cases were
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married and 16.2% were single Figure (2).
Approximately half of the cases (48.6%) were un-intentional deaths, and 43% of the cases were homicidal deaths Table (1). Un-intentional and homicidal cases were higher in Giza than in Cairo (62.2% and 37.8%, respectively), and the only suicidal death (by burning) occurred in Giza
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Figure (3). Moreover, the number of cases increased for each trimester of pregnancy. Most cases (67.5%) occured during the third trimester Table (1) and Figure (4).
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The husband was the perpetrator in 37.5% of cases, followed by the brother 12.5% of the victims Figure (5).
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Regarding the cause of death, 37.5% of cases were killed with sharp
weapons. Blunt weapons were used in 12.5% of cases. Violent asphyxia was detected in 31.3% of cases, followed by smothering (12.5%), throttling (12.5%), and strangulation (6.3%). Dry burn (12.5%) and illegal abortion (6.3%) were the causes of the remaining deaths Table (2). Toxicological analysis proved that two cases from Giza tested positive for ethyl alcohol and cannabis.
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Half of the un-intentional pregnant women’s deaths were the result of caesarian section complications. Peri-operative hemorrhage was the underlying cause of 33.3%) of the cases. Amniotic pulmonary embolism was
was reported in one case Figure (6). Discussion
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the cause of death in 11% of the cases. Un-intentional falling from height
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Violence against women is a worldwide public health problem and human rights concern (Pereira et al., 2013). A review of the literature
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indicates the prevalence of violence during pregnancy (Rasmussen & Knudsen, 1996).
The present study aimed to assess the prevelance of violence as a cause of
maternal mortality in our community as compared to other
countries. This study was conducted based on the autopsies of adult who
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were pregnant at the time of death. Of 317 autopsied women, 37 were pregnant (11.7%). This prevalence is higher than that reported by Abrahams et al. (2013) in South Africa, but lower than that of Dannenberg
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et al. (1995) in New York City (39%). The current study found that there were more autopsied pregnant
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women in 2012 than in 2011 (62.2% and 37.8%, respectively), which reflects a rise in violence against pregnant Egyptian women. This findings contrasts with what was observed by Abrahams et al. (2013) in South Africa, where the incidence of femicide in 2009 was lower than in 1999. Also, the present study showed that the number of autopsied pregnant women was higher in the Giza governorate (62.2%) than the Cairo governorate (37.8%). A similar result was reported in the U.S., where abuse
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during pregnancy increased up to 38% among low-income teenage mothers (Heise & Garcia Moreno, 2002). The majority of the studied pregnant victims were married (62.2%).
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For many women, the family circle is their most violent and harmful environment (Carcedo, 2009). This finding concurs with Mazza et al. (1996), who stated that over a quarter of women in relationships had been
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victims of physical or emotional abuse by their partners.
The present study also showed that homicidal deaths accounted for
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40.5% of the studied pregnant women, while un-intentional deaths were reported for more than half of cases (51.4%). Most were from the Giza governorate, which may indicate more aggression and maltreatment of lowincome pregnant women. The single case of reported suicide also occurred in the Giza governorate. These results coincide with that of violent maternal
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deaths in the U.S. state of Illinois, where homicide, suicide and, substanceabuse related deaths accounted for nearly one fourth of pregnancy-associated deaths from 2002-2013 (Koch & Geller, 2017).
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In the current study, the incidence of violence by homicide, suicide, or un-intention, increased over the course of gestation, and was most prevalent
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during the third trimester (67.5%). This result concurs with that of Ibrahim et al. (2015), who identified signs of violence in 44.1% of pregnant women with high incidence of adverse pregnancy outcomes and death. Similarly, Gazmararian (1996) found that the prevalence of violence during pregnancy varied from 0.9-20.1%, with a higher prevalence of violence during the third trimester (7.4-20.1%).
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The husband was the suspected perpetrator was in 37.5% of these homicide cases, and the victim’s brother or father had lower incidences (12.5% and 6.3%, respectively). The World’s Women Report (2015) stated
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that about one third of women worldwide have experienced violence, and intimate partners are the most common offenders. Such trends peak during women’s reproductive years in both developed and undeveloped countries. In the most extreme cases, this violence can lead to death. About two thirds
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of the victims of intimate partner crimes and family-related homicides were women.
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According to the European Union Agency for Fundamental Rights (2014), most violence ocuurs within intimate relationships. Similar findings were reported by Unal et al. (2016) in Istanbul, Turkey, where the husband was the perpetrator in 20.1% of 537 autopsied women victims and the intimate partner comprised 52.3% of the identified perpetrators. Similarly,
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an Indian study of 400 villages found that 16% of deaths during pregnancy were the result of partner violence (Ganatra et al., 1995). Fleming et al. (2015) attributed the 100% incidence of male offenders-gender norms and
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social constructions of masculinity that make men more likely than women to perpetrate interpersonal violence.
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In the current study, sharp weapons constituted 37.5% of the
intentional deaths of pregnant women, followed by violent asphyxia (31.3%) and blunt weapons (12.5%). Two (12.5%) cases showed signs of burns and illegal abortion was the underlying cause of one case (6.3%). In contrast to this Egyptian study, the Illinois results from 2008-2013 showed that the most common form of homicide of pregnant women was gunshot wounds
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(50%) and 40% were the result of domestic violence (Koch & Geller, 2017). Un-intentional deaths contributed to 48.6% of cases in the present
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study, which indicates the high susceptibility of pregnant women to die during pregnancy or labour due to pre-existing or incidental pathological conditions. It is worth noting that battery during pregnancy is a significant
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contributing factor. These results concur with Kavanaugh & Miller (2012) who found that among women in Virginia who died while pregnant or within a year of pregnancy, homicide contributed to only 8% of cases, and
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suicide to 7% of cases. Other pathological conditions were more common, including cardiovascular disorder (15.1%), amniotic pulmonary embolism (12.5%), cardiomyopathy (12.5%), and hemorrhage in (9.3%). Only two Egyptian cases’ toxicological analysis tested positive for
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either alcohol or cannabinoids. Drug abuse increases the risk of male violence (Keller, 1996), and women who experience violence are more susceptible
to
depression,
anxiety
and
pregnancy
complications
(Richardson & Feder, 1996). Martin et al. (1996) found that 31% of
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violence.
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women who used one or more substances during pregnancy were victims of
The Egyptian government has set many different rules to protect
women against violence and ensure their participation in everyday life. The most significant laws are the Egyptian Constitution of 2014 and the Criminal Code of 1937 with its amendments (Reda, 2017). Crimes against women in Egypt are divided into two groups: misdemeanors and felonies. Misdemeanors are usually punished by fines
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and short-term jail time. Felonies’ punishing law includes different degrees of the crime, and perpetrators will be punished by longer jail time (Reda, 2017) or will face the death penalty, if their victim died (Khaled, 2017).
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United States’ laws consider the fetus as being a person and have more harsh penalties if the woman is murdered while pregnant (National Right to Life Committee, 2016) (Legislatures, 2016). Furthermore, North
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Carolina Senate has set a legislation that would create a separate criminal offense for the death of a fetus when the mother is murdered (North
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Carolina Coalition Against Domestic Violence, 2011). Conclusion
Deaths due to violence during pregnancy are prevalent in the Cairo and Giza governorates. Violence is more prevalent in rural and low-income communities (i.e. Giza) and increases during pregnancy especially during
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the third trimester. The most frequent pregnancy-related deaths was homicide. In addition, the husband was the main perpetrator. Half of the homicidal cases were caused by sharp and blunt weapons. Un-intentional
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pregnant women deaths accounted for about half of these cases, often the result of a lack of medical care during pregnancy or labour.
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Recommendations
Similar studies are necessary in additional governorates to verify the
nature of this violence, reveal its precipitating risk factors, and develop a strategy to combat the violence. National campaigns against violence are needed to raise the public awareness of the impact of interpersonal violence on personal safety, especially that of pregnant women. References
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1. Abrahams N, Mathews S, Martin L, Lombard C, Jewkes R. Intimate Partner Femicide in South Africa in 1999 and 2009. PLoS Medicine. 2013;10(4):e1001412. https://doi.org/10.1371/journal.pmed.1001412
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2. Ballard T, Saltzman L, Gazmararian J, Spitz A, Lazorick S, Marks J. Violence during pregnancy: measurement issues. American Journal of Public Health. 1998;88(2):274-276. Doi 10.2105/ajph.88.2.274
3. Carcedo A. Femicide in Central America 2000–2006. In strengthening
SC
understanding of femicide. [Seattle, WA etc.]. Widyono M. (editor): Program for appropriate technology in health (PATH) : with WHO; Available
M AN U
2009.
at
https://www.path.org/publications/files/GVR_femicide_rpt.pdf 4. Dannenberg A, Carter D, Lawson H, Ashton D, Dorfman S, Graham E. Homicide and other injuries as causes of maternal death in New York City, 1987 through 1991. American Journal of Obstetrics and 1995;172(5):1557-1564.
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Gynecology.
Doi
10.1016/0002-
9378(95)90496-4
5. European Union Agency for Fundamental Rights (2014): Violence women:
an
EU-wide
survey.
Available
at
EP
against
file:///C:/Users/Administrator/Downloads/fra-2014-vaw-survey-main-
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results_en.pdf
6. Fleming P, Gruskin S, Rojo F, Dworkin S. Men's violence against women and men are inter-related: Recommendations for simultaneous intervention.
Social
Science
&
Medicine.
2015;146:249-256.
https://doi.org/10.1016/j.socscimed.2015.10.021 7. Ganatra BR, Coyaji KJ, Rao VN. Too far, too little, too late: a community-based case-control study of maternal mortality in rural
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west Maharashtra, India. Bull World Health Organ. 1998;76(6):591-8. PMID:10191555. Doi 10.1007/bf02723662. 8. Gazmararian J. Prevalence of violence against pregnant women.
RI PT
JAMA: The Journal of the American Medical Association. 1996;275(24):1915-1920.Doi 10.1001/jama.275.24.1915
9. Heise L, Garcia Moreno C. Violence by intimate partners. In: Krug EG et al., eds. World report on violence and health. Geneva, World Organization,
2002:87–121.
Available
SC
Health
at
http://apps.who.int/iris/bitstream/10665/77432/1/WHO_RHR_12.36_
M AN U
eng.pdf
10. Ibrahim ZM, Ahmed WAS, El-Hamid SA, Hagras AM. Intimate partner violence among Egyptian pregnant women: incidence, risk factors, and adverse maternal and fetal outcomes. Clinical and Experimental Obstetrics & Gynecology. June (2015). 42(2):212-9.
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doi: 10.12891/ceog1829.2015
11. Kavanaugh V, Miller F. The Contribution of Violence to PregnancyRelated Deaths in Virginia. Journal of Obstetric, Gynecologic & Nursing.
2012;41:S138-S139.Doi
10.1111/j.1552-
EP
Neonatal
6909.2012.01362_29.x
AC C
12. Keller LE. Invisible victims: battered women in psychiatric and medical
emergency
rooms.
Bull
Menninger
Clin.
1996
Winter;60(1):1-21. Review. PMID: 8742669.
13. Khaled F. Egyptian Laws Punishing Rape Insufficiently Help Victims of Violence. Available at https://theglobepost.com/2018/02/18/egyptsexual-violence-law/, Feb 18, 2018. Retrieved 7 August 2018.
14. Koch AR, Geller SE. Addressing maternal deaths due to violence: the Illinois
experience.
Am
J
Obstet
Gynecol.
2017
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Nov;2017(5):556.e1-556.e6. doi: 10.1016/j.ajog.2017.08.005. Epub 2017 Aug 24. PMID: 28844823. 15. Legislatures, National Conference of State. "Fetal Homicide State
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Laws". www.ncsl.org. Retrieved 6 October 2016. 16. Martin SL, English KT, Clark KA, Cilenti D, Kupper LL. Violence and substance use among North Carolina pregnant women. Am J Public Health. 1996 Jul; 86(7):991-8. Doi 10.2105/ajph.86.7. 991.
SC
PMID: 8669524
17. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional
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violence against women: a general practice-based prevalence study. Med J Aust. 1996 Jan 1;164(1):14-7.PMID: 8559088 18. National Right to Life Committee."State Homicide Laws That Recognize Unborn Victims". www.nrlc.org. Retrieved 6 October 2016.
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19. North Carolina Coalition Against Domestic Violence. "NCCADV Position Statement: Fetal Murder Legislation" (PDF). Retrieved 31 March 2011.
EP
20. Pereira A, Vieira D, Magalhães T. Fatal intimate partner violence against women in Portugal: A forensic medical national study. Journal Forensic
and
Legal
Medicine.
2013;
20(8):1099-
AC C
of
1107.https://doi.org/10.1016/j.jflm.2013.09.015.
21. Rasmussen KL, Knudsen HJ. Violence towards pregnant women. Ugeskr Laeger. 1996 Apr 22; 158(17):2373-6. Review. Danish. PMID:8685989
22. Reda L. Violence Against Women: Egyptian laws, policies in place. Available at https://www.egypttoday.com/Article/2/34864/Violence-
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Against-Women-Egyptian-laws-policies-in-place.
1
Dec
2017.
Retrieved 7 August 2019. 23. Richardson J, Feder G. Domestic violence: a hidden problem for
PMID: 8703527
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general practice. Br J Gen Pract. 1996 Apr;46(405):239-42. Review.
24. The world’s women report (2015). Violence against women, united nation.
Available
at
SC
https://unstats.un.org/unsd/gender/downloads/WorldsWomen2015_ch apter6_t.pdf
M AN U
25. Unal E, Koc S, Unal V, Akcan R, Javan G. Violence against women: A series of autopsy studies from Istanbul, Turkey. Journal of Forensic and
Legal
Medicine.
2016;40:42-46.
https://doi.org/10.1016/j.jflm.2015.11.025
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Acknowledgement
This study was supported by Dr/Hisham Abd El-Hamid, the chair of Egyptian Medico-Legal Authority of the Ministry of Justice in Cairo, Egypt. The authors gratefully acknowledge the staff team working in Zeinhom
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Mortuary staff, who assisted the data collection of this work.
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Homicide
Suicide
Un-intentional
Undetermined
Number (%)
4 6 6 16(43.3%)
1 1(2.7%)
1 17 18(48.6%)
1 1 2(5.4%)
5(13.5%) 7(19%) 25(67.5%) 37(100%)
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*significant P value is <0.05
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Manner of death Trimester First Second Third Number (%)
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Table 1: Distribution of the Cause of Death for Autopsied Pregnant Women and Trimester of Pregnancy at the Time of Death
P-value 0.02*
Table (2): Cause of Death for Autopsied Pregnant Women in Egyptian Governorates Sharp injuries
Blunt injuries
Asphyxia Smothering Strangulation
Burn
Illegal abortion
Number (%)
P-value
Throttling
1 5 6(37.5%)
2 2(12.5%)
2 2(12.5%)
2 2(12.5%)
2 2(12.5%)
1 1(6.3%)
6(37.5%) 10 (62.5%) 16(100%)
0.05*
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*significant P value is <0.05
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Cause of death Governorate Cairo Giza Total (%)
1 1(6.3%)
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14 cases in 2011
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23 cases in 2012
35%
Cairo
43% 57%
Giza
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65%
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Non-significant difference (P-value =0.4)
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Figure 1: Residential Distribution of Autopsied Pregnant Women.
37.5%
33%
22%
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22%
12.5%
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CAIRO 2011
34%
36.5%
22% 12.5%
CAIRO 2012
Married (23 cases)
67%
GIZA 2011
Single (6 cases)
GIZA2012
Unknown (8 cases)
Non-significant difference (P-value =0.1)
Figure 2: Marital status of autopsied pregnant women. .
Cairo Giza
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100%
62.50%
56%
0 HOMICIDE (16 CASES)
SUICIDE (1 CASE)
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44%
37.5%
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100%
UN-INTENTIONAL (18 CASES) Cairo
UNDETERMINED (2 CASES)
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Giza
0
Non-significant difference (P-value =0.1)
Figure 3: Distribution of Autopsied Pregnant Women According to the Manner of Death and Governorate.
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.
13.5% FIRST
67.5%
19%
SECOND
THIRD
Significant difference (P-value =0.02)
Figure 4: Distribution of Autopsied Pregnant Women According to the Period of Gestation at the Time of Autopsy.
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33%
100%
33.3% 33.3%
33%
16.7%
HUSBAND (6 CASES)
BROTHER (2 CASE)
Cairo 2011 (2 cases)
FATHER (1 CASE)
Cairo 2012 (4 cases)
16.7%
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16.7%
FOREIGNER (1 CASE)
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16.7%
100%
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100%
Giza 2011 (4 cases)
UNDETERMINED (6 CASES)
Giza 2012 (6 cases)
Non-significant difference (P-value =0.5)
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Figure 5: Suspected Perpetrator in Homicidal (intentional) Deaths of Pregnant Women.
1
Fall from height (1 case)
1
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Amniotic pulmonary embolism (2 cases)
2
Post-partum hemorrhage (5 cases)
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1 3
1
Ante-partum hemorrhage (1 case)
4
Caesarian section’ complications (9 cases) 0
Cairo
1
2
5 3
4
5
6
7
8
9
Giza
Non-significant difference (P-value =0.7)
Figure (6): Distribution of Autopsied Un-intentional Pregnant Women Deaths According to the Causes of Death.
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1. The number of pregnancy-associated deaths over a 2-years period was around 37 cases. 2. All were between 30-40 years of age with known identity.
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3. Approximately half of the cases were un-intentional deaths.
4. The husband was the main perpetrator in the homicidal deaths.
The incidence of violence increased over the course of gestation.
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5.