PROJECT SUMMARY/ABSTRACT Homicide remains a leading cause of death among women who are pregnant and postpartum, and a majority of these deaths involve intimate partner violence and firearm use. Further upstream interventions are critical in preventing future maternal deaths and the trauma borne by the children, families, and communities they leave behind. Previous research endeavors have largely neglected the influence of state-level firearm policies on violent maternal deaths, despite recent calls for adoption of a human rights approach to addressing and eliminating preventable maternal mortality. This evidence is urgently needed at a time when maternal mortality review committees are mobilizing across the US in order to make systems- and policy-level recommendations to prevent maternal death, and while they are broadening their capacity to review violent maternal deaths in addition to obstetric causes. Our specific aim is to estimate the causal impact of four state-level policies that shape access to and ownership of firearms on incidence of pregnancy- associated homicide. Specifically, we examine 1) state laws that prohibits people convicted of domestic violence misdemeanors or under final domestic violence restraining order from possessing firearms (“possession” policies), and 2) state laws that require abusers convicted of domestic violence misdemeanors or those under domestic violence restraining orders to turn in their firearms when they become prohibited from possessing them (“relinquishment” policies). We have established and will continue to build a state policy database for monitoring changes in state-level firearm policies of interest over time, in conjunction with over ten years of death records for monitoring state-level rates of pregnancy-associated homicide over time. The research analytic design makes use of a natural experiment framework and difference-in- difference analysis, allowing for the comparison of each state to itself, before and after the policy change. This approach is robust to potential biases from unmeasured characteristics that may differ between states and influence the state's population health. Findings from this work will fill a critical gap in the scientific evidence base of the causal impact of state-level firearm policy on violent maternal death, data glaringly absent from both public health prevention efforts and policymaker agendas. Such findings are also imperative to the wider adoption of effective, evidence-based recommendations for state maternal mortality review committees responsible for identification of modifiable factors and interventions that could prevent maternal deaths and advance health equity.

PROJECT NARRATIVE This research represents a significant and innovative contribution to our understanding of the policy-level factors underlying violent maternal death in US states. By focusing on firearm policies that restrict or prohibit firearm possession among domestic violence offenders, we seek to identify the degree to which their enactment alters trends in pregnancy-associated homicide within each state. Findings from this study will establish a scientific evidence-base from which maternal mortality prevention efforts – including policy-level intervention – may advance progress towards elimination of preventable deaths.