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ORIGINAL RESEARCH |
From the Institute for Families in Society, Department of Epidemiology and Biostatistics, School of Public Health, and the Department of Family and Preventive Medicine, School of Medicine, University of South Carolina, Columbia, South Carolina.
Address reprint requests to: Vilma E. Cokkinides, PhD Institute for Families in Society University of South Carolina 937 Assembly Street, Carolina Plaza 12th Floor Columbia, SC 29208 E-mail: vilmac{at}gwm.sc.edu
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Abstract |
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Methods: We used population-based data from 6143 women who delivered live-born infants between 1993 and 1995 in South Carolina. Data on women’s physical violence during pregnancy were based on self-reports of "partner-inflicted physical hurt and being involved in a physical fight." Outcome data included maternal antenatal hospitalizations, labor and delivery complications, low birth weights, and preterm births. Odds ratios and 95% confidence intervals were calculated to measure the associations between physical violence, maternal morbidity, and birth outcomes.
Results: The prevalence of physical violence was 11.1%. Among women who experienced physical violence, 54% reported having been involved in physical fights only and 46% had been hurt by husbands or partners. In the latter group, 70% also reported having been involved in fighting. Compared with those not reporting physical violence, women who did were more likely to deliver by cesarean and be hospitalized before delivery for maternal complications such as kidney infection, premature labor, and trauma due to falls or blows to the abdomen.
Conclusion: Physical violence during the 12 months before delivery is common and is associated with adverse maternal conditions. The findings support the need for research on how to screen for physical violence early in pregnancy and to prevent its consequences.
Intimate partner violence against pregnant women is not unusual. Studies have shown a prevalence of physical violence during pregnancy of between 0.9% and 20%.1 Violence during pregnancy affects women and might lead to pregnancy complications or adverse birth outcomes.2,3
Violence can affect pregnancy through direct or indirect mechanisms.2,3 A blow to a pregnant woman’s abdomen can cause adverse outcomes directly (ie, fetal injury and death, or complications such as preterm labor). The indirect mechanism relates to a woman’s victimization experience from intimate-partner violence and how it can induce intermediary risks (ie, psychologic stress or insufficient access to medical care) that could cause poor outcomes.2,3
Five studies4–8 showed no association between physical violence and low birth weights (LBWs) or preterm births, whereas two others9,10 found modest increases in risk of LBWs among women who experienced intimate-partner violence during pregnancy. Differing study populations, sample sizes, study designs, and varying measures of physical violence might explain discrepant findings among studies.
An understanding of the relationship between physical violence during pregnancy, adverse maternal conditions, and birth outcomes could have important clinical and public health implications. Early identification and intervention to prevent violence against pregnant women might reduce adverse outcomes in pregnancy. Using a population-based, cross-sectional study sample, we assessed the independent association of physical violence during pregnancy with maternal antenatal hospitalizations, labor and delivery complications, LBWs, and preterm births, while controlling for potential confounders.
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Materials and Methods |
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We defined physical violence during pregnancy using two questions within an 18-item inventory of stressful life events.12 Women who reported being "physically hurt by their husbands or partners" or "involved in a physical fight" during the 12 months before delivery were classified as having been exposed to physical violence during pregnancy. We reported elsewhere that women who experienced partner physical violence were similar to those who were involved in physical fights during pregnancy.13 Women denying violent stressors constituted the comparison group. The survey did not include additional questions on timing, severity, and frequency of violence during pregnancy or any questions about emotional or sexual violence by partners during pregnancy.
In the survey, women were asked about hospitalizations before delivery. We categorized their responses as diabetes, high blood pressure, kidney infections, premature labor, nausea, vomiting or dehydration, and vaginal bleeding or placenta problems. Specific conditions originally listed as "other" were recoded as other infections, loss of the infant, or trauma due to falls or blows to the abdominal region. Women who reported no antenatal hospitalizations made up the referent group. For about 1.6% of the study sample, data on hospitalizations were missing. Birth certificates provided information on complications of labor and delivery (including febrile conditions, prolonged or dysfunctional labors, abruptio placentae, premature rupture of membranes [PROM], other excessive bleeding, and "fetal distress") or cesarean delivery. Data on complications of labor and delivery were missing for only five women. From birth certificate data, birth weights were classified as less than 2500 g (LBW) and 2500 g or more. Infants whose gestational age was less than 37 weeks were considered preterm and those whose gestational age was 37 weeks or more were considered term. We also combined birth weight and prematurity categories to create LBW-preterm, LBW-term, normal birth weight–preterm, and normal birth weight–term (comparison group) categories.
Potential confounders of the association between violence during pregnancy, maternal complications, and adverse birth outcomes were maternal race, maternal age, maternal education, poverty status, marital status plus infant’s paternity information, number of previous children, adequacy of prenatal care utilization index,14 smoking and alcohol use during the last trimester of pregnancy, and pregnancy intent at conception.
Simple categorical analyses and logistic regression models using weighted survey data were conducted with Survey Data Analysis (SUDAAN 7.4; Research Triangle Institute, Research Triangle Park, NC) software to adjust standard errors to account for selection and response probabilities of the survey design. We initially examined the prevalence distribution of physical violence during pregnancy. We compared the prevalence of reporting physical violence with selected maternal characteristics and calculated the prevalence odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for potential confounders.
We used logistic regression to calculate ORs and 95% CIs to estimate the association between physical violence during pregnancy (independent variable), maternal conditions, and birth outcomes. The dependent variables in each of the respective models were maternal morbidity (antenatal maternal cause-specific hospitalizations and specific complications of labor and delivery) and birth outcomes (LBW and prematurity). These associations were adjusted for important confounders, including age, poverty status, obtainment of prenatal care, smoking during the third trimester, maternal race, and parity. Confounders were selected for inclusion in the multivariate model if they were associated with the respective outcome and physical violence and if their addition to the model changed the crude OR by 10%.15
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Results |
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). The prevalence of being involved in a physical fight during the year before delivery (9.6%) was twice as high as the prevalence of partner-perpetrated physical violence (5.1%). Also shown in Table 1 are the mutually exclusive categories of physical violence during pregnancy. Those data showed that more than half (54%) of the physical violence was the result of being involved in fights only, and 46% were hurt by husbands or partners. Of the women who reported partner-perpetrated physical violence, 70% said they had been involved in fights.
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shows the weighted prevalence of reporting physical violence by select sociodemographic and maternal behavioral characteristics, along with the adjusted prevalence ORs between physical violence and select maternal characteristics. Because some of those findings were described elsewhere,13 we will summarize the results briefly. Women with greater odds of physical violence have characteristics associated with greater risks for adverse pregnancy outcomes (eg, young age, poverty, unmarried status, unwanted pregnancy, and smoking and drinking alcohol during pregnancy).
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, along with the adjusted ORs with 95% CIs for the association between violence and those maternal conditions adjusted for confounding. Among women who had experienced violence, 27.2% reported antenatal hospitalizations before delivery. After adjustment for confounding factors, the following maternal conditions leading to hospitalizations were found to be associated with reporting physical violence: kidney infections (OR 2.7, 95% CI 1.3, 5.5), premature labor (OR 1.8, 95% CI 1.2, 2.7), and trauma due to falls or blows to the abdomen (OR 20.2, 95% CI 1.9, 206.0).
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. After controlling for age, poverty, obtainment of prenatal care, and smoking status during pregnancy, we found that women who experienced physical violence during pregnancy were 1.5 times more likely to deliver by cesarean. Physical violence was not significantly associated with risk of LBW, preterm birth, or LBW–premature birth combinations.
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Discussion |
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Of the self-reported maternal conditions leading to antenatal hospitalizations, kidney infections, premature labor, and trauma due to falls or blows to the abdominal region were associated with physical violence during pregnancy. We believe that a direct mechanism is most likely indicated by those observations. We are limited in trying to explicate further this mechanism of action because we do not know the timing or severity of violence. Physical violence during pregnancy is the second leading cause of trauma during pregnancy, after motor vehicle accidents.17 In our study, too few women reported trauma to the abdominal area (as expected, given that our study sample was population based and not taken from an emergency department population), so we lacked power to address adequately the association between physical violence and that adverse outcome. Trauma research studies showed that severe physical trauma to the maternal abdomen might lead to hospitalizations that might cause premature labor or delivery.10,18,19 Many women in abusive intimate relationships also experience sexual assault4,10,16 and are at increased risk of contracting sexually transmitted diseases (STDs) from their partners.4 Research established an association between STDs and preterm labor.20 We found that reporting antenatal hospitalization for premature labor was significantly associated with physical violence during pregnancy. That finding might be important for clinical management of high-risk patients by obstetricians and perinatologists because preterm labor correlates with premature birth. Preterm birth and LBW are among the leading causes of perinatal morbidity and mortality.21 We also showed a significant association between physical violence and kidney infections. The effect of physical violence on pregnant women appears to be extensive and such violence is likely to affect every organ system.2
This report showed that physical violence is associated with maternal smoking and drinking of alcohol during pregnancy, which was corroborated by other studies.2,3,4,13 Such risky behavior might be connected to greater levels of stress associated with violence-related victimization,2,3,16 which suggests the need for early identification of intimate-partner violence among pregnant women in substance abuse treatment and cessation programs and the need for appropriate interventions between those treatment programs and shelters for persons who have experienced domestic violence.
We found an association between physical violence during pregnancy and cesarean delivery, independent of other confounding factors (age, poverty, obtainment of prenatal care, and smoking during pregnancy). We cannot rule out other potential confounders, such as previous cesarean delivery and malpresentation, in this association. However, the observed relationship might be due to the fact that women reporting physical violence have various maternal complications and undergo hospitalizations before delivery and thus are monitored medically for untoward outcomes.
After adjustments for maternal age, poverty, involvement in prenatal care, and maternal smoking during pregnancy, we found no association between physical violence during pregnancy and LBW or prematurity. Although those findings are consistent with those of other studies,4–8 two studies9,10 found positive associations between physical violence and LBW. More research is needed to determine how violence can affect birth outcomes.
Our study strengths were the use of a population-based sample that allowed inferences to the entire population of women who had live-born infants, high response rates, and many data on women that served as potential confounders. However, several factors limited the interpretation of our findings. The cross-sectional design precluded examining physical violence as an antecedent factor to some outcomes. Some women might have underreported their physical violence experiences during pregnancy. We did not assess physical violence by timing, severity, and frequency. The self-reported maternal hospitalizations and data on labor and delivery complications from birth certificates could not be verified using medical records. Other important confounders were not assessed, including illicit drug use. Those factors might lead to nondifferential misclassification, which would result in underestimation of the association of physical violence during pregnancy and those outcomes. In future studies, attempts should be made specifically to assess not only physical violence before and during pregnancy but also sexual and emotional violence and the potential effects of these forms of violence on maternal and birth outcomes.
Health professionals must regard violence during pregnancy as a serious public health problem, one requiring the same alertness currently focused on gestational diabetes, preeclampsia, and PROM. Routine screening has been recommended at the various entry points of contact between pregnant women and medical care (eg, primary care, prenatal care, obstetric, and gynecologic services).22
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Footnotes |
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Received July 16, 1998. Received in revised form September 28, 1998. Accepted October 15, 1998.
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2. Newberger EH, Barkan SE, Lieberman ES, McCormick MC, Yllo K, Gary LT, et al. Abuse of pregnant women and adverse birth outcome. Current knowledge and implications for practice. JAMA 1992;267:2370–2.[Medline]
3. Petersen R, Gazmararian J, Spitz A, Rowley DL, Goodwin MM, Saltzman LE, et al. Violence and adverse pregnancy outcomes: A review of the literature and directions for future research. Am J Prev Med 1997;13:366–73.[Medline]
4. Amaro H, Fried LE, Cabral H, Zuckerman B. Violence during pregnancy and substance use. Am J Public Health 1990;80:575–9.
5. Berenson AB, Wiemann CM, Wilkinson GS, Jones WA, Anderson GD. Perinatal morbidity associated with violence experienced by pregnant women. Am J Obstet Gynecol 1994;170:1760–9.[Medline]
6. Grimstad H, Schei B, Backe B, Jacobsen G. Physical abuse and low birthweight: A case-control study. Br J Obstet Gynaecol 1997;104: 1281–7.[Medline]
7. O’Campo P, Gielen AC, Faden RR, Kass N. Verbal abuse and physical violence among a cohort of low-income pregnant women. Womens Health Issues 1994;4:29–37.[Medline]
8. Schei B, Samuelsen SO, Bakketeig LS. Does spousal physical abuse affect the outcome of pregnancy? Scand J Soc Med 1991;19:26–31.[Medline]
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13. Cokkinides VE, Coker AL. Experiencing physical violence during pregnancy: Prevalence and correlates. Fam Community Health 1998;20:19–37.
14. Alexander GR, Kotelchuck M. Quantifying the adequacy of prenatal care: A comparison of indices. Public Health Rep 1996;111:408–18.[Medline]
15. Breslow N, Day N. The design and analysis of case-control studies. Statistical methods in cancer research. IARC Scientific Publications no. 32 (vol 1). Oxford, UK: Oxford University Press, 1984.
16. Stark E, Flitcraft A. Women at risk: Domestic violence and women’s health. Thousand Oaks, California: Sage, 1996.
17. Connolly AM, Katz VL, Bash KL, McMahon MJ, Hansen WF. Trauma and pregnancy. Am J Perinatol 1997;14:331–6.[Medline]
18. Williams MA, Lieberman E, Mittendorf R, Monson RR, Schoenbaum SC. Risk factors for abruptio placentae. Am J Epidemiol 1991;134:965–72.
19. Webster J, Chandler J, Battistitta D. Pregnancy outcomes and health care use: Effects of abuse. Am J Obstet Gynecol 1996;174: 760–7.[Medline]
20. Reynolds HD. Bacterial vaginosis and its implications in preterm labor and premature rupture of membranes. A review of the literature. J Nurse Midwifery 1991;36:289–96.[Medline]
21. Institute of Medicine. Preventing low birthweight. Washington, DC: National Academic Press, 1985.
22. Campbell JC. Abuse during pregnancy: Progress, policy, and potential. Am J Public Health 1998;88:185–7.
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