Firearm Homicide in Pregnant Women and State-Level Firearm Ownership

Importance: Homicide is the leading cause of death among pregnant women, mostly from firearms. State-level variability in pregnancy-associated homicide rates and their association with firearm ownership is not well characterized. Objectives: To describe pregnancy-associated firearm homicide rates across states and examine their association with state-level firearm ownership prevalence. Design, Setting, and Participants: This retrospective cross-sectional study using the National Violent Death Reporting System included women of childbearing age (15-49 years) who died from homicide in 37 states (January 1, 2018, to December 31, 2021). Women were categorized as pregnant (including in the last 12 months) vs nonpregnant. Data were analyzed between January 2023 and July 2025. Exposure: The primary exposure was state-level firearm ownership prevalence. Main Outcomes and Measures: The primary outcome was state-level pregnancy-associated firearm homicide rates. Firearm ownership prevalence was estimated using a proxy: the ratio of state firearm suicides to total suicides. Multivariable generalized estimating equations with a negative binomial link were used to estimate adjusted incident rate ratios (IRRs) with 95% CIs for the outcome of pregnancy-associated homicide, adjusting for estimated state-level firearm prevalence, year, and state-level covariates (unemployment, poverty, insurance, age, sex, and population density). Results: Among homicides in 7063 women (median IQR age, 30.0 24.0-38.0 years; 153 2.2% American Indian or Alaska Native, 115 1.6% Asian or Pacific Islander, 3278 46.4% Black or African American, 2565 36.3% White, 123 1.7% other other or unspecified race and >1 race, and 29 0.4% unknown), 434 (6.1%) occurred in pregnant women. Most homicides (250 57.6%) occurred among women of non-Hispanic Black race. Firearms were used in 341 homicides (78.6%) in pregnant women. Firearm homicide rates were higher in pregnant vs nonpregnant women (38.63 vs 28.20 per 1 000 000 live births; IRR, 1.37; 95% CI, 1.22-1.53). Across states, pregnancy-associated firearm homicide rates ranged from 0 to 111.43 per 1 000 000 live births. In adjusted models, the adjusted IRRs were 1.06 (95% CI, 1.03-1.09) for all-cause homicide and 1.08 (95% CI, 1.04-1.12) for firearm homicide for each 1% increase in estimated firearm ownership. Conclusions and Relevance: In this cross-sectional study of homicides among women, state-level firearm ownership was significantly associated with all-cause and firearm-specific homicide among pregnant women, independent of state-level factors. These results suggest that homicide prevention interventions should focus on women, especially during the increased risk period of pregnancy.