Newborns Killed or Left to Die by a Parent:  A Population-Based Study FREE

The risk of homicide on the first day of life (neonaticide) is 10 times greater than the rate during any other time of life.¹ Neonaticide has been attributed to motives and circumstances associated with the mother's perceived need to keep the pregnancy and birth unknown to her family and associates.^2- 3 Theories about the causes of this behavior include shame about an unwanted or illegitimate infant and/or the obvious sexual activity, mental illness,⁴ difficult relationships with parents,² immaturity,⁵ and a culture that promotes self-destructive impulses.⁶ The mother may deny to herself that she was pregnant, and thus be surprised by the birth.^5,7- 8 Public and professional conceptions of the situations involving these cases are often based on the stereotype of the unwed adolescent girl, especially one who is from a religious family or feels she cannot confide in her parents.^2,9 As of 2002, 42 states have passed "Safe Haven" or "Safe Surrender" laws to prevent neonaticide (William L. Pierce, PhD, written communication, February 21, 2003).¹⁰ These laws allow parents to anonymously transfer an unwanted newborn to certain persons or authorities, such as hospitals, without being charged with infant abandonment.^11- 12

To estimate the incidence of newborn infants killed or discarded and left to die, we investigated all deaths of newborns 0 to 4 days of age in North Carolina and characterized the perpetrators and circumstances of these deaths to inform Safe Haven policy.

We reviewed the case records of all deaths regardless of cause of all liveborn infants 4 days of age or younger listed in the North Carolina Medical Examiner (ME) database for the 16-year period from January 1, 1985, through December 31, 2000.¹³ The ME case files include the death certificate, the name of involved law enforcement officers, and the ME's report, which contains details of the circumstances surrounding the death, the autopsy, and any toxicology studies. The manner of death (homicide, accident, natural, suicide, undetermined) was determined for each case by the Office of the Chief Medical Examiner. The designation of a death as a homicide depended on a determination made by the ME that the death was the consequence of deliberate actions on the part of the perpetrator to cause harm to the infant. Intent was inferred in most cases from scene and historical information or, in some instances, from statements made to the authorities by the perpetrator. It was assumed that the parent(s) of a newborn would know that some level of immediate care and support to the infant was necessary and that an apparent failure to provide that care to the infant constituted a deliberate act, albeit of omission. In instances where there was serious question in regard to whether or not the parent was able to appreciate the need for such care because of mental impairment, homicide was not ruled. In one instance not ruled a homicide, the infant had what would have been a rapidly (if not immediately) lethal cardiac anomaly, so it was inconclusive that lack of care or abandonment caused the death.

For liveborn infants, all homicide cases and cases determined by our review to be deaths related to discarding of the newborn and committed or likely to have been committed (from the circumstances) by a parent regardless of manner were coded into the data set. Variables abstracted included the victim's name, date of birth, age, sex, race, county of residence, and death; date, time, circumstances, and location of death; and location of the body, the manner of death, and the means of death (such as suffocation, stabbing, or drowning). Medical examiner narratives were reviewed for perpetrator and other pertinent information. When necessary, law enforcement officials were contacted for additional perpetrator information. Homicide cases were further reviewed to identify those where neither parent was noted as a perpetrator. We supplemented ME data with data obtained from linked birth and death files from the State Center for Health Statistics. Variables extracted from the birth certificate part of the infant death file consisted of the mother's name, age, race, marital status, identity of the father, number of live children, children now dead, last menstrual period, plurality, and month prenatal care began. Statistical analysis was performed using SAS, version 8.2 (SAS Institute Inc, Cary, NC).

Thirty-four cases of newborn deaths by homicide or by discarding where the perpetrator was either confirmed to be a parent (n = 29) or likely to have been a parent (n = 5) were identified over the 16-year period. Thirty-one cases were ruled homicides and 3 deaths were ruled either as accidental or natural but related to conditions of discarding and lack of providing care for the newborn (Table 1). During this time period, North Carolina had a total of 1 644 718 liveborn infants; therefore, 0.002% of all liveborn infants were known to have been killed or discarded, for a rate of 2.1 per 100 000 newborns per year. In 2001, there were 4 028 000 liveborn infants in the United States. Therefore, if the United States as a whole had a similar proportion of newborns actively or passively killed, as many as 85 lives per year might have been saved if Safe Haven laws were available in all states and in the unlikely event that all parents of these infants took advantage of these laws.

Table 2 and Table 3 show the characteristics of the newborns, circumstances of their deaths, mothers' characteristics, and fathers' identities. Newborn males comprised 58.8% of the cases and females 35.3% of the cases, with 5.9% indeterminate due to advanced decomposition of the bodies. Testing for differences between the population proportion, the male to female proportion was statistically significant (test statistic: z = 1.99, P = .045). Of all newborns in this 16-year period, 51% were female and 49% were male. Forty-one percent of the infants were white. Black infants, 52.9% of the cases, were overrepresented compared with the overall population of newborns, of whom approximately 28% were black. Data were not available for Hispanic ethnicity until 1988. None of the cases from 1988 through 2000 were known to be Hispanic. The mean age of the mothers was 19.1 years (range, 14-35 years), and 20.6% were married. The mother was determined to be the perpetrator in 29 of the 34 cases. Information was available about prenatal care for 17 of the cases. Eight of the 17 had received prenatal care. Thirty-five percent of the infants were second or third born. Although it is not a routinely collected variable, in 8 cases (23.5%), the ME narratives noted that the mother denied being pregnant. Analysis of the legal outcomes is beyond the scope of this study, but we noted where we were able to obtain information on legal outcomes that sentences of perpetrators to imprisonment varied from none to 25 years.

In the process of case reviews, we found 7 other cases coded as homicides of infants aged 0 to 4 days that did not meet the inclusion criteria for the study (Table 4). These 7 cases were not included in further analyses.

Over a 16-year period in North Carolina, we report on 34 newborns known to be killed or discarded in the first day of life by (or likely by) the parents, an annual rate of 2.1 per 100 000 newborns. The majority of the cases (91.2%) were ruled homicides, while 3 were found to be unintentional or due to natural causes. Mothers were the perpetrators in all cases where a perpetrator was positively identified. Approximately one fifth were married and a similar proportion had received some prenatal care. To our knowledge, this study is the only population-based case series that has been conducted in the United States. A Rio de Janeiro case series from 1900 to 1995 identified a total of 72 newborn homicides, of which 53 were determined to be homicides by the mothers of the newborns.¹⁴ Cases not ruled homicide were not studied. Twelve percent of those mothers (mean age, 22.5 years; range, 17-48 years) were married, a lower percentage than in this study. As we found, there were more male victims than female (56.6% vs 43.4%). In our study, about one third of the mothers were 21 years of age or older. Studies and news reports tend to focus on adolescent girls.^2,15- 16 Moreover, 35% of our cases were second or third pregnancies. Perhaps the most unexpected finding was that 20.6% of the mothers were married and slightly more had received some prenatal care, albeit usually late. These findings suggest that targets for educational programs about Safe Haven options need to be populationwide (rather than focused exclusively on pregnant adolescents) and that family planning and prenatal clinics be targeted specifically.

The phenomenon of mothers needing to surrender newborns anonymously became such a problem in Europe in the Middle Ages¹⁷ that many churches contained slots where the mother could slip the baby in and leave unseen, perhaps after ringing a bell. This practice of "baby drops" has recently been reinstituted in California and several other countries, including Germany and South Africa.^10- 11

Our study is limited by several factors. Even though all known neonaticides or deaths due to discarding within a 16-year period were identified, small numbers and missing values may restrict generalizability to the United States as a whole. Our study lacked some information about the mothers such as their mental state at the time of the birth, substance abuse or mental health history, socioeconomic profile, or whether they were already under observation by the state child protective services system. Therefore, it was not possible to estimate how many of the mothers might have been willing to take advantage of a Safe Haven law, had one been in effect. Finally, the number of newborns killed or discarded may actually be higher since it is unknown how many deaths may have occurred without ever being discovered.

In conclusion, this study provides an opportunity to understand the epidemiology of cases of active or passive killing of newborns by their parents. Data from this study may aid prevention efforts such as Safe Haven programs so that states, health departments, adolescent pregnancy prevention programs, and other related organizations can use their limited resources more effectively. In addition, for known cases, the study provides an upper estimate for the number of lives that could be saved under Safe Haven programs in the event, although unlikely, that all susceptible parents participated.