Hidden toll of violent deaths during pregnancy and the postpartum period: a nationwide analysis of Mexican death records.

Introduction: Violent deaths during pregnancy and the postpartum period remain an unmet global public health priority. These include deaths from self-inflicted (ie, suicide) and externally perpetrated violence (including deaths due to assault, legal intervention and operations of war or of undetermined intent). Mexico-where both the levels of violence and data completeness are high-offers a unique opportunity to assess how current international maternal surveillance frameworks obscure the burden of lethal violence during this period. Methods: We analysed data on all deaths of pregnant and postpartum women, up to one year following the end of pregnancy, regardless of birth outcome, from the implementation of International Classification of Diseases, 10th Revision (ICD-10) onwards (1998-2024) in Mexico. Deaths from violence were compared with maternal and late maternal causes, categorised by ICD-Maternal Mortality grouping. Modalities of violence were compared by timing of death (pregnant or postpartum). Results: Between 1998 and 2024, official statistics recorded 36 662 pregnancy-related deaths of women aged 10-54 in Mexico, of which 1855 were due to violence: 1287 from external violence (assault: n=1133, undetermined intent: n=154) and 568 from self-inflicted violence. Violent deaths increased since 2010, across the study period, surpassed or were comparable to leading maternal obstetric causes: exceeding pregnancy-related infection (n=929) and approaching those from abortive outcome (n=2101). The leading modality of external violence was firearm-related death (n=650) followed by hanging/strangulation (n=206), whereas hanging/strangulation (n=423) was most common among self-inflicted deaths followed by self-poisoning (n=104). Conclusions: Violence during pregnancy and the postpartum period remains an overlooked public health concern, insufficiently prioritised within maternal health and violence prevention agendas. International definitions and existing surveillance systems fail to capture the burden of these violent deaths: suicides need to be better reported within maternal death statistics, while a new indicator is needed to explicitly monitor homicides during pregnancy and the postpartum period. Robust vital statistics data from Mexico underscore the urgent need to integrate violence prevention into maternal health frameworks, strengthen clinical screening and address the structural determinants of suicide and homicide during pregnancy and the postpartum period.