Pregnancy-Related Violence Research Paper

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Since the late 1960s and early 1970s, violence against women has been identified as a serious social problem in the United States. It is estimated that almost 2 million U.S. women a year will be physically assaulted and more than 300,000 will experience a completed or attempted rape (Tjaden and Thoennes 2000). More recently, the subject of violence against women has commanded even greater attention on the part of public health officials as an important reproductive health issue. In particular, there has been increasing concern about the relationship between intimate partner violence and pregnancy. This concern has come about as a result of a greater understanding of the changing dynamics of abusive relationships, particularly the awareness that the frequency, intensity, and impact of violence may change during the course of an intimate relationship and different stages of the life course, including pregnancy (Mahoney, Williams, and West 2001). In addition to a number of other risk factors, pregnancy and parenthood may be particularly risky life transitions, as they present both economic and psychological stressors to partners in an intimate relationship.

Outline

I. Prevalence Rates of Pregnancy-Related Violent Victimization

II. Are Pregnant Women at Greater Risk of Intimate Partner Violence?

III. What Are the Motives/Risk Factors for Pregnancy-Related Violence?

IV. What Are the Consequences of Pregnancy-Related Violence?

A. Later Entry into Prenatal Care

B. Low-Birth-Weight Infants

C. Premature Labor

D. Fetal Trauma

E. Unhealthy Maternal Behaviors

F. Health Issues for Mother

V. How Is the Medical Profession Working to End Pregnancy-Related Violence?

VI. Conclusion

I. Prevalence Rates of Pregnancy-Related Violent Victimization

How much pregnancy-related violence occurs? Estimates of violence during pregnancy range from 7 percent (Campbell et al. 1992) to between 20 and 30 percent of pregnant women (Bullock and McFarlane 1989). In addition, researchers using national probability samples have found prevalence rates ranging from 15.0 percent (Gelles 1990) to 23.6 percent (Jasinski and Kaufman Kantor 2001). Using the most conservative estimates of pregnancy-related violence, approximately 150,000 to 300,000 pregnant women experience abuse every year.

Why is there such a wide range of reported prevalence rates? One of the first issues to consider when evaluating such diverse results is the type of sample being studied. For example, much of the research that examines the relationship between pregnancy and violence uses hospital- or clinic-based samples (e.g., samples of either postpartum women or women during prenatal care visits) (Martin et al. 2001, 2004; Rachana et al. 2002). These samples produce prevalence estimates of violence against women who are pregnant. In contrast, researchers using national probability samples are estimating the risk for victimization among either all women or all women of childbearing age regardless of pregnancy status. Although each type of research design has its purpose, the differences need to be noted, as they influence how prevalence rates are calculated. Moreover, regardless of which type of sample is being used, there is clear evidence that pregnancy-related violence has serious negative consequences for both the woman and her unborn child.

II. Are Pregnant Women at Greater Risk of Intimate Partner Violence?

An important question, particularly for public health officials, is that of risk. If being pregnant increases the risk for violent victimization, then certain interventions are warranted. This would seem at first to be a simple question to answer. However, once again researchers have reached different conclusions based on the type of sample they have included in their studies. Many researchers examining pregnancy-related violence, for example, use small samples of either postpartum women or women attending a prenatal clinic and do not include a comparison group of women who are not pregnant (Bullock and McFarlane 1989; Campbell et al. 1992; Stewart 1994). Unfortunately, this reliance on anecdotal reports from pregnant women or hospital samples of pregnant women does not make it possible to empirically test whether or not pregnancy, per se, increases the risk for violence. Furthermore, this body of research is focused primarily on examining the consequences of violent behavior for the infant (Parker et al. 1994; Webster, Chandler, and Battistutta 1996) as well as improving assessment techniques among physicians, rather than on establishing whether or not pregnancy is a risk factor for intimate partner violence (McFarlane et al. 1992; Norton et al. 1995). Although these are noteworthy endeavors and are likely to lead to improvements in health care outcomes for women and children, the question of whether pregnant women are at a greater risk of assault by their male partners compared with women who are not pregnant remains largely unanswered.

Research using national probability samples can address the question of risk because the sample studied includes both women who are pregnant and women who are not pregnant. Studies using these types of samples have consistently reported no difference in risk due to pregnancy. For example, Gelles’ 1990 analysis of data from the 1985 National Family Violence Survey found that after controlling for age, pregnant women were not significantly more likely to be victims of assaults by their male partners compared with women who were not pregnant. Similarly, researchers analyzing the 1992 National Alcohol and Family Violence Survey found that for both Anglo and Hispanic families, there was no direct effect of pregnancy on violent victimization risk after controlling for age, socioeconomic status, and stressful life events occurring during the pregnancy year (Jasinski and Kaufman Kantor 2001). More recently Jasinski (2001) found that pregnant women were no more likely to be victims of intimate partner violence than women who were not pregnant. However, persistent violence was more likely to occur among couples in which the male partner perceived that the pregnancy of the female occurred sooner than intended. Each of the studies discussed above did not find that pregnancy was a risk factor for intimate partner violence once other established risk factors were taken into consideration. Given contradictory evidence regarding pregnancy as a risk factor for intimate partner violence, what conclusions can be drawn?

Although studies using a probability sample seem to agree that pregnancy does not increase the risk for violent victimization, they were not designed to specifically look at this issue and consequently have not included all the necessary questions needed to create a complete picture of the violence/pregnancy relationship. Furthermore, it should be noted that these studies, although finding no increased risk for victimization, also have not found a decreased risk. Until there is more research on the dynamics of pregnancy-related violence, it would be unwise to state definitively that pregnancy is or is not a risk factor for violence.

III. What Are the Motives/Risk Factors for Pregnancy-Related Violence?

The life of a woman who is abused by her intimate partner is intertwined with her abuser’s life, greatly reducing feelings of safety and security, as well as opportunities to leave the relationship. Each of these characteristics takes on new meaning if the victim is pregnant. What is known about the dynamics of pregnancy-related violence, however, is limited. It is unclear, for example, whether pregnancy precipitates abuse in previously nonviolent relationships or whether, for some, pregnancy offers any immunity to ongoing or intermittent assaults.

What can be concluded from this conflicting evidence? Regardless of the exact dynamics of pregnancy-related violence, most of the research finds that women who were abused while they were pregnant had a history of victimization (Glander et al. 1998; Horrigan, Schroeder, and Schaffer 2000; Smikle et al. 1996). This would suggest that women who have a history of victimization should be identified as an at-risk group with specific intervention efforts targeted to them. At the same time, it appears that although some women suffer abuse inordinately, the specific patterns and risk markers for abuse among these women have not been conclusively identified (Petersen et al. 1997). This gap in the research literature makes the development of comprehensive prevention and intervention programs extremely difficult and of primary concern to health care practitioners. Although the exact relationship between pregnancy status and intimate partner violence has yet to be identified, sufficient research does exist to be suggestive of the appropriate direction for prevention and intervention programs.

For example, research focusing on characteristics of the mother or the pregnancy as potential risks has produced several consistent patterns of risk that could be used to develop prevention programs aimed at reducing violence experienced during pregnancy. One factor that has emerged as a consistent risk factor for violence is low socioeconomic status (measured with educational levels, income, and/or employment) (Cokkinides and Coker 1998; Gazmararian et al. 1995; Goodwin et al. 2000; Martin et al. 2004). It also appears as if women who are abused do not have the same levels of social support as do women who are not abused (Glander et al. 1998; Sagrestano et al. 2004; Wiemann et al. 2000). Each of these two factors— low socioeconomic status and low levels of social support—may also be related to elevated levels of stress and in combination may increase the risk for violence. Other pregnancy-related factors that may increase the level of stress experienced by a couple and consequently increase the risk for intimate partner violence include first-time parenting (Jasinski 2001) and unplanned or unwanted pregnancies (Cokkinides et al. 1999; Jasinski 2001). Possible explanations for this pattern of behavior include jealousy of the unborn child and the perception that the pregnancy will interfere with the woman’s role as caretaker for her partner (Campbell et al. 1995) and questions of paternity (Burch and Gallup 2004). It is also possible that a pregnancy not planned by the male partner might represent something that he cannot control and therefore increases the risk for violence.

Normative transitions associated with the entrance or exit into a social role, such as parenthood, may also increase the risk for victimization. As such a transition, pregnancy or the anticipation of parenthood for both new and experienced parents may increase the level of stress in the family and as a result increase the risk for violence (Curry and Harvey 1998). In addition, pregnancy or the birth of a child may intensify preexisting strains such as low socioeconomic status. Studies finding that young pregnant women are more likely to have been abused than older pregnant women also suggest that the combination of pregnancy and youth may be particularly stressful (Hedin et al. 1999; Muhajarine and D’Arcy 1999; Parker et al. 1994; Stewart and Cecutti 1993). Stress associated with financial hardships and chronic poverty and unemployment has the potential to tax family functioning, and the cumulative effect of multiple stressors can affect levels of marital conflict. Stress may also affect the ability to process information effectively and the selection of particular conflict resolution behaviors in given circumstances, potentially leading to frustration and perhaps violence.

IV. What Are the Consequences of Pregnancy-Related Violence?

Violence during pregnancy greatly reduces the possibility that a healthy lifestyle leading to safe motherhood can be reached; instead, a number of negative consequences are likely to result for both the mother and her unborn child. These consequences include late entry into prenatal care, low-birth-weight babies, premature labor, fetal trauma, unhealthy maternal behaviors, and health issues for the mother.

A. Later Entry into Prenatal Care

In addition to this conceptualization of safe motherhood, one of the goals of the federal initiative called Healthy People is that 90 percent of pregnant women will begin prenatal care in the first trimester. Unfortunately, women involved in violent relationships often enter prenatal care later in their pregnancy than do women in nonviolent relationships (Dietz et al. 1997; Gazmararian et al. 1995; Goodwin et al. 2000; McFarlane et al. 1992; Parker 1993; Parker et al. 1993, 1994). Moreover, some women may delay their prenatal care as late as the third trimester (McFarlane et al. 1992). One study, for example, found that 38 percent of women in abusive relationships registered for prenatal care later than twenty weeks gestation compared with 23 percent of the women who were not abused (Norton et al. 1995). Late entry into prenatal care may be a risk factor for pregnancy complications, as it reduces or eliminates the possibility of early risk assessment of and education in healthy maternal behaviors.

B. Low-Birth-Weight Infants

Although researchers generally agree that violence and abuse are associated with delays in prenatal care, the same level of agreement is not present with regard to other outcomes of pregnancy-related violence, such as low-birth-weight infants. It has been argued by some researchers, for example, that battered women are more likely than nonbattered women to give birth to preterm and low-birth-weight infants (Bullock and McFarlane 1989; Campbell et al. 1999; Curry and Harvey 1998; Parker et al. 1994). In one study, of the 100 patients who were victims of domestic violence, 16 percent had low-birth-weight babies, compared with 6 percent of the 389 patients who were not domestic violence victims (Fernandez and Krueger 1999). Other researchers have found that the percentage of victims with low-birth-weight babies was twice as high as that of nonvictims (Bullock andMcFarlane 1989). In addition to the violence experienced by pregnant women, low birth weight may also be associated with late entry into prenatal care, along with other unhealthy behaviors by the mother (e.g., smoking, poor nutrition) (Bohn and Holz 1996).

In contrast, there are also a number of studies that have not found any relationship between violence and low-birth-weight infants. For example, Cokkinides et al. (1999) found that violence was not significantly associated with low birth weight. Their study used the South Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) data from 6,143 women who delivered live infants between 1993 and 1995. Similarly, Shumway and associates’ (1999) study indicated that birth weight and gestational age at delivery did not vary significantly with a history of, or the degree of, violence experienced during pregnancy. Some researchers, however, have suggested that the findings of no relationship between low birth weight and violence may be a function of confounding variables such as low socioeconomic status and poor nutrition (Bullock and McFarlane 1989). In other words, low-birth-weight infants are more likely to be born to mothers of low socioeconomic status with poor nutritional habits, and since many hospital-based studies use samples of women with these characteristics, it is difficult to untangle which factors are ultimately responsible for the negative outcome. Moreover, studies do not always control for gestation length when looking at consequences such as low birth weight. Differences in sample size and type as well as a lack of standard cutoff points for what constitutes low birth weight could also account for differences across studies.

C. Premature Labor

In addition to low birth weight, there is also contradictory evidence regarding the relationship between violence and premature labor. Several studies, for example, have concluded that women who are victims of intimate partner violence are more likely to give birth prematurely compared with women who are not abused. Berenson and associates (1994), for example, found that assaulted women were almost twice as likely to experience preterm labor compared with those who were not assaulted. Similarly, Shumway et al. (1999) found that women who were abused were 2.3 times more likely to experience preterm labor. In addition, an increased risk for preterm labor was associated with more serious violence. Fernandez and Krueger’s (1999) study found that of the 100 patients who were victims of domestic violence, 22 percent had preterm deliveries compared with only 9 percent of the 389 patients who were not victims of domestic violence. Other researchers have found the risk of preterm labor to be as much as 5 times greater among victims of severe abuse compared to women who were not abused (Shumway et al. 1999). Although there are multiple studies finding a link between abuse and premature labor, there are also several studies that have not found a relationship between violence and premature labor (Cokkinides et al. 1999; Grimstad et al. 1997). As with much of the research on pregnancy-related violence, differences in empirical findings may be due to a variety of factors, including the failure to control for other variables related to preterm labor, as well as differences in research design and sample type.

D. Fetal Trauma

One of the most serious negative consequences of pregnancy-related violence is fetal trauma (e.g., miscarriage, spontaneous abortion, etc.). In contrast to some of the other negative consequences reviewed, research focusing on this type of negative outcome has been relatively consistent it its findings; abuse puts the unborn baby at great risk. For example, Jacoby et al.’s (1999) study of 100 women receiving prenatal care found that women who experienced any form of abuse were significantly more likely to miscarry (42.3 percent versus 16.2 percent, respectively). In addition, they found an association between current abuse and at least one spontaneous abortion (miscarriage) in the woman’s obstetric history. Other researchers have also found an increased risk for miscarriages among abused women (Berrios and Grady 1991; Renker 1999). Violence has also been associated with fetal injury and death (Bohn 1990; Webster et al. 1996).

E. Unhealthy Maternal Behaviors

In addition to the direct effects of violence on the health and well-being of the unborn child, violence may also indirectly contribute to negative consequences by increasing the risk for unhealthy maternal behaviors (Plichta 2004). For example, several studies have found that abused women are more likely to smoke than women who are not abused (Cokkinides and Coker 1998; Cokkinides et al. 1999; Grimstad et al. 1997; Martin et al. 1996; McFarlane and Parker 1996; Wiemann et al. 2000). In addition, much of the same research has also found an association between violence victimization and alcohol and drug use. Martin et al.’s (1996) study of 2,092 prenatal patients in North Carolina found that during pregnancy, victims were more likely to smoke, drink, and use drugs than were women who were not victimized. Moreover, after controlling for demographic factors, victims were more likely to be in the more severe substance abuse categories during pregnancy than women who were not victims of violence. In one of the few studies with a racially and ethnically diverse sample, Berenson and associates (1991) found that drug use was related to battering for white and black women in their sample but not for Hispanic women. These unhealthy behaviors may be associated with negative consequences for the unborn child as well as for the mother.

F. Health Issues for Mother

After more than three decades of research focused on intimate partner violence, the negative psychological and social consequences of such victimization have been clearly identified. Victims of intimate partner violence report feelings of helplessness, depression, low self-esteem, suicidal thoughts, and anxiety, all indicators of psychological distress (Straus and Gelles 1990). Battered women are also more likely to visit emergency rooms and to have chronic health complaints (Stark and Flitcraft 1988). In addition, both experiencing and witnessing violence have been associated with a greater risk of violence (as both a victim and a perpetrator) in the next generation. All of these consequences are significant for women who are pregnant as well as for their unborn children. Besides the negative health consequences experienced by the unborn child, several studies have found that violence is associated with negative health consequences for the mother as well. Moreover, many of these health issues are also relevant for the health of the unborn child. Bohn and Holtz’s (1996) review of the literature identifies health issues such as an unhealthy diet, severe postpartum depression, and breastfeeding difficulties that are associated with victimization. Other researchers have found that abused women suffer from more stress and receive less support from their partner, and others (Curry and Harvey 1998; Sagrestano et al. 2004). In addition, maternal health issues such as severe depression (Horrigan et al. 2000), lower self-esteem (Curry and Harvey 1998), kidney infections (Cokkinides et al. 1999), poor weight gain, anemia, and first- or second-trimester bleeding (Parker et al. 1994) have all been associated with violence victimization. Other researchers have focused on the interval between pregnancies, finding that victims of abuse tend to have very short intervals between pregnancies (‘‘rapid repeat pregnancies’’). Each of these consequences puts both the mother and the child at risk for long-term health-related consequences.

V. How Is the Medical Profession Working to End Pregnancy-Related Violence?

Although there are a number of areas with regard to pregnancy-related violence in which the research evidence is inconclusive, there is no dispute that intimate partner violence has only negative outcomes; and for women who are pregnant, these negative outcomes can have drastic consequences. Given this information, the most logical place for prevention and intervention efforts to begin is with health care providers. Pregnancy is often a woman’s first entry into the health care system and perhaps her first contact with a helping profession; consequently professionals who deal with pregnant women and new mothers are in a unique position to screen for intimate partner violence along with other health-related factors and initiate intervention if needed (Sampselle et al. 1992). Despite the fact that violence during pregnancy may be more common than many of the items women are often asked about by their health care providers, most women report not being asked about violence (Friedman et al. 1992). Careful assessment, however, of both family risk markers (e.g., family-of-origin exposure, substance abuse), family stressors, and current conflict management strategies may provide a more complete picture of the patient and allow for the opportunity to prevent any occurrence of violence. For women who report that they have already been victimized, health care providers are in an excellent position to provide individuals with linkages to appropriate services. Screening for domestic violence is also essential among women presenting with trauma- and non-trauma-related symptoms in hospital emergency departments (Dienemann et al. 1999), as their injuries may be related to intimate partner violence.

Appearing to be most effective are screening questions that are direct (Naumann et al. 1999; Norton et al. 1995) and repeated. Naumann and associates (1999), for example, found that although women often find it difficult to start a conversation about abuse, they will answer direct questions. This concept of universal screening of women seeking any health care has been identified as an essential component of comprehensive health care for women (Koss, Koss, and Woodruff 1991). In addition to identifying victims and getting them assistance, the very process of assessment can be just as important, because it acknowledges that violence against pregnant women is a very serious issue (Parker et al. 1999). In other words, if women hear their health care providers asking about victimization, they may feel that the subject is okay to talk about. By making discussions of violence more commonplace in the health care setting, victims may be more comfortable in asking for help from their health care providers.

VI. Conclusion

Increasingly, more attention is being devoted to violence against women as a reproductive health issue. However, empirical knowledge remains relatively scarce regarding the prevalence of pregnancy-related violence and the specific dynamics of violent relationships before, during, and after pregnancy. Differences in research designs and assessments have made it difficult to definitively conclude that pregnant women are at a greater risk for intimate partner violence compared with women who are not pregnant; however, the consequences for pregnant victims remain serious. What knowledge researchers do have suggests that the same dynamics present in violent relationships in which women are not pregnant are magnified when they are. In addition, there is the added impact of potentially harmful health consequences of physical and sexual violence for both the mother and her unborn child. Researchers are continuing to investigate the dynamics of pregnancy-related violence and, as suggested by some of the studies of practitioners, are taking a close look at how they interact with patients. Future work would benefit greatly from joint projects that unite researchers with practitioners with the ultimate goal of healthy women, healthy babies, and violence-free relationships.

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