Devakumar, D

Osrin, D

PLoS Medicine

UCL Discovery

PERSPECTIVEChild Homicide: A Global Public HealthConcernDelan Devakumar1*, David Osrin21 Institute of Epidemiology and Health Care, University College London, London, United Kingdom,2 Institute for Global Health, University College London, London, United Kingdom* d.devakumar@ucl.ac.ukDespite recent increases in child survival, some 5.9 million children still die each year, andreducing global childhood mortality remains a public health priority [1]. The greatest numbersof deaths are due to infections, intrapartum events, and preterm births, but reductions in allcauses of mortality are needed to reach the Sustainable Development Goal target of 25 deathsfor every 1,000 live-born infants. In a research article in PLOS Medicine, Naeemah Abrahamsand colleagues shed some light on the occurrence of child homicide [2]. Tragedy radiates fromsuch events, backward in time to the pressure and emotional burden that might lead people,willfully or not, to end the life of a child, and forward to the effects on parents and families.Children who survive attempted homicide may go on to suffer long-term traumatic conse-quences [3].Abrahams and colleagues examined data on homicides of children aged under five years inSouth Africa. They began by assessing records of unnatural deaths over a single year, 2009, inpostmortem reports from a sample of medico-legal laboratories of different sizes and in urbanand rural settings. They contacted investigating police officers and interviewed them to gathermore information. Most of the deaths (74.4%) were of infants less than one year old (of whom53.2% were neonates in their first 28 days of life). Mortality rates among neonates, infants, andchildren aged 1–4 years were 19.6, 28.4, and 1.0 per 100,000 live births, respectively. These fig-ures are substantial: assuming an overall neonatal mortality rate of 12–14 per 1,000, the neona-tal mortality estimate from homicide in the present study corresponds to ~1.5% of all neonataldeaths in South Africa in 2009.Were the high rates of child homicide found in the study a product of South Africa’s highaggregate homicide rate (31 per 100,000), or were they unexpected [4]? Global homicide ratesaverage 6.2 per 100,000, but there is large variation. Young people under the age of 20 yearsmake up around a quarter of homicide victims [4]: 95,000 children were killed in 2012, a rateof eight per 100,000. Rates are particularly high in Latin America (12 per 100,000) and east andcentral Africa (10 per 100,000). The highest estimate is for El Salvador, at 27 per 100,000 [3]. Insome countries, such as Venezuela, improvements in child health have been vitiated by childhomicides [3].We should view global estimates with caution as data are often incomplete, analysis requiresassumptions, and misclassification is particularly likely with regard to homicide of younginfants [3]. In general, homicides are likely to be underreported, particularly for neonates incountries that do not have complete coverage of birth registration and where deliveries takeplace outside institutions. Categorisation is always going to be elusive, but Abrahams and col-leagues used the best methods they could, with an emphasis on conservative estimates. Theresearchers excluded cases for which no information was available and deaths ascribed toPLOSMedicine | DOI:10.1371/journal.pmed.1002004 April 26, 2016 1 / 3OPEN ACCESSCitation: Devakumar D, Osrin D (2016) ChildHomicide: A Global Public Health Concern. PLoSMed 13(4): e1002004. doi:10.1371/journal.pmed.1002004Published: April 26, 2016Copyright: © 2016 Devakumar, Osrin. This is anopen access article distributed under the terms of theCreative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in anymedium, provided the original author and source arecredited.Funding: There was no specific funding for thisstudy. DD is supported by the National Institute ofHealth Research. DO is supported by The WellcomeTrust.Competing Interests: The authors have declaredthat no competing interests exist.Provenance: Commissioned; not externally peerreviewedsudden infant death syndrome (of which up to 10% might represent homicide) [5], whichcould have produced an underestimate of the burden of child homicide. Conversely, they clas-sified all cases of abandonment and subsequent death as homicide, which might have producedan overestimate.The most common antecedent to death was abandonment of young infants, but there waslittle information on cause of death beyond this. Concealment of pregnancy is relatively com-mon worldwide [6], and other studies have shown that suffocation and drowning are frequentmethods of infanticide [7]. Causal inference is difficult if the child’s body is found in a partiallydecomposed state, and misclassification of stillbirths is possible. An assessment of abandonedfetuses and newborn infants in South Africa, by du Toit-Prinsloo and co-workers, found that35% were decomposed. Amongst infants of greater than 26 weeks gestation, 28% (n = 31) werethought to have been born alive, but differentiation was not possible in 31% [8].Abrahams and colleagues found no difference in child homicide rates by sex, although therewas a decreased likelihood of male deaths in rural settings compared to urban settings. Theyrightly draw comparisons with south Asia and China, where both feticide and infanticide ofgirls have been a serious concern [9,10], but we should be cautious, given the modest size ofAbrahams and colleagues’ study. In a related paper, Mathews and co-workers describe the epi-demiology of child homicide in South Africa [11]. The pattern of homicide is similar for boysand girls, but changes with age. The homicide rate amongst males aged 15–17 years was fivetimes that for females of the same age.Abrahams and colleagues found—as have others—that mothers were the perpetrators intwo-thirds of cases (maternal filicide). Studies from high-income countries suggest that thecharacteristics of mothers implicated in infanticide at birth and homicides of older infants aredifferent. Women who commit neonaticide—the bulk of deaths—are more often young, unem-ployed or in school, and unmarried. Women implicated in the homicide of older infants tendto be older, and the homicide often occurs within a cycle of abuse [7]. The association of infan-ticide with maternal mental health is complex, and some studies support a link, while others donot [6]. Some women who commit infanticide are living with mental illness, including frankpsychosis, but most infanticide does not seem to be associated with overt maternal mental ill-ness [7].What can the health community do? There are two general approaches: child protectionand law enforcement, and primary prevention. Protecting vulnerable children is a priority,with an emphasis on supporting under-resourced and sometimes nonexistent child protectionservices, as is convicting perpetrators. In many cases, primary prevention of homicide throughwork with parents and families may be the best approach. Referring to deaths caused byparents, Resnick suggested a classification that included altruistic motives (to relieve suffering),acute psychosis, unwanted pregnancy, fatal consequences of child maltreatment, and revengeagainst another person, often a spouse [12]. Each of these categories has implications for theway we think about potential public health approaches. Some countries allow women to leavetheir infants anonymously in a safe place. The USA, for example, has introduced “safe havens”where infants can be abandoned legally. The effectiveness of such initiatives has yet to be deter-mined, and it is not known whether mothers who might commit infanticide would call onthem [13].We agree with Abrahams and colleagues that more funds should go into maternity services,and also suggest that interventions need to be instigated before conception. As many births areunwanted, accessible and contextually appropriate family planning interventions are needed.Much work needs to be done with adolescent women to provide advice and support on sexualhealth, contraception, and childbirth. For women who present antenatally, a mental healthassessment should be part of routine practice, with extra support for those in whom conditionsPLOSMedicine | DOI:10.1371/journal.pmed.1002004 April 26, 2016 2 / 3are diagnosed or predicted [14]. Mortality data should be disaggregated and include homicidestatistics, even if the numbers are small, so that we can move forward with a clearer picture ofwhere interventions would yield the greatest benefit. We know a little, but not enough.Author ContributionsWrote the first draft of the manuscript: DD. Contributed to the writing of the manuscript: DDDO. Agree with the manuscript’s results and conclusions: DD DO. Both authors have read,and confirm that they meet, ICMJE criteria for authorship.References1. You D, Hug L, Ejdemyr S, Idele P, Hogan D, Mathers C, et al. Global, regional, and national levels andtrends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a system-atic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet. 2015; 386:2275–2286. doi: 10.1016/S0140-6736(15)00120-8 PMID: 263619422. Abrahams N, Mathews S, Martin LJ, Lombard C, Nannan N, Jewkes R. Gender differences in homicideof neonates, infants, and children under 5 y in South Africa: results from the cross-sectional 2009National Child Homicide Study. PLoS Med. 2016; 13:e1002003.3. United Nations Children’s Fund. Hidden in plain sight: a statistical analysis of violence against children.New York: United Nations Children’s Fund; 2014.4. United Nations Office on Drugs and Crime. Global study on homicide. Vienna: United Nations Officeon Drugs and Crime; 2013.5. Levene S, Bacon CJ. Sudden unexpected death and covert homicide in infancy. Arch Dis Child. 2004;89:443–447. PMID: 151026376. Friedman SH, Horwitz SM, Resnick PJ. Child murder by mothers: a critical analysis of the current stateof knowledge and a research agenda. Am J Psychiatry. 2005; 162:1578–1587. doi: 10.1176/appi.ajp.162.9.1578 PMID: 161356157. Porter T, Gavin H. Infanticide and neonaticide: a review of 40 years of research literature on incidenceand causes. Trauma Violence Abuse. 2010; 11:99–112. doi: 10.1177/1524838010371950 PMID:205545028. du Toit-Prinsloo L, Pickles C, Smith Z, Jordaan J, Saayman G. The medico-legal investigation of aban-doned fetuses and newborns-a review of cases admitted to the Pretoria Medico-Legal Laboratory,South Africa. Int J Legal Med. 2016; 130:569–574. doi: 10.1007/s00414-015-1198-y PMID: 259352389. Sen A. Missing women-revisited. BMJ. 2003; 327:1297–1298. doi: 10.1136/bmj.327.7427.1297 PMID:1465680810. Hesketh T, Zhou X, Wang Y. The end of the one-child policy: lasting implications for China. JAMA.2015; 314:2619–2620. doi: 10.1001/jama.2015.16279 PMID: 2654525811. Mathews S, Abrahams N, Jewkes R, Martin LJ, Lombard C. The epidemiology of child homicides inSouth Africa. Bull World Health Organ. 2013; 91:562–568. doi: 10.2471/BLT.12.117036 PMID:2394040312. Resnick PJ. Child murder by parents: a psychiatric review of filicide. Am J Psychiatry. 1969; 126:325–334. doi: 10.1176/ajp.126.3.325 PMID: 580125113. Friedman SH, Resnick PJ. Neonaticide: phenomenology and considerations for prevention. Int J LawPsychiatry. 2009; 32:43–47. doi: 10.1016/j.ijlp.2008.11.006 PMID: 1906429014. Hatters Friedman S, Resnick PJ. Child murder by mothers: patterns and prevention. World Psychiatry.2007; 6:137–141. PMID: 18188430PLOSMedicine | DOI:10.1371/journal.pmed.1002004 April 26, 2016 3 / 3

Child Homicide: A Global Public Health Concern

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Child Homicide: A Global Public Health Concern

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