INTIMATE PARTNER VIOLENCE DURING PREGNANCY: Oregon PRAMS 2001

1
INTIMATE PARTNER VIOLENCE DURING PREGNANCY
Oregon PRAMS 2001

• Bertha Alicia Moseson, MD, MPH
• 10th Annual MCH EPI Conference, Atlanta
• December 8, 2004

2
INTIMATE PARTNER VIOLENCE (IPV)

• IPV (domestic violence, battering, spousal abuse)
  is violence committed by a spouse, ex-spouse,
  current or former boyfriend or girlfriend
• Both men and women are victims of IPV
• Majority of perpetrators are men
• Most suffer multiple acts over time
• Cuts across socioeconomic, religious, and ethnic
  lines

3
PREVALENCE OF IPV IN USA

• 2.1 of women 18 and older are victims of
  violence (gt2 million women)
• 75 are victims of intimate partner violence
• More women than men experience IPV, and women are
  more likely to be injured
• 324,000 experience IPV during pregnancy
• Prevalence is 4-8 in most studies and as high as
  20 in some studies

4
CONSEQUENCES OF INTIMATE PARTNER VIOLENCE IN
PREGNANCY (IPVP)

• Puts pregnant woman and fetus at risk for
  physical and mental health problems
• Associated with increased smoking and poor weight
  gain, both factors for delivery of low birth
  weight babies
• Risk to fetus and mother as high as other
  conditions that are routinely screened for in
  pregnancy

5
OBJECTIVES OF THIS STUDY

• To develop a model, using Oregon PRAMS data, that
  might predict when a pregnant woman is being
  battered by her partner
• To use the model to identify women in prenatal
  care who are being physically abused by their
  partners earlier in the cycle of violence

6
METHODS Data collection and population

• Oregon Pregnancy Risk Assessment Monitoring
  System (PRAMS), 2001
• 2490 surveys mailed/1795 responded (72.1)
• 1548 answered question about IPVP
• Excluded
• All women lt20yo
• 26 women did not answer question about IPVP

7
METHODSStatistical Analysis

• Data management SAS for windows v 8e
• Crosstab and logistic regression SUDAAN 8.02
• Outcome variable
• Intimate Partner Violence in Pregnancy (IPVP)
• Crosstab for association CMH Chi-square with
  p-value lt.05 considered significant
• Logistic regression of selected variables with
  significant OR based on 95 CI

8
METHODSThe Question

• During your most recent pregnancy, did your
  husband or partner push, hit, slap, kick, choke,
  or physically hurt you in any other way?
• No
• Yes

9
MEHTODSModel Building

• Four categories of variables selected for model
  building (some variables found in more than one
  model)
• 1. Male partner characteristics
• 2. Pregnancy characteristics
• 3. Relationship characteristics
• 4. Maternal socio-demographic factors

10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
RESULTS Highly correlated variables not used in
model building

• Highest odds ratios in our study, suggest these
  are proxy variables for IPVP
• During the 12 months before you got pregnant, did
  your husband/partner push, hit, slap, kick,
  choke, or physically hurt you in any other way?
  (OR 321.39)
• During the 12 months before your baby was born
  did you and your husband/partner argue more than
  usual? (OR 272.22)
• During the 12 months before your baby was born,
  were you involved in a physical fight? (OR 81.78)

16
RESULTSEffect of Pregnancy on IPV

• Prevalence of IPV before pregnancy 4.17
• 68 women in sample
• Prevalence of IPV during pregnancy 2.45
• 36 women in sample
• 5 of these women indicated battering started
  during pregnancy

17
DISCUSSION Husband/Partner said he did not want
her to be pregnant

• Likely to cause increased stress in an already
  stressful relationship
• May be related to feelings of loss of control by
  a controlling male partner
• Jealousy if woman gets more attention
• Anger if he feels he is not the father

18
DISCUSSION Loss of a previous pregnancy

• Association has been shown as an outcome in
  several studies
• Possible mechanisms
• Trauma to the uterus and placenta
• Smoking and drug use
• Depression and inadequate diet
• Sexually transmitted diseases and HIV
• Preterm labor

19
DISCUSSION Someone close to you has a problem
with drinking or drugs

• Found to be significant in other PRAMS studies
• A coping mechanism for stress and PTSD
• What came first? Battering or substance abuse
• Independent of question about womans alcohol use
  during pregnancy

20
DISCUSSION Lots of bills you couldnt pay

• Consistently more significant than income
• Income lt15,000 Crude OR 2.48 (0.78,7.48)
• Being on OHP Crude OR 2.25 (0.65,7.72)
• Lots of bills you couldnt pay
• Crude OR 13.56 (3.34, 63.26)
• Adjusted OR 7.87 (1.84, 33.65)

21
DISCUSSION Surveillance for IPVP

• In Oregon, in 2001, only 49 of women in prenatal
  care recalled having been asked about IPVP
• Many asked only at intake history and physical
• Women need to develop trust in provider
• Providers dont want to know, because so few
  resources available to pregnant women

22
LIMITATIONS

• Women lt 20 yo not asked about IPVP
• Only women with live born baby surveyed
• Questionnaire mailed to womans home
• Questions open to interpretation
• Asking for recall of events up to 24 months ago
• Reluctance to reveal sensitive, embarrasing and
  potentially threatening information

23
CONCLUSIONS

• The model has identified factors which are
  associated with IPVP in Oregon Women
• These factors can guide prenatal care providers
  in identifying women at higher risk for IPVP
• Obstetrical care providers must be encouraged to
  identify and counsel women in abusive
  relationships or refer them for counseling
• For the health of the mother and fetus
• For better delineation of this Public Health
  problem

24
CONCLUSIONS

• If a woman denies abuse, but admits to partner
  doesnt want her to be pregnant, previous
  pregnancy loss, close to someone with drug or
  Etoh problem, or lots of bills she cant pay,
  she should be asked, in private, about abuse at
  each prenatal visit

25
FUTURE WORK

• Health People 2010 goal for IPV 3.3/1000
• Increased awareness and training for OB providers
  to detect and document abuse
• Increased public health awareness
• More services for pregnant women
• More research on factors causing IPVP, more
  emphasis on working with abuser

26
ACKNOWLEDGEMENTS

• Oregon Department of Human Services, Office of
  Family Health
• Oregon Health Science University, Department of
  Public Health Preventive Medicine