Child Homicide: A Global Public Health Concern

In this perspective, Delan Devakumar and David Osrin discuss Abrahams and colleagues’ findings in the context of evidence about child homicide in different countries, and consider etiology along with implications for child protection and prevention.

Funding: There was no specific funding for this study. DD is supported by the National Institute of Health Research. DO is supported by The Wellcome Trust.
Competing Interests: The authors have declared that no competing interests exist.
Provenance: Commissioned; not externally peer reviewed sudden infant death syndrome (of which up to 10% might represent homicide) [5], which could have produced an underestimate of the burden of child homicide. Conversely, they classified all cases of abandonment and subsequent death as homicide, which might have produced an overestimate.
The most common antecedent to death was abandonment of young infants, but there was little information on cause of death beyond this. Concealment of pregnancy is relatively common worldwide [6], and other studies have shown that suffocation and drowning are frequent methods of infanticide [7]. Causal inference is difficult if the child's body is found in a partially decomposed state, and misclassification of stillbirths is possible. An assessment of abandoned fetuses and newborn infants in South Africa, by du Toit-Prinsloo and co-workers, found that 35% were decomposed. Amongst infants of greater than 26 weeks gestation, 28% (n = 31) were thought 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 there was a decreased likelihood of male deaths in rural settings compared to urban settings. They rightly draw comparisons with south Asia and China, where both feticide and infanticide of girls have been a serious concern [9,10], but we should be cautious, given the modest size of Abrahams and colleagues' study. In a related paper, Mathews and co-workers describe the epidemiology of child homicide in South Africa [11]. The pattern of homicide is similar for boys and girls, but changes with age. The homicide rate amongst males aged 15-17 years was five times that for females of the same age.
Abrahams and colleagues found-as have others-that mothers were the perpetrators in two-thirds of cases (maternal filicide). Studies from high-income countries suggest that the characteristics of mothers implicated in infanticide at birth and homicides of older infants are different. Women who commit neonaticide-the bulk of deaths-are more often young, unemployed or in school, and unmarried. Women implicated in the homicide of older infants tend to be older, and the homicide often occurs within a cycle of abuse [7]. The association of infanticide with maternal mental health is complex, and some studies support a link, while others do not [6]. Some women who commit infanticide are living with mental illness, including frank psychosis, but most infanticide does not seem to be associated with overt maternal mental illness [7].
What can the health community do? There are two general approaches: child protection and law enforcement, and primary prevention. Protecting vulnerable children is a priority, with an emphasis on supporting under-resourced and sometimes nonexistent child protection services, as is convicting perpetrators. In many cases, primary prevention of homicide through work with parents and families may be the best approach. Referring to deaths caused by parents, Resnick suggested a classification that included altruistic motives (to relieve suffering), acute psychosis, unwanted pregnancy, fatal consequences of child maltreatment, and revenge against another person, often a spouse [12]. Each of these categories has implications for the way we think about potential public health approaches. Some countries allow women to leave their 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 determined, and it is not known whether mothers who might commit infanticide would call on them [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 are unwanted, accessible and contextually appropriate family planning interventions are needed. Much work needs to be done with adolescent women to provide advice and support on sexual health, contraception, and childbirth. For women who present antenatally, a mental health assessment should be part of routine practice, with extra support for those in whom conditions are diagnosed or predicted [14]. Mortality data should be disaggregated and include homicide statistics, even if the numbers are small, so that we can move forward with a clearer picture of where interventions would yield the greatest benefit. We know a little, but not enough.

Author Contributions
Wrote the first draft of the manuscript: DD. Contributed to the writing of the manuscript: DD DO. Agree with the manuscript's results and conclusions: DD DO. Both authors have read, and confirm that they meet, ICMJE criteria for authorship.