Violence and reproductive health: current knowledge and future research directions

Pregnancy outcomes and intimate partner violence in New Zealand

AIM

This study aims to describe pregnancy outcomes for a population-based sample of New Zealand women, and to explore the relationship between lifetime experience of intimate partner violence (IPV) and two non-birth pregnancy outcomes: spontaneous abortion (miscarriage) and termination of pregnancy (abortion).

METHODS

Face-to-face interviews were conducted with a random sample of 2391 women who had ever been pregnant, aged 18-64 years old, in two regions (urban and rural). Both outcome measures were determined by asking women if they had ever had a miscarriage or an abortion. Analyses were conducted using logistic regression.

RESULTS

Almost one in three ever-pregnant women reported having at least one miscarriage, and at least one in ten reported terminating a pregnancy. Even controlling for potential confounders, women who had ever experienced IPV were 1.4 times more likely to report they had ever had a miscarriage compared with women who had never experienced violence (P = 0.008), and were 2.5 times more likely to report they had ever had an abortion (P < 0.0001). Ethnicity was significantly associated with experiencing a miscarriage (Asian and Pacific women were less likely compared with European/Pākehā women), and having ever had an abortion (Asian women were 3.5 times more likely compared with Pākehā women).

CONCLUSIONS

In this population-based sample, miscarriage was relatively common, as was termination of pregnancy. IPV was significantly associated with both induced and spontaneous abortion. Healthcare settings that see women experiencing these pregnancy outcomes need to be cognisant of the link with current and historical IPV, and be able to respond to women appropriately.

Domestic violence and contraceptive use in a rural Indian village

This study uses qualitative methods to examine how domestic violence affects the use of contraceptives by women in a rural village in India. The study highlights how multilevel factors are linked to a woman's ability to contracept and make fertility decisions in a context where being a wife implies obedience, limited mobility, sexual availability, and high fertility. The authors find that violence is normalized, or considered acceptable, if women do not adhere to expected gender roles. Although women's ability to make autonomous decisions is shown to be limited, the study explores covert strategies used to avoid pregnancy, which also tend to increase women's risk of experiencing domestic violence.

The clinical content of preconception care: care of psychosocial stressors

In the period before conceiving, many women are under considerable psychosocial stress, which may affect their ability to conceive and to carry a pregnancy successfully to term. Thus, health care providers who interact with women in the preconception and interconception period should ask their patients about possible psychosocial risks. It is no longer sufficient to wait until the woman mentions a problem or seeks advice; the provider must be proactive, because many women do not realize the potential impact of stressors on their pregnancy outcomes nor are they always aware that their provider is interested in their psychosocial as well as their physical health. An income that puts women below or near the federal poverty level is one such stress. If a woman's economic situation can be improved before the pregnancy, she is more likely to be healthy after conception, because increased income can reduce financial stress, improve food security, and improve well-being in other ways. Therefore, all women should be asked about their economic status and those who appear to be struggling financially should be referred to an agency that can check their eligibility for various types of financial assistance. Many women of childbearing age have difficulty accessing the primary care services needed for preconception care. Usually this is due to lack of insurance, but it may also be caused by living in an area with an insufficient number of providers. Certainly all women who are uninsured, and possible many who are on Medicaid and have difficulty finding providers who will accept Medicaid, have access problems. All women should be asked about their health insurance coverage and their usual source of care. If they do not have health insurance, they should be referred to an agency that can determine their eligibility. If they do not have a usual source of care, one should be established that will accept their insurance coverage or provide care free of charge or on a sliding fee basis. Intimate partner violence, sexual violence outside of an intimate relationship (usually rape), and maltreatment (abuse or neglect) as a child or adolescent place a woman at elevated risk during a pregnancy, as well as having possible adverse impacts on the fetus, the infant, and the child. Studies show that women believe it is appropriate for health care providers to ask about interpersonal violence, but that they will not report it spontaneously. Therefore, screening for ongoing and historical interpersonal violence, sexual violence, and child maltreatment should be incorporated into routine care by all health care providers.

Violent lives of women: critical points for intervention/life charting

Each year, 5.3 million women are abused and several thousand die at the hands of intimate partners. If family violence were better understood, it could be predicted, described by patterns and prevented. Life charting (LC) is a method developed to explicate complex phenomena, such as bipolar disorder. This study tested the feasibility and usefulness of LC in deriving data about critical points in life when interventions could reduce or prevent family violence. Two research questions guided the study: (1) Does LC yield valid, reliable data when used as a review with women exposed to violence? (2) Is LC feasible for use in research?

Intimate partner violence and women's contraceptive use

Intimate partner violence has been hypothesized as a factor associated with women's risk for problems in contraception use or access. This article explores differences in contraceptive use between abused and nonabused women, using a case-control study of 225 women. Women experiencing physical and emotional abuse were more likely to report not using their preferred method of contraception in the past 12 months compared with nonabused women (OR = 1.9; 95% CI = 1.0 to 3.7). Health care providers need to consider how intimate partner violence may influence their patients' use of contraceptives, which has implications for the high risk of unintended pregnancies among abused women.

Sexual violence among pregnant women in India

AIM

To discover the extent of sexual violence during pregnancy, its correlation to various variables and effects, and to consider future possibilities for creating awareness in health providers, health seekers and communities for prevention.

METHODS

Two thousand pregnant women were interviewed using a semi-structured, pre-designed, pre-tested questionnaire with some open-ended questions in the local language.

RESULTS

Of 2000 women, 1959 (97.95%) reported that they had had sex with their partners during the current pregnancy. Of the 2000, 615 (30.7%) women had not wished to have sex during the pregnancy, but had been forced to do so.

CONCLUSION

Women suffer with recurrent marital rape during pregnancy with considerable after effects. This sexual violence takes place irrespective of education or socioeconomic status.

The design, implementation and acceptability of an integrated intervention to address multiple behavioral and psychosocial risk factors among pregnant African American women

BACKGROUND

African American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format.

METHODS

Six academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported.

RESULTS

Forty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended > or = 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed.

CONCLUSION

While implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.

Contraceptive use and associations with intimate partner violence among a population-based sample of New Zealand women

AIM

To outline the use of contraception among a representative sample of New Zealand women, and explore associations with intimate partner violence (IPV), and contraception and condom use.

METHODS

Face-to-face interviews were conducted with a random sample of 2790 women who had ever had sexual intercourse, aged 18-64 years old in two regions (urban and rural) in New Zealand. Analyses were conducted using logistic regression and Wald chi(2) tests.

RESULTS

Almost all women had used contraception at some point in their life, and almost one half of all women 18-49 years were currently using methods of contraception. Contraceptive use and methods varied significantly by location. Women who had ever experienced IPV were significantly more likely to report having ever used contraception, compared with women who had not experienced IPV (91% vs 85.2%). While having a partner who refused to use or tried to stop women from using a method of contraception was rare, it was significantly more common among women who had ever experienced IPV (5.4% vs 1.3%).

CONCLUSIONS

Most women have used contraception at some point. Women who have ever experienced IPV were: more likely to have used contraception than women who have not experienced IPV, and to have had partners who refused to use condoms or prevented women from using contraception. Partner refusal may be a key indicator of IPV. These findings emphasise the importance of family violence screening at routine health consultations.

The impact of psychological abuse by an intimate partner on the mental health of pregnant women

Objective

The objective of this first population-based study in Hong Kong was to assess the impact of psychological abuse by an intimate partner on the mental health of pregnant women.

Design

Survey.

Setting

Antenatal clinics in seven public hospitals in Hong Kong.

Population

Three thousand two hundred and forty-five pregnant women.

Methods

The Abuse Assessment Screen (AAS) and demographic questionnaires were administered face-to-face at 32–36 weeks of gestation. At 1 week postpartum, the AAS, Edinburgh Postnatal Depression Scale and SF-12 Health Survey were administered by telephone.

Main outcome measures

Intimate partner violence, postnatal depression and health-related quality of life.

Results

Two hundred and ninety six (9.1%) of the participants reported abuse by an intimate partner in the past year. Of those abused, 216 (73%) reported psychological abuse only and 80 (27%) reported physical and/or sexual abuse. Forty six (57.5%) in the physical and/or sexual abuse group also reported psychological abuse. Women in the psychological abuse only group had a higher risk of postnatal depression compared with nonabused women (adjusted OR: 1.84, 95% CI: 1.12–3.02). They were also at a higher risk of thinking about harming themselves (adjusted OR: 3.50, 95% CI: 1.49–8.20) and had significantly poorer mental health-related quality of life (P < 0.001). The higher risks of postnatal depression and thinking of harming themselves were not observed in the physical and/or sexual abuse group although significantly poorer mental health-related quality of life (P < 0.001) was observed.

Conclusions

Psychological abuse by an intimate partner against pregnant women has a negative impact on their mental health postdelivery. Furthermore, psychological abuse in the absence of physical and/or sexual abuse can have a detrimental effect on the mental health of abused women. The findings underscore the importance of screening pregnant women for abuse by an intimate partner and the need for developing, implementing and evaluating interventions to address psychological abuse.

Please cite this paper as: Tiwari A, Chan K, Fong D, Leung W, Brownridge D, Lam H, Wong B, Lam C, Chau F, Chan A, Cheung K, Ho P. The impact of psychological abuse by an intimate partner on the mental health of pregnant women. BJOG 2008;115:377–384.

Cueing prenatal providers effects on discussions of intimate partner violence

BACKGROUND

Intimate partner violence (IPV) during pregnancy poses a significant health risk to the mother and developing fetus. Practice guidelines recommend that prenatal providers screen for and counsel their patients about IPV, yet many physicians express reluctance or discomfort regarding such discussions. The Health in Pregnancy (HIP) computer program was designed to improve prenatal providers' counseling about behavioral risks.

METHODS

English-speaking women 18 years or older, less than 26-weeks pregnant, and receiving prenatal care at one of the five participating clinics in the San Francisco area, were randomized in parallel groups in a controlled trial (June 2006-present; data analyzed June 2007). Participants reporting one or more risks were randomized to intervention or control in stratified blocks. Providers received summary "cueing sheets" alerting them to their patient's risk(s) and suggesting counseling statements.

RESULTS

Thirteen percent (37/286) of the sample reported current IPV. Provider cueing resulted in 85% of the IPV-intervention group reporting discussions with their provider, compared to 23.5% of the control group (p<0.001).

CONCLUSIONS

IPV discussions were influenced strongly by cueing providers. Provider cueing is an effective and appropriate adjunct to routine risk counseling in prenatal care.

Physical abuse during pregnancy and preterm delivery

OBJECTIVE

This study was undertaken to assess the relationship between physical abuse during pregnancy and preterm delivery.

STUDY DESIGN

We conducted a hospital-based survey on physical abuse during pregnancy, which included 2660 women with consecutive live births. Women were interviewed and violence was assessed using the Abuse Assessment Screen. Data on sociodemographic, behavioral, and obstetric variables were also obtained. Mothers of preterm (<37 weeks; n = 217) were contrasted with mothers of term newborn infants (n = 2428). Logistic regression analysis was performed to estimate adjusted odds ratios.

RESULTS

Twenty-four percent of mothers of preterm newborn infants had experienced physical abuse during pregnancy compared with 8% of mothers of term newborn infants (P < .0001). Violence was associated with preterm birth even after controlling for age, marital status, education, income, parity, planned pregnancy, antenatal care, smoking, alcohol, and illicit drugs use (odds ratio = 3.14, 95% confidence interval, 2.00-4.93).

CONCLUSION

Women who have had physical abuse during pregnancy present a large increase in the risk of preterm delivery, independently from a large set of sociodemographic and behavioral characteristics usually recognized as determinants of preterm birth.

Perspectives of African-American women on infant mortality

Twice as many African-American infants die each year when compared to White infants. This study explores the lived experiences of African-American women to identify factors related to this racial gap in infant mortality. Thirteen African-American women from two Virginia towns participated in either a focus group or in-depth interviews. Content and interpretive analysis revealed several themes. Participants indicated that the experiences of stress and racism are constant factors in African-American women's lives and are inseparable from their pregnancy experiences. Participants noted the importance of social support and the health care provider-client relationship for positive pregnancy outcomes.

We don't like to think about it: intimate partner violence during pregnancy and postpartum

Violence directed by an intimate partner toward the pregnant woman and her fetus, or during the first year after delivery, is often either not recognized by professionals or suspected but not addressed. There is no typical abused woman; in fact, intimate partner violence occurs across all social, economic, educational, and professional settings. Physical or sexual abuse may be readily observed in some instances or well hidden at other times; the emotional components of verbal, economic, and isolation abuse are often difficult to assess. All types of intimate partner violence require sensitive assessment and intervention by healthcare professionals, as numerous undesirable outcomes for both the mother and her fetus/baby have been identified. Suggestions for assessment and intervention (primary, secondary, and tertiary) are offered.

Male partner pregnancy-promoting behaviors and adolescent partner violence: findings from a qualitative study with adolescent females

OBJECTIVE

To examine the context of pregnancy and sexual health among adolescent females with a history of intimate partner violence (IPV). This paper reports on a subset of females who described abusive male partners' explicit pregnancy-promoting behaviors (ie, messages and behaviors that led females to believe their partner was actively trying to impregnate them).

METHODS

Semistructured interviews were conducted with 53 sexually active adolescent females, with known history of IPV, about violence, sexual experiences, and related behaviors. Interviews were analyzed using a content analysis approach; 14 interviews in which females reported that partners were actively trying to impregnate them were further analyzed for pregnancy and contraceptive use.

RESULTS

Participants (N = 53) were aged 15 to 20 years, with notable minority representation, 21% African American (n = 11) and 38% Latina (n = 20). Over half (n = 31, 58%) had experienced pregnancy. A key finding was that approximately one quarter of participants (26%, n = 14) reported that their abusive male partners were actively trying to get them pregnant. Females' stories revealed that abusive male partners desiring pregnancy manipulated condom use, sabotaged birth control use, and made explicit statements about wanting her to become pregnant.

CONCLUSIONS

Pregnancy-promoting behaviors of male abusive partners may be one potential mechanism underlying associations between adolescent IPV and pregnancy. These findings suggest that exploring pregnancy intentions and behaviors of partners of sexually active adolescents may help to identify youth experiencing IPV. The frequency of birth control sabotage and explicit attempts to cause pregnancy in adolescent IPV needs to be examined at the population level.

Homicides and intimate partner violence: a literature review

The purpose of this article is to examine the literature on intimate partner homicides (IPH). The review begins by describing the factors, magnitude, and consequences associated with IPH, focusing on studies from the United States. Second, the article discusses the public health implications of preventing IPH and the limitations associated with the IPH literature. Last, the article concludes with recommendations of IPH in terms of practice, policy, and research.

Postpartum women's evaluations of an audio/video computer-assisted perinatal violence screen

For universal screening to become a reality, research must first validate the effectiveness and acceptability of violence screening. This study describes postpartum women's perceptions of an anonymous computer-assisted self-interview for perinatal violence screening. A sample of 519 postpartum women completed interviews that included audio and video enhancements. Post-response evaluations were positive with most women, indicating that they preferred computer interviews to face-to-face or written abuse screening. In addition, participants indicated that the computer format and associated anonymity positively influenced their willingness to answer the violence questions truthfully. Computer interviews offer an alternative approach to violence screening that may help women who are hesitant to disclose abuse directly to their healthcare providers.

An exploration of maternal intimate partner violence experiences and infant general health and temperament

OBJECTIVES

While the women's health consequences of intimate partner violence have received much research attention, less is known about how maternal abuse experiences affect infant health and well-being. Existing studies have also been unable to examine specific types of intimate partner violence such as psychological aggression, physical abuse, and sexual coercion. This secondary data analysis explored the prevalence, patterns, and types of intimate partner violence within a large cohort of mothers and explored the relationship between maternal intimate partner violence experiences and infant's general health and temperament at 1 year of age.

METHODS

Existing data were drawn from the Fragile Families and Child Wellbeing study which collected data through surveys conducted shortly after the infant's birth (baseline) and at 1 year of age (follow-up). Records from 4,141 mothers recruited from 75 hospitals, in 20 cities, in the US were used. Bivariate and multivariate regression analyses were conducted.

RESULTS

Results show high rates of intimate partner violence. Maternal reports of any intimate partner violence at baseline or follow-up were both significantly associated with increased odds of less than excellent infant general health and difficult temperament. Independent examination of psychological, physical, and sexual abuse revealed differential relationships between the types of intimate partner violence and infant health outcomes.

CONCLUSIONS

Results from this study contribute to our understanding of the infant health threats associated with maternal intimate partner violence experiences. Additional research addressing the complex relationship between maternal abuse experiences and infant health and specific intervention implications is warranted.

Pregnancy following partner rape: what we know and what we need to know

Despite more than 30 years of research on violence against women and scores of publications on intimate partner violence during pregnancy and consequences for maternal and infant health, little is known about the incidence and outcomes of pregnancies that follow partner rape. The occurrence and consequences of partner rape and violence during pregnancy are reviewed as well as the one study identified on the characteristics and consequences of pregnancy following partner rape. Literature on unintended pregnancy and violence against women is also reviewed. Directions for future research are explored, including the need for studies that explore women's control of their sexuality within the context of intimate partner relationships, how and when to ask women about partner rape, and how to include males as the solution to ending rape.

Pregnancy Intention and Its Relationship to Birth and Maternal Outcomes

OBJECTIVE

To examine whether there are associations between pregnancy intention (intended, unwanted, mistimed, or ambivalent) and negative birth and maternal outcomes: low birth weight (less than 2,500 g), preterm delivery (fewer than 37 weeks), small for gestational age, premature labor, hypertension, and other maternal outcomes.

METHODS

We analyzed data from the population-based Pregnancy Risk Assessment Monitoring System, including 87,087 women who gave birth between 1996 and 1999 in 18 states. Information on pregnancy outcomes was derived from birth certificate data and a self-administered questionnaire completed postpartum. We employed SUDAAN (RTI International, Research Triangle Park, NC) for univariable and logistical regression analyses.

RESULTS

In analyses controlling for demographic and behavioral factors, women with unwanted pregnancies had an increased likelihood of preterm delivery (adjusted odds ratio [OR] 1.16, 95% confidence interval [CI] 1.01-1.33) and premature rupture of membranes (adjusted OR 1.37, 95% CI 1.01-1.85) compared with women with intended pregnancies. Women who were ambivalent toward their pregnancies had increased odds of delivering a low birth weight infant (adjusted OR 1.15, 95% CI 1.02-1.29); in contrast, women with mistimed pregnancies had a lower likelihood (adjusted OR 0.92, 95% CI 0.86-0.97).

CONCLUSION

Pregnancy intention, specifically unwanted and ambivalent, may be an indicator of increased risk for some poor birth and maternal outcomes and should be considered in interventions aimed at improving the health of the mother and child.

LEVEL OF EVIDENCE

III.

Violence against women as a public health issue

Violence can be considered "infectious" in rape-prone cultures that celebrate violence and domination. The number of annual injuries and deaths due to violence against women and girls is high enough to demand the type of active interventions and public policies that have been targeted at infectious diseases by public health agencies. In this article, we review data on the physical and mental health effects that violence has on victims of domestic violence, rape, stalking, and sexual harassment. We also focus on the economic costs to the health care system, business and industry, families, and the broader society that accrue as a result of the widespread violence against women and girls. Victims' suffering can never be accounted for by economic data, but those data may be helpful in pushing governments to allocate funds and agencies to take preventive actions.

Sexual and reproductive health: a matter of life and death

Despite the call for universal access to reproductive health at the 4th International Conference on Population and Development in Cairo in 1994, sexual and reproductive health was omitted from the Millennium Development Goals and remains neglected (panel 1). Unsafe sex is the second most important risk factor for disability and death in the world's poorest communities and the ninth most important in developed countries. Cheap effective interventions are available to prevent unintended pregnancy, provide safe abortions, help women safely through pregnancy and child birth, and prevent and treat sexually transmitted infections. Yet every year, more than 120 million couples have an unmet need for contraception, 80 million women have unintended pregnancies (45 million of which end in abortion), more than half a million women die from complications associated with pregnancy, childbirth, and the postpartum period, and 340 million people acquire new gonorrhoea, syphilis, chlamydia, or trichomonas infections. Sexual and reproductive ill-health mostly affects women and adolescents. Women are disempowered in much of the developing world and adolescents, arguably, are disempowered everywhere. Sexual and reproductive health services are absent or of poor quality and underused in many countries because discussion of issues such as sexual intercourse and sexuality make people feel uncomfortable. The increasing influence of conservative political, religious, and cultural forces around the world threatens to undermine progress made since 1994, and arguably provides the best example of the detrimental intrusion of politics into public health.

Abuse during pregnancy: current theory and new contextual understandings

This study used Landenburger's theory, a process of leaving and recovering from an abusive relationship, as a framework to interview 35 pregnant women identified as being at high risk for abuse. Results are reported on 18 women who disclosed active abuse during the study. Landenburger's model was not a good fit. Our participants became trapped and endured violent relationships if they perceived this was the best situation for their unborn child. Additionally the chaos, instability, and lack of resources experienced by these women likely contributed to their inability to complete the four phases described by Landenburger's model for non-pregnant women.

Reproductive health and domestic violence: are the poorest women uniquely disadvantaged?

We use Demographic and Health Survey data from Cambodia, the Dominican Republic, and Haiti to compare women in different poverty and violence categories in terms of their experience of selected reproductive health outcomes. "Poor" women are those who belong to the bottom quintile of households arrayed according to a widely accepted asset-based wealth index. The results suggest that women who are both poor and have experienced violence are not unique in their reproductive health disadvantage. In particular, for all three reproductive health outcomes we consider the negative association with having experienced violence cuts across all women, poor and wealthy.

Exposure to violence among substance-dependent pregnant women and their children

This study examined the prevalence of exposure to violence among drug-dependent pregnant women attending a multidisciplinary perinatal substance abuse treatment program. Participants (N = 715) completed the Violence Exposure Questionnaire within 7 days after their admission to the program. Their rates of lifetime abuse ranged from 72.7% for physical abuse to 71.3% for emotional abuse to 44.5% for sexual abuse. Their rates of abuse remained high during their current pregnancy, ranging from 40.9% for emotional abuse to 20.0% for physical abuse to 7.1% for sexual abuse. Nearly one third of the women reported having physical fights with their current partner (lifetime), and 25% of these women reported that children were present during those physical fights. A total of 30% of the women perceived a need for counseling regarding exposure to violence for themselves and 15% perceived a need for counseling for their children. Study findings confirm previous reports of high rates of abuse and violence exposure among substance-abusing pregnant women and their strong need for counseling for psychosocial sequelae. This study affirmed the value of routine screening for violence exposure in this at-risk population as well as the need to train therapists in specific strategies for helping such women address this complex array of problems.

Social norms and beliefs regarding sexual risk and pregnancy involvement among adolescent males treated for dating violence perpetration

The present study explored perceived sexual norms and behaviors related to sexual risk and pregnancy involvement among adolescent males (ages 13 to 20) participating in programs for perpetrators of dating violence. The purpose of this study was to generate hypotheses regarding the contexts and mechanisms underlying the intersection of adolescent dating violence, sexual risk and pregnancy. Six focus groups were conducted (N = 34 participants). A number of major themes emerged: 1) male norm of multiple partnering, 2) perceived gain of male social status from claims of sexual activity, 3) perception that rape is uncommon combined with belief that girls claiming to be raped are liars, 4) perception that men rationalize rapes to avoid responsibility, 5) condom non-use in the context of rape and sex involving substance use, 6) beliefs that girls lie and manipulate boys in order to become pregnant and trap them into relationships, and 7) male avoidance of responsibility and negative responses to pregnancy. The combination of peer-supported norms of male multiple partnering and adversarial sexual beliefs appear to support increased male sexual risk, lack of accountability for sexual risk, and rationalization of rape and negative responses to pregnancy. Further research focused on the context of male sexual risk and abusive relationship behaviors is needed to inform intervention with young men to promote sexual health and prevent rape, dating violence, and adolescent pregnancy.

Postpartum mothers' disclosure of abuse, role, and conflict

Experts evaluating evidence of the occurrence and effects of abuse before, during, and after pregnancy have called for research on the context within which violence occurs. This study elicited postpartum mothers' perceptions of roles and conflict in their abusive intimate relationships. Thirty newly delivered African-, Anglo-, and Hispanic-American abused mothers consented to be interviewed. While ethnicity, cultural norms, and economic issues framed their descriptions, more than half (57%) described their relationships as not abusive even though they reported experiencing behaviors defined as abuse on standardized abuse screening instruments. Several women found ways to take care of themselves within the abusive relationship. The concerns that these diverse abused postpartum mothers expressed can serve as a foundation for the development of culturally sensitive interventions.

Perinatal violence assessment: teenagers' rationale for denying violence when asked

OBJECTIVE

To describe teenagers' experiences with perinatal violence assessment.

DESIGN

A descriptive design utilizing qualitative content analysis.

SETTING

Participants were recruited from gynecologic clinics of two level III maternity units and interviewed offsite.

PARTICIPANTS

Twenty nonpregnant teenagers between the ages of 18 and 20 years who had experienced physical or sexual abuse in the year before or during (or both) a pregnancy occurring within the last 3 years were recruited for this study, regardless of past pregnancy outcome.

METHODS

Data were analyzed using categorical content analysis.

RESULTS

Participants reported a range of violence experiences from their parents, current and past intimate partners, and gangs (groups). Four categories emerged that addressed their reasons for not disclosing violence to their health care providers: Power/Powerlessness, Fear/Hope, Trust/Mistrust, and Action/Inertia.

CONCLUSIONS

Abused teenagers have unique needs and concerns that should be addressed when providing pregnancy care.

Posttraumatic stress disorder part II: development of the construct within the North American psychiatric taxonomy

TOPIC

The impairment associated with posttraumatic stress disorder (PTSD) carries with it staggering costs to the individual, to the family, and to society as a whole. Although there is strong evidence that gender plays a significant role in responses to stress and trauma, gender specificity is still not well incorporated into clinical or research work in the area of PTSD.

PURPOSE

This is the second of three articles examining the sufficiency of the current PTSD construct to articulate the full spectrum of human responses to trauma. This article chronicles ongoing refinements to the original PTSD criteria and the subsequent controversies.

SOURCE OF INFORMATION

Existing bodies of theoretical and research literature related to the effects of trauma.

CONCLUSION

In a third article we will review evidence supporting the existence of a more complex posttraumatic stress reaction associated with interpersonal trauma (physical/sexual abuse/assault).

A predictive model to identify women with injuries related to intimate partner violence

PURPOSE

The diagnosis of intimate partner violence (IPV) is challenging. The authors conducted a cross-sectional study to develop a predictive model to identify IPV-related injuries and validate the model with an independent sample.

MATERIALS AND METHODS

The authors enrolled women older than 18 years seeking treatment for injuries. They randomized the sample into index and validation datasets. They used the index dataset to develop a predictive model; the validation set served as an independent sample for assessing the predictive model's goodness of fit. Study variables included risk of self-report of an IPV-related injury and demographic and socioeconomic variables. The outcome variable was self-reported injury etiology (IPV or other). The authors used multiple logistic regression techniques to develop a predictive model that they then applied to the validation dataset, and they measured goodness of fit with the Hosmer-Lemeshow test.

RESULTS

The sample was randomized into index (n = 201) and validation (n = 104) sets. For the index set, age, race and risk of IPV were associated with IPV-related injuries (P < .01). The accuracy of the model was 92 percent. Application of the model to the validation dataset resulted in excellent agreement between the observed and actual number of women with IPV-related injuries (accuracy: 93 percent). No statistically significant differences existed between the observed and predicted outcomes (P = .64).

CONCLUSIONS

A predictive model composed of age, race and risk of experiencing IPV accurately characterizes women likely to report IPV-related injuries.

CLINICAL IMPLICATIONS

Once the clinician diagnoses IPV-related injury, he or she can intervene to prevent future IPV-related injuries.

Seizing the 9-month moment: addressing behavioral risks in prenatal patients

OBJECTIVE

Our qualitative study explored prenatal care providers' methods for identifying and counseling pregnant women to reduce or stop smoking, alcohol use, illicit drug use, and the risk of domestic violence.

METHODS

We conducted six focus groups (five with OB/Gyn physicians, one with nurse practitioners and certified nurse midwives), total N=49, using open-ended questions. Investigators analyzed transcripts to identify and describe themes.

RESULTS

Three major themes emerged: (1) specific risk-prevention tactics or strategies exist that are useful during pregnancy; (2) some providers address patients' isolation or depression; and (3) providers can adopt a policy of "just chipping away" at risks. Specific tactics included normalizing risk prevention, using specific assessment techniques and counseling strategies, employing a patient-centered style of smoking reduction, and involving the family.

CONCLUSIONS

Providers generally agreed that addressing behavioral risks in pregnant patients is challenging. Patient-centered techniques and awareness of patients' social contexts help patients disclose and discuss risks.

PRACTICE IMPLICATIONS

Brief but routine assessment and risk reduction messages require little time of the provider, but can make a big difference to the patient, who may make changes later.

Women's views of prenatal violence screening: acceptability and confidentiality issues

OBJECTIVE

The purpose of this research was to address the need for evidenced-based practices for violence screening by identifying women's perceptions of, and experiences with, prenatal violence screening.

METHODS

Audio- and video-enhanced anonymous computer interviews were completed by women in 2 Level III postpartum units.

RESULTS

The sample was composed of 519 primarily African-American and white women who were educationally and economically diverse. Although 312 women (60.1%) reported being screened for violence by a health care provider at some point during their pregnancy, only 201 of 519 (38.7%) were asked by their prenatal care provider, with the remaining women reporting that they were screened during emergency room, triage visits, and labor and delivery admission. Of those who were screened by their prenatal care provider 195 of 201 (97%) women stated that they were not embarrassed, angry, or offended when assessed. Of the 66 women who were both abused and screened during their pregnancy, only 11 women disclosed abuse, with a resulting disclosure rate of 16.7%; however, 29 abused women who denied abuse to their health care provider stated that they would have changed their response if they had known that violence disclosure was not reportable in their state unless the victim was seriously injured or was wounded with a lethal weapon.

CONCLUSION

This study provides evidence that the great majority of pregnant women are not offended when screened for domestic violence and may increase their disclosure if they are told about state reporting mandates that preclude mandatory reporting for adults.

LEVEL OF EVIDENCE

II-3.

Relationships between physical abuse during pregnancy and risk factors for preterm birth among women in Manitoba

OBJECTIVE

To describe the prevalence and correlates of physical abuse during the year of pregnancy and to explore the association between physical abuse and other risk factors for preterm birth.

DESIGN

Secondary analysis of data from a case-control study of risk factors for preterm birth.

SETTING

Two tertiary care hospitals in the Canadian province of Manitoba.

PARTICIPANTS

Six hundred eighty postpartum women who delivered a live singleton newborn after spontaneous onset of labor.

MAIN OUTCOME MEASURES

Instruments included the Abuse Assessment Screen, Prenatal Psychosocial Profile, Perceived Stress Scale, and a questionnaire to collect data on demographic characteristics, complications during pregnancy, and lifestyle behaviors.

RESULTS

Sixty-four women (9.4%) reported being physically abused during the year of pregnancy. Abused women were significantly more likely to be younger, single, of lower income, and less educated than nonabused women. Significant correlates of abuse, after adjusting for other factors in a logistic regression, included the following: illicit drug use, low support from partner, moving two or more times in the past year, high life event stress, bladder infection during pregnancy, Aboriginal race/ethnicity, and single marital status.

CONCLUSION

This study suggests that physical abuse during pregnancy is associated with other risk factors for preterm birth, particularly stress and behavioral risk factors such as substance abuse.

Physician-identified barriers to intimate partner violence screening

BACKGROUND

Intimate partner violence (IPV) causes approximately 2 million injuries and 1300 deaths each year. Despite the high frequency of IPV among women seeking healthcare, only a small proportion report being asked by healthcare professionals about abuse. This study examined perceived barriers to IPV screening among obstetricians/gynecologists, family physicians, and internists, so that protocols for IPV training can be tailored to those particular areas of difficulty.

METHODS

A cross-sectional survey of 143 obstetricians and gynecologists, family practice physicians, and internists in a medium-sized upstate New York city was conducted. Factor analysis was performed. Two IPV barrier domains emerged and were examined using a multivariate analysis to determine associations between the domains and physician characteristics.

RESULTS

For general knowledge, there were greater perceived barriers if the respondent was male but fewer perceived barriers if the respondent was an obstetrician/gynecologist and fewer perceived barriers if the respondent had 5-10 years in practice. For practice policy, there were greater perceived barriers if the physician was in a private practice setting and fewer perceived barriers if the physician was an obstetrician/gynecologist.

CONCLUSIONS

These findings provide direction for training in IPV recognition. They support a need for continued training throughout the physician's career. More importantly, the findings support a need for better practice systems to encourage routine screening for IPV by healthcare providers.

Injury Location and Screening Questionnaires as Markers for Intimate Partner Violence

PURPOSE

We sought to evaluate the performance of 2 different screening questionnaires for intimate partner violence (IPV), in conjunction with injury location, as markers for IPV-related injuries.

METHODS

We implemented a cross-sectional study and enrolled a sample of women presenting to the emergency department for evaluation and management of nonverifiable injuries. Study subjects were randomly assigned to receive 1 of 2 IPV screening questionnaires: the Partner Violence Screen (PVS) or the short-Woman Abuse Screening Tool (short-WAST). We evaluated a combination of 2 markers of IPV-related injury: (1) injury location, classified as head/neck/facial (HNF) or other and (2) responses to the IPV questionnaires: positive or negative. Our predictor variable was the probability of self-report of IPV-related injury defined as (1) high probability (HNF injuries were present and there was a positive response to the IPV questionnaire) or (2) low probability (all other combinations of injury location and responses to the questionnaires). The outcome variable was self-reported injury etiology, IPV or other. Demographic variables were also recorded for our study sample. Univariate and bivariate statistical analyses were computed for the sample. Sensitivity, specificity, and positive and negative predictive values and odds ratios were calculated (P < .05).

RESULTS

The sample was composed of 200 women. The sensitivities/specificities for the PVS-injury location and short-WAST-injury location combinations were 0.75/0.70 and 0.77/0.61, respectively. The odds ratios for IPV-related injury etiology were 10.2 (3 < OR < 41, P = .01) for the PVS-injury location combination and 3.7 (0.90 < OR < 15, P = .07) for the short-WAST-injury location combination.

CONCLUSIONS

A set of markers composed of injury location and the PVS was statistically associated with the likelihood of reporting IPV-related injuries. The short-WAST did not perform as well as the PVS in the study's clinical setting.

Domestic violence against women in Egypt--wife beating and health outcomes

Research has consistently demonstrated that a woman is more likely to be abused by an intimate partner than by any other person. Many negative health consequences to the victims have been associated with domestic violence against women. Data from the 1995 Egyptian Demographic and Health Survey, a nationally representative household survey, were analyzed for 6566 currently married women age 15-49 who responded to both the main questionnaire and a special module on women's status. Multivariate logistic regressions were used to examine the association of ever-beating, beating in past year or frequency of beatings in past year with contraceptive use, pregnancy management, and report of health problems. Thirty-four percent of women in the sample were ever beaten by their current husband while 16% were beaten in the past year. Ever-beaten women were more likely to report health problems necessitating medical attention as were women beaten in the past year compared to never-beaten women. Regarding reproductive health, higher frequency of beating was associated with non-use of a female contraceptive method, while ante-natal care (ANC) by a health professional for the most recent baby born in the past year was less likely among ever-beaten women (OR = 0.17, p < 0.05). Unexpectedly, among professional ANC patients, those ever-abused were more likely to make four or more visits (OR = 36.54, p < 0.05). In Egypt as elsewhere around the world, wife beating is related to various negative health outcomes. Women's programmes must take domestic violence into account if they want to better address the needs of a non-negligible proportion of their target population.

The Relationship Between Birth Predictedness and Violence During Pregnancy Among Women in La Paz and El Alto, Bolivia

OBJECTIVES

The main objectives were to estimate the prevalence of predicted and unpredicted last births using a prospective approach and to estimate the prevalence of violence during the last pregnancy. In addition, the relationship between birth predictedness and violence during pregnancy was examined.

METHODS

The target population for this study was women who had participated in the 1994 Demographic and Health Survey (DHS) and lived in El Alto and La Paz Bolivia (n = 1308). In 1997, 816 women were located and re-interviewed. During this three-year interval, 127/816 women had given birth to their last child.

RESULTS

Of the last births that occurred during the three-year interval, 82% were unpredicted (18% were to women who stated in 1994 that they wanted to postpone childbirth for more than three years and 64% were to women who stated they wanted to wanted to forego childbearing entirely). Twenty-eight percent of women reported that they had experienced violence during their last pregnancy. No statistically significant relationship was found between birth predictedness and violence during their pregnancy.

CONCLUSIONS

The majority of births that occurred in the three-year study interval were unpredicted. The prevalence of violence during pregnancy was alarmingly high among this sample of women. Further investigation on violence during pregnancy is needed and should be expanded to examine how violence during pregnancy impacts maternal and infant outcomes, which have remained poor in this country. In addition, the high rates of unpredicted births illustrate that work remains to be done in addressing women's ability to control their fertility.

Intimate partner violence and physical health consequences: policy and practice implications

Extensive research indicates that intimate partner violence (IPV) poses a significant risk to the physical health of women. IPV is associated with increased mortality, injury and disability, worse general health, chronic pain, substance abuse, reproductive disorders, and poorer pregnancy outcomes. IPV is also associated with an overuse of health services and unmet need for services, as well as strained relationships with providers. The body of IPV research has several critical gaps. There are almost no longitudinal studies of IPV and health. Most studies are clustered into a few specialties, with almost no research in the areas of allied health, dentistry, or management. A common definition of IPV is still not used. Finally, with some notable exceptions, there has been little success in moving the health care system to routinely screen women for IPV.