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ORIGINAL RESEARCH |
From Texas Woman’s University, Houston, Texas; Johns Hopkins University, Baltimore, Maryland; and University of Texas Health Sciences Center, Houston, Texas.
Address reprint requests to: Judith McFarlane, DrPH, Texas Woman’s University, Parry Chair in Health Promotion & Disease Prevention, 1130 John Freeman Boulevard, Houston, TX 77030; E-mail: jmcfarlane{at}twu.edu.
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ABSTRACT |
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METHODS: A ten-city case-control design was used with attempted and completed femicides as cases (n = 437) and randomly identified abused women living in the same metropolitan area as controls (n = 384). The attempted and completed femicide cases were identified from police and medical examiner records. Interviews of attempted femicide victims and a proxy for the femicide victim were compared with data from abused controls, identified via random digit dialing in the same ten cities.
RESULTS: Abuse during pregnancy was reported by 7.8% of the abused controls, 25.8% of the attempted femicides, and 22.7% of the completed femicides. Five percent of the femicide victims were murdered while pregnant. After adjusting for significant demographic factors, such as age, ethnicity, education, and relationship status, the risk of becoming an attempted/completed femicide victim was three-fold higher (adjusted odds ratio 3.08, 95% adjusted confidence interval 1.86, 5.10) for women abused during pregnancy. Black women had more than a three-fold increase in risk (adjusted odds ratio 3.6, 95% adjusted confidence interval 2.4, 5.5) as compared with white women. Compared with women not abused during pregnancy, controls and attempted/completed femicide victims abused during pregnancy reported significantly higher levels of violence.
CONCLUSION: Femicide is an important, but often unreported, cause of maternal mortality. This is the first report of a definite link between abuse during pregnancy and attempted/completed femicide. This research documents the immediate need for universal abuse assessment of all pregnant women.
"My husband beat me during each pregnancy. He threw away the vitamins, tore up the prescriptions, and would not let me return to the clinic. He said I did not need the vitamins and medicine for the infections. I was too scared to go to the emergency room. I knew the doctor or nurse would look at me and think: why does she stay? When he shot me during the last pregnancy, I knew I had to leave." — 33-year-old mother with three children
Just how many pregnant women are abused depends on the population surveyed and instruments used. Estimates of the prevalence, developed from clinic-based studies, range from 0.9% to 20.1% with most studies reporting a prevalence of 3.9% to 8.3%.1,2 When reported by age, adolescents consistently report more intimate partner violence compared with adult women.3–5 Studies concur that complications of pregnancy, including low weight gain, anemia, infections, and first- and second-trimester bleeding are positively associated with abuse,6–8 as are higher maternal rates of depression, suicide attempts, tobacco, alcohol, and illicit drug use.9,10 In terms of pregnancy outcomes, the results are mixed. In some studies, abuse has been associated significantly with lower birth weights, even controlling for confounders such as substance use, ethnicity, and gestational age.3,4,6,11 However, this association has not been found in other studies.7,12–15 Different study methods and definitions of abuse have been used in these studies and may account for the conflicting results.16 However, a recent meta-analysis of eight studies used a fixed-effects model to determine that women who reported physical, sexual, or emotional abuse during pregnancy were more likely (odds ratio 1.4, 95% confidence interval 1.1, 1.8) to give birth to a baby with low birth weight.17
In addition to health consequences, abuse can result in femicide to pregnant women. A review of all maternal deaths occurring in Cook County, Illinois, between 1986–1989 found that homicides made up 26% of the 95 maternal deaths.18 Similarly, homicide accounts for 25% of injury deaths to pregnant women in New York City between 1987–1991.19 Recent statewide analysis of death certificates in North Carolina between 1992–1994 and Maryland between 1993–1998 found 13% and 20%, respectively, of pregnancy-associated deaths were homicides (as compared with embolisms, which comprised 9% of pregnancy-associated deaths), making homicide the leading cause of death among pregnant or recently pregnant women in Maryland.20,21 In contrast, homicide was the fifth leading cause of death among nonpregnant women during the same period.
In two tri-ethnic studies, women abused while pregnant reported more frequent and severe abuse compared with women abused before pregnancy but not during pregnancy.22,23 Regarding the severity of abuse experienced by pregnant women, one study of 329 Hispanic women found 30% were threatened with death, and 11% had a knife or gun used on them.24 On the basis of these findings, it appears that abuse during pregnancy is a major threat to the health and survival of pregnant women.
Pregnancy offers a "window of opportunity" wherein abused women are usually seen often by health care professionals and can receive a thorough abuse assessment and prolonged intervention protocol. If abuse during pregnancy is predictive of severe and potentially lethal abuse, pregnant women should be so advised. No published studies were identified that investigated the association of abuse during pregnancy and subsequent intimate partner femicide.
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MATERIALS AND METHODS
This ten-city case-control design was used with attempted and completed femicides as cases (n = 437) and randomly identified abused women living in the same metropolitan area as controls (n = 384). Cases and controls are drawn from these ten cities between 1994 and 2000: Baltimore, MD; Houston, TX; Kansas City, KS; Kansas City, MO; Los Angeles, CA; New York, NY; Portland, OR; Seattle, WA; St. Petersburg/Tampa area, FL; and Wichita, KS. Coinvestigators at each site worked with shelters, law enforcement, medical examiner, or district attorney offices to identify eligible cases. Sampling quotas for cases and controls for each city were determined by the annual number of intimate partner femicides. For example, if 16 completed intimate partner femicides occurred in Houston during 1996, then 16 attempted intimate partner femicides were identified and interviewed and 16 abused controls interviewed. Institutional Review Board approval was obtained as required by each site.
Femicide Cases (n = 263)
Using police or medical examiner femicide closed-case records, at least two potential proxy informants for the victim, someone knowledgeable about her relationship with the perpetrator, were identified and contacted by mail. Letters were sent to known addresses explaining the study and giving proxies the option not to be contacted further. Proxy informants were most often siblings, mothers, close family friends, or other family members.
Once contacted, a prescreening questionnaire was administered to assess length of time the informant had known the victim and perpetrator, and their knowledge level about the relationship. If this person did not feel qualified to answer questions about the relationship, they were asked to refer the investigator to other potential informants. Once a knowledgeable informant was identified and had consented, a brief demographic profile of the informant was completed, followed by an interview questionnaire about the relationship between the deceased woman and intimate partner. Subsequent questions focused on the characteristics of the relationship, including type, frequency, and severity of any prior violence. To profile the relationship of victim and perpetrator within a close proximity to the lethal event, questions focused on the 12 months preceding the femicide. The interview took about 1–2 hours. Approximately 10% of identified proxies refused to participate, at which point a second knowledgeable proxy was identified. A detailed account of field strategies for locating and interviewing proxies is presented elsewhere.25 After informed consent, interviews were completed in English or Spanish according to the proxy’s preference.
Attempted Femicide Victim Cases (n = 174)
Using the inclusion criteria that appear in Appendix 1 and closed-case police and district attorney records, women who had survived an attempt on their life were identified and contacted by mail. Once contacted, consent was obtained, and a convenient time was arranged for the interview. As with the proxies, all interviews were conducted by prepared researchers experienced in conducting sensitive communications with victims of domestic abuse. The same questionnaire was used with the proxy informants and the attempted femicide victims. None of the identified attempted femicide victims refused to participate. Interviews were completed in English or Spanish according to the woman’s preference.
Abused Control Group (n = 384)
To form a control sample, proportionate sampling, based on the number of intimate partner femicides, and random digit dialing (up to six attempts per telephone number) were used to select women who had been in a relationship in which they were "romantically or sexually involved with someone" at some time in the past 2 years in the same cities as the attempted and completed femicides occurred. A woman was considered "abused" if she had been physically assaulted, threatened with serious violence, or stalked by a current or former intimate partner during the past 2 years, as determined using a modified Conflict Tactics Scale26 with stalking items added.27 English- and Spanish-speaking telephone interviewers from an experienced telephone survey firm completed the interviews. Similar to the procedures for the attempted victim cases and proxy respondents for completed femicide cases, the consent form was read to all potential abused control women, and informed consent was obtained before proceeding with the telephone interview. Of the women who met the study criteria for abused controls, and were read the consent statement, 43% agreed to participate.
MEASURES
Abuse and Pregnancy
A series of questions specific to pregnancy was asked of all participants. Participants were asked if the woman was pregnant at the time of the femicide/attempt/"worse abuse." If yes to pregnant, participants were asked if the partner or ex-partner who physically abused her was the father of the baby and the outcome of the pregnancy. Additionally, participants were asked if the partner or ex-partner who physically abused her had EVER, at any time in the relationship, hit her while she was pregnant.
Type and Extent of Violence
A 16-item survey (see Appendix 2) was used to document the frequency and type of stalking and threatening behaviors by the intimate partner perpetrator during the 12 months preceding the attempted or completed femicide. The first six items deal with stalking and were developed by Tjaden and Thoennes28 as part of the Violence and Threats of Violence Against Women in America Survey.29 The definition of stalking used for this study is similar to the Model Antistalking Code for States30 and is taken directly from the report by Tjaden and Thoennes.28 Stalking is defined as "a course of conduct directed at a specific person that involves repeated visual or physical proximity, nonconsensual communication, or verbal, written or implied threats, or a combination thereof, that would cause a reasonable person fear," with "repeated," meaning on two or more occasions.
Ten questions relating to threatening behaviors (Appendix 2, items 7–16) were selected from the Sheridan HARASS instrument.31 All questions were limited to the 12-month period before the attempted or completed femicide incident. Respondents answered yes or no to each behavior. They also indicated approximately how often these behaviors happened on a Likert scale: 1) once only, 2) a few times, 3) many times. In this study, reliability (coefficient 
) of the entire instrument was 0.81 for the attempted femicide women, 0.82 for the completed femicide victims, and 0.73 for the abused controls.
Danger Assessment Scale
The Danger Assessment Scale, consisting of 17 items with a yes/no response format, was designed to assist women in determining their potential risk for becoming a homicide victim.32 All items refer to risk factors that have been associated with murder in situations involving abuse. Questions asked in this study appear in Appendix 3. Because abuse during pregnancy was the outcome of interest, this item was removed before scoring. Initial reliability of the instrument was 0.71 and ranged from 0.60 to 0.86 in five subsequent studies.32 In this study, reliability (coefficient ) was 0.74 for the attempted femicide women, 0.80 for the femicides, and 0.76 for the abused controls. With the exception of "beaten by the perpetrator while pregnant," all danger items were limited to the 12-month period before the attempted, completed femicide incident, or worst incident for abused controls.
Statistical Procedures
Only women reporting ever being pregnant were included in the analyses. Means, standard deviations, and frequencies were used to describe the demographic characteristics of the attempted femicides, completed femicides, and abused controls. The attempted and completed femicides were to be combined only if their demographic characteristics and the number of women abused during pregnancy were similar. Independent t tests and 
2 analyses were used to identify significant differences between the groups. Because of the increase in type I error resulting from the multiple testing necessary to make the decision to combine the groups, the overall level of significance of 0.05 was adjusted, using Bonferonni’s adjustment, to 0.01 (0.05/7) for each demographic variable.
The women were further stratified by abuse during pregnancy status, and two-way analyses of variance were used to investigate differences in violence scores. Additionally, independent t tests and 2 analyses were used to assess demographic differences between women abused and never abused among the controls and attempted/completed femicides. Finally, stepwise logistic regression was used to estimate the odds of becoming a completed or attempted femicide victim if the victim was previously abused during pregnancy. Because of the exploratory nature of the study, each analysis between the controls, the attempted, and the completed femicides was treated as independent, and the level of significance was maintained at = 0.05.
RESULTS
The 821 women in this case-control study consisted of 174 women who survived an attempt on their life by their intimate partner (attempted femicides), 263 women killed by their intimate partner (completed femicides), and 384 women physically abused or threatened with physical harm but no attempt on their life was made (controls). Of the 821 women, only 687 (357 controls, 132 attempted femicides, and 198 completed femicides) reported ever being pregnant, thus 134 were excluded from the analyses. Demographic characteristics for the women who had at least one previous pregnancy paralleled the characteristics of all 821 women and are shown in Table 1
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Type and Extent of Violence
After the a priori decision to combine the attempted and completed femicides only if their demographic characteristics and the number of women abused during pregnancy were similar, analyses were completed, and results indicated that the attempted and completed femicides were not significantly different (P < .01), so they were subsequently merged (n = 330) and compared with abused controls (n = 357).
Scores for stalking, threatening behaviors, and danger were calculated for each group of women. Three two-way analyses of variance were used to determine if there was a difference in stalking, threatening behaviors, and danger scores among the controls and attempted/completed femicides abused and never abused during pregnancy. Results showed that women abused during pregnancy had significantly higher stalking, threats, and danger scores (see Table 2). No significant interaction between abuse group (controls and the attempted/completed femicides) and abuse during pregnancy was observed, thus indicating that women abused during pregnancy in both abuse groups had higher scores.
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). Results indicated that age, ethnicity, and employment were significantly different (P 
.05) between controls who were abused or never abused during pregnancy. Among the controls, women never abused during pregnancy were 3 years older than those abused during pregnancy. The controls abused during pregnancy included 25% white women, 29% Latina women, and 39% black women, whereas the controls never abused during pregnancy included 48% white women, 22% Latina women, and 22% black women. The number of employed controls (77%) never abused during pregnancy was significantly higher than the 61% employed controls abused during pregnancy.
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.05) between the attempted/completed femicides abused and never abused during pregnancy. Attempted/completed femicides never abused during pregnancy were 5 years older than attempted/completed femicides abused during pregnancy. The number of attempted/completed femicides never abused during pregnancy with at least a high school education (70%) was significantly higher than the attempted/completed femicides abused during pregnancy (55%). More than half (55%) of the attempted/completed femicides were employed, compared with the 68% of those who had never been pregnant.
Stepwise logistic regression was used to estimate the odds of becoming a completed or attempted femicide victim if the woman was previously abused during pregnancy. Criteria for demographic variables to be entered into the model were based on changes in the likelihood ratio statistic (P .05). Hosmer and Lemeshow’s goodness-of-fit statistic was used to assess model fit. Odds ratios, unadjusted and adjusted to control for differences in demographics between the two groups (ORs and aORs), with 95% confidence intervals (CIs and aCIs) were reported.
As shown in Table 4, the odds of becoming an attempted/completed femicide victim increased more than three-fold (OR 3.70, 95% CI 2.33, 5.87) for women abused during pregnancy. Even after adjusting for the demographic factors of age, ethnicity, education, and relationship, the risk of becoming an attempted/completed femicide was (aOR 3.08, 95% aCI 1.86, 5.10) only marginally reduced. Black women had more than a three-fold increase in risk (aOR 3.6, 95% aCI 2.4, 5.5) compared with white women. Women who had not graduated from high school were more than twice as likely (aOR 2.2, 95% aCI 1.4, 3.5) to become a femicide victim. Women were almost twice as likely to be killed or almost killed (aOR 1.8, 95% aCI 1.2, 2.7) by an ex-partner than a current partner. Although age was statistically significant, the 5% increase in risk for each year increase in age was not meaningfully significant (aOR 1.05, 95% aCI 1.03, 1.07).
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The controls pregnant at the time of this incident included six black women, three white women, and seven Latina women. The attempted/completed femicides included 11 black women, four white women, and five Latina women. One woman reported as "other" was included in each group. Nine pregnant abused controls and 12 attempted/completed femicides had at least a high school education; eight pregnant abused controls and ten attempted/completed femicides were not employed; and five pregnant abused controls and nine attempted/completed femicides had former relationships with the abuser.
DISCUSSION
This investigation is the first case-control study to examine the association of abuse during pregnancy with associated levels of violence and specific demographic characteristics before attempted/completed intimate partner femicide. The most important limitation of the study is the necessary reliance upon proxy respondents for data on completed femicide cases. However, our pilot study found good agreement between the summed Danger Assessment scores from victims of attempted femicide and their proxies. Furthermore, there was no clear tendency for proxy respondents to under- or over-report attempted femicide victims’ exposure to specific risk factors compared with the victims’ self-reports. Other limitations of the study include the exclusion of women not in large urban areas (except for the Wichita, KS, site) and women without phones in the control group. Furthermore, the study relies totally on self-reports, which may under-report or over-report abuse during pregnancy because of inadequate recall and/or lack of voluntary disclosure. No attempt was made to independently confirm any of the information. Even with these limitations, we were able to demonstrate that, when controlling for demographic characteristics, women reporting abuse during pregnancy are at a three-fold risk of becoming an attempted or completed femicide victim.
To summarize our findings, 8% of the abused controls reported ever being abused during pregnancy, 26% of the attempted, and 23% of the completed femicides were abused during pregnancy. Significant ethnic differences emerged for the controls. The majority of abused controls reporting abuse during pregnancy were black women. All types of violence were significantly higher for women reporting abuse during pregnancy, irrespective of abused control or attempted/completed femicide status. This finding has also been reported previously,23 although this is the first report of a definite link with actual and attempted femicide. Abuse during pregnancy should be seen as a sign of a particularly dangerous batterer. Women abused during pregnancy were at a three-fold risk of femicide with 5.7% of the attempted femicides and 4.8% of the femicides pregnant at the time of the incident. When the worst abuse, attempted, or completed femicide occurred during pregnancy, infant viability was 50% for abused controls and attempted femicides.
There are no case control studies with which we can compare our findings. Clinical implications are straightforward. Abuse during pregnancy occurs in about 4–8% of all pregnancies, and violence during pregnancy may be more common than other conditions for which health care professionals routinely screen.1 Abuse during pregnancy should be seen as an important risk factor for attempted or completed femicide. Homicide has been found to be an important, but often unreported, cause of maternal mortality.33 In fact, in New York City, Chicago, and the states of Maryland and Virginia, where careful examination of records from all sources occurred, homicide was the leading cause of maternal mortality.18–21 Intimate partners are the largest single category of perpetrators of violence against women in this country. Records in New York City, between 1990 and 1997, show approximately 40% of femicide victims murdered by intimate partners (of the cases that could be categorized, which was 54% of the total).34 In this study, women abused during pregnancy by their intimate partner were at a three-fold risk of being murdered by that same partner, with 5% of the women murdered while pregnant.
Almost 20 years ago, the surgeon general called for routine assessment of abuse of pregnant women.35 Healthy People 201036 has specific violence abatement objectives. The ACOG has emphasized the existence of partner violence and the need for routine assessment of all women.37,38 The American College of Nurse-Midwives39 and the Association of Women’s Health, Obstetric, and Neonatal Nurses40 both promote screening for all women presenting for midwifery care. The position of the American Academy of Family Physicians is that family physicians must be able to recognize and know how to treat family violence.41 The Council on Scientific Affairs of the American Medical Association lists four steps to increase detection of abuse among female patients, beginning with routine screening at the entry points of contact between women and medical care (eg, primary care, emergency services, obstetric and gynecologic services, psychiatric services, and pediatric care).42 Routine screening is followed with validation of the abuse. Statements that many people experience abuse and abuse is serious offer validation to the victim. The third step is specific documentation in the medical record as to location and extent of trauma as well as symptomatology. The fourth action is referral to trained staff within the care setting and to specific outside resources. Referral action is always guided by protocols that address safety issues.
Specific protocols for intervention in cases of abuse during pregnancy and for identification, assessment, and intervention in health care settings have been tested and published.43,44 Brief clinical interventions have proven effective in increasing abused women’s safety-seeking behaviors.45,46 A simple abuse assessment and intervention protocol integrated into the routine procedures of a prenatal clinic can lead to increased detection of abuse, referral, and documentation in the maternity medical record.47,48 The evidence is indisputable. Abuse is common during pregnancy, a threat to maternal and child health, and may result in death. So when do we start to act to protect the safety and well-being of mother and child?
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Footnotes |
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Received September 13, 2001. Received in revised form February 25, 2002. Accepted March 21, 2002.
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REFERENCES |
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S. L. Martin, R. J. Macy, K. Sullivan, and M. L. Magee Pregnancy-Associated Violent Deaths: The Role of Intimate Partner Violence Trauma Violence Abuse, April 1, 2007; 8(2): 135 - 148. [Abstract] [PDF]
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M. A. Dutton, B. L. Green, S. I. Kaltman, D. M. Roesch, T. A. Zeffiro, and E. D. Krause Intimate Partner Violence, PTSD, and Adverse Health Outcomes. J Interpers Violence, July 1, 2006; 21(7): 955 - 968. [Abstract] [PDF]
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 L. J. Koenig, D. J. Whitaker, R. A. Royce, T. E. Wilson, K. Ethier, and M. I. Fernandez Physical and Sexual Violence During Pregnancy and After Delivery: A Prospective Multistate Study of Women With or at Risk for HIV Infection Am J Public Health, June 1, 2006; 96(6): 1052 - 1059. [Abstract] [Full Text] [PDF]
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 K. F. Lutz Abuse Experiences, Perceptions, and Associated Decisions During the Childbearing Cycle West J Nurs Res, November 1, 2005; 27(7): 802 - 824. [Abstract] [PDF]
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C. C. Pallitto, J. C. Campbell, and P. O'Campo Is Intimate Partner Violence Associated with Unintended Pregnancy? A Review of the Literature Trauma Violence Abuse, July 1, 2005; 6(3): 217 - 235. [Abstract] [PDF]
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J. Chang, C. J. Berg, L. E. Saltzman, and J. Herndon Homicide: A Leading Cause of Injury Deaths Among Pregnant and Postpartum Women in the United States, 1991-1999 Am J Public Health, March 1, 2005; 95(3): 471 - 477. [Abstract] [Full Text] [PDF]
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 J. Campbell, C. Garcia-Moreno, and P. Sharps Abuse During Pregnancy in Industrialized and Developing Countries Violence Against Women, July 1, 2004; 10(7): 770 - 789. [Abstract] [PDF]
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M. R. Decker, S. L. Martin, and K. E. Moracco Homicide Risk Factors Among Pregnant Women Abused by Their Partners: Who Leaves the Perpetrator and Who Stays? Violence Against Women, May 1, 2004; 10(5): 498 - 513. [Abstract] [PDF]
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 J. Nurse, S. T Bauer, E. M Shadigian, P. Davies, A. Taft, K. Hegarty, M. Crilly, A. Howe, M. M Goodwin, P. Dietz, et al. Screening for domestic violence BMJ, December 14, 2002; 325(7377): 1417 - 1417. [Full Text] [PDF]
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 Abuse During Pregnancy Linked with Subsequent Homicide Journal Watch Psychiatry, September 18, 2002; 2002(918): 11 - 11. [Full Text]
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 Abuse During Pregnancy Linked with Subsequent Homicide Journal Watch (General), August 13, 2002; 2002(813): 4 - 4. [Full Text]
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