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Physical Violence Against U.S.

Women Around the Time of Pregnancy, 2004 2007


Susan Y. Chu, PhD, MSPH, Mary M. Goodwin, MPA, MA, Denise V. DAngelo, MPH
Background: Previous research shows that the prevalence of intimate partner violence (IPV)
around the time of pregnancy varies from 4% to 9%, but no studies have distinguished between abuse rates by former versus current partners.

Purpose: This study aims to estimate the prevalence of IPV among U.S. women shortly before and during pregnancy and to compare the rates and predictors of abuse perpetrated by current partners with the rates and predictors of abuse perpetrated by former partners. Methods: Using data from 27 states and New York City, the prevalence of physical abuse by current
and former intimate male partners was estimated among 134,955 women who delivered a singleton, full-term infant in 2004 2007. Multivariable logistic regression was used to determine the demographic, pregnancy-related, and stress factors that predicted the risk of IPV.

Results: Prevalence of IPV from either a former or current partner was 5.3% before and 3.6% during pregnancy. Prevalence of abuse by a former partner was consistently higher than the prevalence of abuse by a current partner. The three strongest predictors of IPV during pregnancy were the womans partner not wanting the pregnancy (current: AOR 3.47, 95% CI 3.13, 3.85; former: AOR 3.22, 95% CI 2.90, 3.76); having had a recent divorce or separation (current: AOR 3.23, 95% CI 2.92, 3.58; former: AOR 3.54, 95% CI 3.20, 3.91); and being close to someone having a drug or alcohol problem (current: AOR 3.05, 95% CI 2.78, 3.36; former: AOR 2.97, 95% CI 2.70, 3.27). Maternal characteristics (age, education, race, marital status, woman did not want the pregnancy) were less important predictors. Conclusions: Assessments of abuse should ask specifcally about actions by both current and
ex-partners.
(Am J Prev Med 2010;38(3):317322) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Introduction
iolence against women by male intimate partners, also known as intimate partner violence (IPV), is a major public health problem with serious short- and long-term health consequences.1 Intimate partner violence during pregnancy can be particularly harmful because of the potential additional adverse effects on neonatal infant and maternal health.2,3 Previous studies4 6 in the U.S. have reported prevalences of IPV around the time of pregnancy varying from 4% to 9%, with higher rates associated with young age; divorced, separated, or single marital status; black or Native
From the Division of Reproductive Health, CDC, Atlanta, Georgia Address correspondence and reprint requests to: Susan Y. Chu, PhD, MSPH, Division of Reproductive Health, CDC, 4770 Buford Highway, Mailstop K-23, Atlanta GA 30341. E-mail: syc1@cdc.gov. 0749-3797/00/$17.00 doi: 10.1016/j.amepre.2009.11.013

American race/ethnicity; presence of children in the home; receipt of government assistance; low household income; and certain stressful life events.5,6 Although having had a divorce, separation, or being single is known to be associated with IPV, prior studies57 of IPV among pregnant women were based on data from survey instruments that did not ask specifcally whether the violence was from a former husband or partner. The purpose of this study was to estimate the prevalence of IPV among U.S. women shortly before and during pregnancy and to compare the rates and predictors of abuse perpetrated by current partners with the rates and predictors of abuse perpetrated by former partners.

Methods
Data used were collected from 2004 through 2007 by the Pregnancy Risk Assessment Monitoring System (PRAMS),
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an ongoing U.S. surveillance system that collects information on maternal behaviors associated with pregnancy on state-specifc populations and links this information to birth certifcate data. Presently, health departments in 37 states, one city, and one tribalstate collaborative project participate in collecting PRAMS surveillance data. Sampling methods have been described elsewhere8,9; briefly, each month, a stratifed systematic sample of 100 300 new mothers who are state residents and have delivered a live-born infant in the preceding 2 6 months is selected from birth-certifcate records. A self-administered, 14-page questionnaire is mailed to each mother. If the mother fails to respond, a second or third questionnaire is mailed to her. If there continues to be no response to the questionnaire, telephone interviews are conducted to follow up with the mother. Each mothers questionnaire is linked to her childs birth certifcate. The mothers age, race, ethnicity, education, marital status, parity, and paternal education were obtained from birth certificates; all other variables were based on responses to the PRAMS questionnaires. To minimize nonresponse bias and ensure reasonable representation of each states entire population of women delivering a live-born infant, a CDC PRAMS working group set a response rate threshold of 70%; therefore, all states in this analysis achieved an overall response rate of 70% or greater for each year of data included. This resulted in an initial study population of 137,366 women from New York City and 27 states. Data were available for all 4 years from Arizona, Colorado, Hawaii, Maine, Maryland, North Carolina, Rhode Island, Utah, and Vermont; for 2004 2006 from Alaska, Georgia, Illinois, Michigan, Minnesota, Mississippi, Nebraska, New Jersey, New York (excluding New York City), Ohio, Oklahoma, Oregon, South Carolina, Washington, West Virginia, and New York City; and for 2004 and 2005 from Florida, Louisiana, and New Mexico. Because of state reporting laws, Illinois, Oregon, and Vermont PRAMS surveys do not ask women aged 18 years questions about IPV; therefore, data from these three sites include information collected only from women aged 18 years. Data from all other participating states include information on IPV from all women who gave birth to a live-born infant regardless of age. The CDC IRB approved the PRAMS protocol, and all participating states and New York City approved the study analysis plan. Data are weighted to adjust for survey design, noncoverage, and nonresponse; therefore, they represent all women delivering a live-born infant in each respective state for the years included. To assess the prevalence of physical abuse around the time of pregnancy, the PRAMS questionnaire asked women the following four questions: (1) During the 12 months before you got pregnant with your new baby, did an ex-husband or ex-partner push, hit, slap, kick, choke, or physically hurt you in any other way? (2) During the 12 months before you got pregnant, were you physically hurt in any way by your hus-

band or partner? (3) During your most recent pregnancy, did an ex-husband or ex-partner push, hit, slap, kick, choke, or physically hurt you in any other way? and (4) During your most recent pregnancy, were you physically hurt in any way by your husband or partner? Prior to 2004, the PRAMS core questionnaire asked about physical violence perpetrated by only a current husband or partner or by anyone else. The specifc questions about physical violence by ex-husbands or ex-partners were added to allow for the calculation of rates of IPV as defned by the CDC (the intentional use of physical force with the potential for causing death, disability, injury, or harm by current spouses or non-marital partners or former marital or non-marital partners).10 The prevalences of IPV perpetrated by a current husband/ partner, by a former husband/partner, and by either partner before and during pregnancy were calculated separately and then the rates were compared by selected demographic factors (maternal age, race/ethnicity, education, and marital status; parental education); delivery hospitalization covered by Medicaid (as a marker for SES); prenatal care measures (trimester of entry into care, total number of prenatal care visits, whether a healthcare provider discussed abuse at a prenatal care visit); whether the pregnancy was intended by the woman and her husband or partner; and stressful situations during the 12 months before the birth of her baby. A womans intent to become pregnant was assessed by the following question: Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? If a woman indicated that she wanted the pregnancy at that time or sooner, the pregnancy was categorized as intended. If the woman indicated that she had wanted the pregnancy later or had not wanted to be pregnant then or at any time in the future, the pregnancy was categorized as unintended. Intention or acceptance of the pregnancy by the husband or partner was assessed by asking the mother whether he had said he did not want her to be pregnant during the 12 months before her new baby was born. In contrast to the previous questions about the perpetrator of IPV, this question did not distinguish between former and current partners. Stratifying by whether the perpetrator of violence was a current or former partner, the association between womens IPV risk and exposure to stressful situations during the 12 months before their babys birth was calculated. Stressful situations included whether someone close to them had a problem with drinking or drugs; whether they had gotten a separation or divorce; whether they and/or their husband or partner had lost a job; and whether they had bills they could not pay, had moved to a new address, or were homeless. The mothers were also asked whether their husband or partner went to jail during the 12 months prior to their delivery. To assess the independent effects of demographic factors, pregnancy intent, and exposure to stressful situations on the
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risk of IPV, a multivariable logistic model was used, which included factors that were signifcantly associated with IPV in our univariate analysis. Factors were entered into the model as categoric variables using groupings from the univariate analysis. SAS, version 9.1, and SUDAAN, version 9.0, were used to account for the selection and response probabilities of the survey design. All analyses were conducted in 2009.

Results
Of the 137,366 women surveyed, 2411 women (1.8%) with missing values to the physical abuse questions were excluded, leaving 134,955 women for this analysis. Of these, 10.3%, 25.1%, 27.0%, 21.9%, and 15.8% (weighted proportions) were aged 20, 20 24, 2529, 30 34, and 35 years, respectively. About half were non-Hispanic white (54.6%), and 17.0%, 15.4%, 3.5%, 2.7%, 1.1%, and 5.7% were non-Hispanic black, Hispanic, Asian, AmericanIndian, Alaskan- Native, and other nonwhite, respectively. About 42% were nulliparous; 62.7% were married at the time of delivery. Almost all (98.8%) women received some prenatal care, and most (82.2%) received care in the frst trimester; 46.0% of the deliveries were paid for by Medicaid. In the 12 months before pregnancy, 5.3% 0.1% of women reported IPV; overall and for nearly every level of every category, the prevalence of IPV by former partners was signifcantly higher than that by current partners (overall: former, 4.5% 0.1% vs current, 3.5% 0.1%). Detailed data are provided in Appendix A, available online at www.ajpm-online.net. Nearly one in ten women aged 20 years reported having experienced IPV before pregnancy by either partner; IPV rates also were higher among Alaskan-Native (11.6% 0.8%); American-Indian (11.2% 1.0%); and non-Hispanic black (8.5% 0.3%) women than among women of other racial/ethnic groups (white, 4.3% 0.1%; Hispanic, 5.9% 0.3%; Asian, 2.4% 0.4%). Married women were much less likely to have experienced IPV than unmarried women (married, 2.4% 0.1%, vs unmarried, 10.3% 0.2%). Intimate partner violence was more common if the mother and father had less than a high school education (maternal: less than high school, 8.9% 0.3%, vs more than high school, 2.9% 0.1%; paternal: less than high school, 7.1% 0.3%, vs more than high school, 1.9% 0.1%); if the mother had three or more live births (three or more births, 7.1% 0.3%, vs nulliparous, 5.3% 0.2%); if the delivery hospitalization was paid for by Medicaid (Medicaid, 9.0% 0.2%, vs not Medicaid, 2.3% 0.1%); and if the mother received late or no prenatal care (no care, 9.2% 1.2%; third trimester only, 9.1% 0.8%; frst trimester, 4.6% 0.1%).
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The prevalence of IPV during the 12 months before pregnancy varied signifcantly by whether the woman and her husband or partner wanted the pregnancy, but the difference was much more dependent on the husbands or partners reported intention (husband or partner did not want pregnancy, 18.0% 0.6%, vs no given intention, 4.1% 0.1%; mother did not want pregnancy, 5.7% 0.2%, vs mother wanted pregnancy, 2.1% 0.1%). Although exposure to stressful situations was associated with greater risk of IPV overall, the prevalence of IPV was particularly high among women exposed to the following stressors: having been close to someone with a drinking or drug problem (18.7% 0.5%); having had a recent separation or divorce (22.5% 0.6%); having been homeless (21.4% 1.0%); and having been in jail or having a partner who had been in jail (29.2% 0.9%). About half the women reported that their prenatal care provider had discussed abuse with them; however, having had such a discussion was not strongly associated with the prevalence of IPV (provider discussed abuse, 5.8% 0.2%, vs provider did not discuss abuse, 4.8% 0.1%). Overall, rates of IPV during pregnancy were consistently lower than rates of IPV during the 12 months prior to pregnancy; however, the prevalence of IPV during pregnancy was 14.2% 0.5% among women whose husband or partner did not want the pregnancy, 15.6% 0.5% among those who were recently separated or divorced, 16.1% 0.9% among those who had been homeless, and 22.5% 0.9% among those who had been in jail or had a partner who had been in jail. The prevalence of IPV during pregnancy was also higher among non-Hispanic blacks (6.8% 0.3%); American Indians (6.5% 0.7%); Alaska Natives (8.1% 0.7%); women who were aged 20 years (7.1% 0.4%); were not married (7.2% 0.2%); received late or no prenatal care (7.0% 0.7% and 7.7% 1.2%, respectively); had a partner who did not want the pregnancy (14.2% 0.5%); were close to someone with a drinking or drug problem (12.7% 0.4%); had lost their job (9.4% 0.4%) or had a partner who had lost his job (8.8% 0.4%); and had bills they could not pay (8.4% 0.3%). Results of the multivariable analysis showed that the three strongest predictors of a womans risk for IPV during pregnancy were having a partner who did not want the pregnancy (current partner: AOR 3.47, 95% CI 3.13, 3.85; former partner: AOR 3.22, 95% CI 2.90, 3.76); having had a recent divorce or separation (current partner: AOR 3.23, 95% CI 2.92, 3.58; former partner: AOR 3.54, 95% CI 3.20, 3.91); and being close to someone with a drug or alcohol problem (current partner: AOR 3.05, 95% CI 2.78, 3.36; former partner: AOR 2.97, 95% CI 2.70, 3.27; Table 1). Maternal characteristics (age, education, race/ethnicity, marital status,

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Table 1. Multivariable predictors of physical abuse by current husband/partner during pregnancy, PRAMS, 2004 2007, AOR (95% CI)
Variable
Partner didnt want pregnancy Divorce Drugs Intimate partner lost job Medicaid-covered delivery Mother lost job Unmarried Mother didnt want pregnancy Maternal race Maternal education Maternal age Paternal education

Current partner
3.47 (3.13, 3.85) 3.23 (2.92, 3.58) 3.05 (2.78, 3.36) 1.72 (1.55, 1.90) 1.55 (1.38, 1.73) 1.34 (1.20, 1.50) 1.40 (1.26, 1.55) 1.18 (1.07, 1.29) 1.11 (1.08, 1.14) 0.93 (0.87, 1.00) 0.90 (0.86, 0.94) 0.78 (0.72, 0.84)

Former partner
3.22 (2.90, 3.76) 3.54 (3.20, 3.91) 2.97 (2.70, 3.27) 1.61 (1.45, 1.78) 1.52 (1.37, 1.71) 1.37 (1.23, 1.54) 1.85 (1.69, 2.07) 1.12 (1.02, 1.23) 1.12 (1.09, 1.15) 0.92 (0.86, 0.98) 0.90 (0.86, 0.94) 0.80 (0.74, 0.86)

PRAMS, Pregnancy Risk Assessment Monitoring System

pregnancy intent) were less strongly associated with IPV risk.

Discussion
This study had two noteworthy fndings concerning the characteristics of women who may be at particularly high risk for IPV during and shortly before pregnancy. First, it showed that women are at greater risk for violence from a former husband or partner than from a current one, which suggests that assessments of abuse should specifcally ask about actions by both current and ex-partners. Second, it showed that IPV risk around the time of pregnancy is strongly associated with having had a recent divorce or separation, having a partner who expressed that he did not want the pregnancy, and being close to someone with a drinking or drug problem. The fndings of this analysis have some limitations. Data from PRAMS are based on self-reported information and are subject to nonresponse bias, a bias that might particularly affect stigmatized issues such as IPV and result in underestimates of the prevalence of IPV among childbearing women. Second, because the timing of IPV and certain occurrences (e.g., separation and divorce) is not known, only associations are measured, which do not necessarily imply cause and effect. Third, because three states did not collect IPV information from girls aged 18 years, and this age group had higher IPV rates,

the overall IPV prevalence will be an underestimate. A fourth limitation is that it was unknown whether the partner was the father of the infant and whether the reported IPV was perpetrated by the same man who became separated from the woman during the survey period. In addition, the present study could not determine whether a husband or partner who did not want the pregnancy was the former or current partner or whether he was the same partner who engaged in IPV. In addition, PRAMS gathers data only from women who delivered live-born infants. Thus, women whose pregnancies ended in induced or spontaneous abortion or stillbirth were not included; because it is unknown whether IPV prevalence differs by pregnancy outcome, the impact of these exclusions is uncertain. Finally, the PRAMS data used in this study did not reflect IPV that occurred during the postpartum period, when violence may increase or begin to have a direct effect on the newborn child.11 Despite these limitations, the study fndings provide recent, population-based estimates of IPV prevalence among U.S. women during and shortly before the time of pregnancy based on data from a large sample of U.S. women who gave birth. The study has the advantage that the IPV questions are embedded in a survey that already asks women about other intimate experiences around the time of pregnancy, a salient time for new mothers. Moreover, the PRAMS questionnaire incorporated questions about stressful life events, which in this analysis were shown to be signifcantly associated with risk for IPV. Pregnancy is a time when the majority of U.S. women access healthcare services, and prenatal care provides a unique opportunity to ask about violence and to assess abuse among women at increased risk. In the PRAMS sample analyzed in this study, almost all women (98.8%) received some prenatal care, and most (82.2%) received care in the frst trimester. Although these percentages are somewhat higher than corresponding 2006 percentages reported by the National Center for Health Statistics12 based on data from 18 states (92.1% and 69.0%, respectively), both sets of data clearly show that the majority of U.S. women have repeated contact with a prenatal care provider. Moreover, because most pregnant women are young, prenatal care targets the age group of women that is at the highest risk for physical abuse.13 Because IPV victims are often isolated from friends, family, and other social support, prenatal visits may be one of the few opportunities to assist and offer appropriate referrals to women who are being abused.14,15 Many major professional medical organizations16 19 recommend universal screening for IPV in healthcare settings. The American College of Obstetricians and Gynecologists16 places special emphasis on identifying and providing interventions for women abused during pregwww.ajpm-online.net

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nancy, and the American Medical Association recommends routine IPV screening for all female patients. However, evidence-based guidelines, such as those of the U.S. Preventive Services Task Force20 and the Canadian Task Force on Preventive Care,21 have concluded that evidence concerning the effectiveness of IPV screening is insuffcient to recommend for or against its universal use. The lack of beneft of universal screening could be due to the lack of effective interventions for IPV and current reliance on passive referrals to community services.22 Specifc active interventions, such as close case follow-up of IPV survivors or perinatal home-visiting programs, could more effectively prevent recurrence of IPV and provide more long-term social support.23 In the absence of clear guidelines on how or whether to implement routine screening, clinicians should nevertheless be particularly alert for the possibility that women with a history of these events may be the victims of IPV. PRAMS Working Group: Alabama, Albert Woolbright, PhD; Alaska, Kathy Perham-Hester, MS, MPH; Arkansas, Mary McGehee, PhD; Colorado, Alyson Shupe, PhD; Delaware, Charlon Kroelinger, PhD; Florida, Jamie Fairclough, MPH; Georgia, Carol Hoban, MS, MPH; Hawaii, Mark Eshima, MA; Illinois, Theresa Sandidge, MA; Louisiana, Joan Wightkin; Maine, Kim Haggan; Maryland, Diana Cheng, MD; Massachusetts, Hafsatou Diop, MD, MPH; Michigan, Violanda Grigorescu, MD, MSPH; Minnesota, Jan Jernell; Mississippi, Marilyn Jones; Missouri, Venkata Garikapaty, MSc, MS, PhD, MPH; Montana, JoAnn Dotson; Nebraska, Brenda Coufal; New Jersey, Lakota Kruse, MD; New Mexico, Eirian Coronado; New York State, Anne Radigan-Garcia; New York City, Candace Mulready-Ward, MPH; North Carolina, Paul Buescher, PhD; North Dakota, Sandra Anseth; Ohio, Connie Geidenberger; Oklahoma, Alicia Lincoln; Oregon, Kenneth Rosenberg, MD; Pennsylvania, Kenneth Huling; Rhode Island, Sam Viner-Brown, PhD; South Carolina, Mike Smith; South Dakota, Christine Rinki, MPH; Tennessee, David Law, PhD; Texas, Eric Miller, PhD; Utah, Laurie Baksh; Vermont, Peggy Brozicevic; Virginia, Marilyn Wenner; Washington, Linda Lohdefnck; West Virginia, Melissa Baker, MA; Wisconsin, Katherine Kvale, PhD; Wyoming, Angi Crotsenberg; CDC PRAMS Team, Applied Sciences Branch, Division of Reproductive Health. The fndings and conclusions in this report are those of the authors and do not necessarily represent the offcial position of the CDC. No fnancial disclosures were reported by the authors of this paper.

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Appendix Supplementary Data


Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.amepre. 2009.11.013.

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