Physical Violence During the 12 Months Preceding Childbirth -- Alaska, Maine, Oklahoma, and West Virginia, 1990-1991

In addition to clearly defined health risks that develop during pregnancy (e.g., toxemia and diabetes), pregnant women are at risk for physical violence inflicted by intimate partners (1). Although estimates in public and private health-care settings indicate that 4%-17% of women experience violence during pregnancy (2-5), population-based prevalence estimates of this problem have not been available. This report uses 1990 and 1991 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) in Alaska, Maine, Oklahoma, and West Virginia to assess the prevalence of physical violence against women during the 12 months preceding childbirth * and its relation to maternal characteristics.

PRAMS is a population-based surveillance system used in 13 states ** and the District of Columbia to supplement data from birth certificates with self-reported behavioral information obtained from mothers (6). A stratified systematic sample of 100-200 new mothers in each state is selected monthly from birth certificates. Sampled women are mailed a 14-page questionnaire 3-6 months after delivery. This report includes an analysis of responses from women in the four states *** that have both data available for 1990 and 1991 and questionnaire response rates of at least 70% (range: 71%- 84%). Data were weighted to account for survey design and nonresponse. Standard errors (SEs) were estimated using SUDAAN (7). Weighted percentages and SEs represent accurate state-based population estimates.

Respondents were asked if their "husband or partner physically hurt {them}" during the 12 months preceding childbirth. In addition, the PRAMS questionnaire elicited information about household crowding ****; participation in the Special Supplemental Food Program for Women, Infants, and Children (WIC) during pregnancy; initiation of prenatal care; and planning status (i.e., intended or unintended *****) of the pregnancy. Data on maternal education, race, age, and marital status were obtained from birth certificates.

In each state, most respondents had completed at least 12 years of education, were white, were aged greater than or equal to 25 years, were married, were not living in crowded conditions, had not participated in WIC during pregnancy, had initiated prenatal care during the first trimester, and had had an intended pregnancy (Table_1). The percentage of women who reported having been physically hurt by their husband or partner during the 12 months preceding childbirth varied among the four states, from 3.8% in Maine to 6.9% in Oklahoma (Table_2). In general, in each state, rates of physical violence were higher for women who had completed fewer than 12 years of education, were of races other than white, were aged less than or equal to 19 years, were unmarried, were living in crowded conditions, had participated in WIC during pregnancy, had had delayed or no prenatal care, and had had an unintended pregnancy.

Reported by: M VandeCastle, Alaska Dept of Health and Social Svcs. J Danna, MPH, Maine Dept of Human Svcs. E DeCoster, Oklahoma State Dept of Health. T Thomas, MPA, West Virginia Dept of Health and Human Resources. Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: Each year, approximately 1.8 million (3.4%) women in the United States are physically assaulted by their partners (8). Similar proportions were indicated in the findings in this report for new mothers who had experienced violence during the 12 months preceding childbirth in Alaska, Maine, Oklahoma, and West Virginia. Although this analysis indicates that certain subgroups are at increased risk for physical violence during pregnancy, health-care providers should be aware of this risk among all pregnant women. In addition, efforts are needed to determine how health-care providers can more effectively identify women at risk for physical violence and to evaluate intervention programs and examine further the patterns of violence during pregnancy.

Although this analysis provides state-based population estimates, the findings are subject to at least five limitations. First, because respondents were asked to report violent incidents that occurred during the 12 months preceding childbirth, the precise timing of the incidents could not be determined; for example, it could not be determined whether reported violence began during pregnancy in what were previously nonviolent relationships. Second, respondents may have had different interpretations of what constituted being physically hurt. Third, many factors that may be associated with violence during pregnancy were either not available (e.g., characteristics of the perpetrator of the violence) or not readily ascertainable from this analysis. For example, women of races other than white were at increased risk for physical violence during the 12 months preceding childbirth; however, race is most likely a proxy for other risk factors (e.g., poverty) that increase the risk for violence during pregnancy among these women. Fourth, PRAMS does not include women who had spontaneous or induced abortions or fetal deaths; the effect of including these women on the estimated frequency of violence during pregnancy is unknown. Finally, violence during the 12 months preceding childbirth may have been underreported by some women because of the social stigma associated with violence.

Because some women receive health care only during pregnancy, interviews and physical examinations conducted during routine prenatal-care visits may assist in identifying some women who are experiencing violence (5). In addition, because other women who are experiencing violence may seek care at emergency departments, these facilities should establish strategies for identifying these women. The Joint Commission on Accreditation of Healthcare Organizations recommends that accredited emergency departments establish policies, procedures, and education programs to guide staff in the treatment of battered adults (9). Furthermore, all health-care providers should establish relations with organizations that can provide battered women with referral services such as emergency housing, court accompaniment, legal aid, health care, and support groups (10).

References

1. Newberger EH, Barken SE, Lieberman ES, et al. Abuse of pregnant women and adverse birth outcome: current knowledge and implications for practice. JAMA 1992;267:2370-2.

2. Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol 1985;66:185-90.

3. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc J 1993;149:1257-63.

4. Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence study. Am J Public Health 1987;77:1337-9.

5. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176-8.

6. Adams MM, Shulman HB, Bruce C, Hogue C, Brogan D, The PRAMS Working Group. The Pregnancy Risk Assessment Monitoring System: design, questionnaire, data collection and response rates. Paediatr Perinat Epidemiol 1991;5:333-46.

7. Shah BV, Barnwell BG, Hunt PN, LaVange LM. SUDAAN user's manual, release 5.50. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

8. Straus MA, Gelles RJ. How violent are American families? In: Straus MA, Gelles RJ, eds. Physical violence in American families: risk factors and adaptations to violence in 8,145 families. New Brunswick, New Jersey: Transaction Publishers, 1990:95-112.

9. Joint Commission on Accreditation of Healthcare Organizations. Accreditation manual for hospitals. Vol 1 -- standards. Oakbrook Terrace, Illinois: Joint Commission on Accreditation of Healthcare Organizations, 1992:21-2.

10. Morey MA, Beleiter ML, Harris DJ. Profile of a battered fetus. Lancet 1981;2:1294-5.

* The 3 months before and 9 months during pregnancy. 

** Alabama, Alaska, California, Florida, Georgia, Indiana, Maine, Michigan, New York, Oklahoma, South Carolina, Washington, and West Virginia. 

*** For Alaska, the sample size was 2975; for Maine, 2500; for Oklahoma, 3505; and for West Virginia, 3632. 

**** Determined by dividing the total number of persons living in the household by the total number of rooms in the house. Women were classified as living in crowded conditions if the calculation was more than one person per room. 

***** A pregnancy that, at the time of conception, the woman never wanted or did not want until later in life.
Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Characteristics of new mothers, by state --- Alaska, Maine, Oklahoma,
and West Virginia, Pregnancy Risk Assessment Monitoring System, 1990--1991 *
==============================================================================================
                                                                                   West
                                  Alaska          Maine          Oklahoma        Virginia
                                 (n=2975)        (n=2500)        (n=3505)        (n=3632)
                              --------------  --------------  --------------  --------------
Characteristic                 %     (SE +)    %      (SE)     %      (SE)     %      (SE)
--------------------------------------------------------------------------------------------
Education (yrs)
  <12                         14.6  (+/-0.7)  14.4  (+/-0.9)  23.8  (+/-1.3)  27.4  (+/-1.0)
   12                         44.0  (+/-1.1)  42.8  (+/-1.2)  38.5  (+/-1.4)  45.2  (+/-1.2)
  >12                         41.4  (+/-1.1)  42.8  (+/-1.2)  37.7  (+/-1.4)  27.4  (+/-1.0)

Race
  White                       68.5  (+/-0.7)  98.2  (+/-0.3)  80.1  (+/-1.2)  96.3  (+/-0.4)
  Black                        3.4  (+/-0.4)   0.6  (+/-0.2)  10.1  (+/-1.0)   3.4  (+/-0.4)
  Other &                     28.1  (+/-0.5)   1.2  (+/-0.3)   9.8  (+/-0.8)   0.3  (+/-0.1)

Age group (yrs)
   <=19                       11.0  (+/-0.7)  10.8  (+/-0.8)  14.4  (+/-1.1)  18.3  (+/-0.9)
  20-24                       26.0  (+/-0.9)  27.8  (+/-1.1)  28.8  (+/-1.3)  33.1  (+/-1.1)
   >=25                       63.0  (+/-1.0)  61.4  (+/-1.2)  56.8  (+/-1.5)  48.6  (+/-1.1)

Marital status
  Married                     72.4  (+/-0.9)  75.7  (+/-1.1)  74.7  (+/-1.3)  73.1  (+/-1.0)
  Unmarried                   27.6  (+/-0.9)  24.3  (+/-1.1)  25.3  (+/-1.3)  26.9  (+/-1.0)

Household crowding @
  Yes                         19.2  (+/-0.7)   8.8  (+/-0.7)  15.8  (+/-1.1)  11.5  (+/-0.7)
  No                          80.8  (+/-0.7)  91.2  (+/-0.7)  84.2  (+/-1.1)  88.5  (+/-0.7)

Participation in WIC **
  during pregnancy
  Yes                         28.4  (+/-0.9)  28.9  (+/-1.1)  40.7  (+/-1.4)  48.7  (+/-1.1)
  No                          71.6  (+/-0.9)  71.1  (+/-1.1)  59.3  (+/-1.4)  51.3  (+/-1.1)

Initiation ofprenatal care
  First trimester             65.2  (+/-0.9)  71.5  (+/-1.1)  65.2  (+/-1.4)  63.2  (+/-1.0)
  Delayed/None ++             34.8  (+/-0.9)  28.5  (+/-1.1)  34.8  (+/-1.4)  36.8  (+/-1.0)

Planning status of pregnancy
  Intended                    57.4  (+/-1.1)  63.1  (+/-1.2)  53.7  (+/-1.5)  60.3  (+/-1.2)
  Unintended &&               42.6  (+/-1.1)  36.9  (+/-1.2)  46.3  (+/-1.5)  39.7  (+/-1.2)
--------------------------------------------------------------------------------------------
 * Percentages are weighted to account for survey design and nonresponse and reflect
   state-based population estimates. The weighted sample size for Alaska was 19,012;
   for Maine, 31,123; for Oklahoma, 88,215; and for West Virginia, 40,560.
 + Standard error.
 & In Alaska, 93% of mothers categorized as "other" were Alaskan Native; in Oklahoma,
   86% of mothers categorized as "other" were American Indian.
 @ Determined by dividing the total number of persons living in the household by the
   total number of rooms in the house. Women were classified as living in crowded
   conditions if the calculation was more than one person per room.
** Special Supplemental Food Program for Women, Infants, and Children.
++ Comprises women who initiated prenatal care during the second or third trimester or
   did not receive any prenatal care.
&& A pregnancy that, at the time of conception, the woman never wanted or did not want
   until later in life.
==============================================================================================

TABLE 2. Percentage * of women who reported having been physically hurt by their
husband or partner during the 12 months preceding childbirth +, by state and selected
characteristics of mother -- Alaska, Maine, Oklahoma, and West Virginia,
Pregnancy Risk Assessment Monitoring System, 1990-1991
=========================================================================================================
                                                                                             West
                                   Alaska             Maine             Oklahoma           Virginia
                                  (n=2975)           (n=2500)           (n=3505)           (n=3632)
                               ---------------    ---------------    ---------------    ---------------
Characteristic                  %      (SE &)      %       (SE)       %       (SE)       %       (SE)
-------------------------------------------------------------------------------------------------------
Education (yrs)
  <12                          11.1   (+/-1.7)     6.5   (+/-1.7)    12.9   (+/-2.3)     7.5   (+/-1.2)
   12                           7.8   (+/-0.8)     4.2   (+/-0.7)     6.0   (+/-1.1)     5.4   (+/-0.8)
  >12                           2.4   (+/-0.5)     2.3   (+/-0.5)     4.3   (+/-1.0)     2.3   (+/-0.6)

Race
  White                         4.6   (+/-0.6)     3.7   (+/-0.5)     5.7   (+/-0.8)     5.1   (+/-0.5)
  Black                          @      ---         @      ---        9.0   (+/-3.1)     6.8   (+/-2.8)
  Other **                      9.7   (+/-0.7)      @      ---       14.6   (+/-3.6)      @      ---

Age group (yrs)
   <=19                        10.2   (+/-1.9)     7.5   (+/-2.0)    10.7   (+/-2.6)     7.6   (+/-1.5)
  20-24                         8.2   (+/-1.1)     5.8   (+/-1.1)     9.2   (+/-1.8)     7.6   (+/-1.1)
   >=25                         4.5   (+/-0.5)     2.2   (+/-0.5)     3.6   (+/-0.7)     2.4   (+/-0.5)

Marital status
  Married                       3.8   (+/-0.5)     2.3   (+/-0.4)     4.3   (+/-0.7)     2.8   (+/-0.4)
  Unmarried                    12.0   (+/-1.2)     8.3   (+/-1.4)    14.7   (+/-2.2)    11.3   (+/-1.4)

Household crowding ++
  Yes                           7.4   (+/-0.9)     6.4   (+/-2.1)    10.6   (+/-2.5)     6.4   (+/-1.6)
  No                            5.8   (+/-0.6)     3.6   (+/-0.5)     6.2   (+/-0.8)     4.8   (+/-0.5)

Participation in WIC &&
  during pregnancy
  Yes                           9.7   (+/-1.0)     6.9   (+/-1.2)    11.1   (+/-1.5)     8.0   (+/-0.9)
  No                            4.7   (+/-0.5)     2.5   (+/-0.5)     3.8   (+/-0.7)     2.3   (+/-0.5)

Initiation of prenatal care
  First trimester              4.9   (+/-0.6)      3.5   (+/-0.5)     5.7   (+/-0.9)     4.1   (+/-0.6)
  Delayed/None @@              8.3   (+/-0.9)      4.3   (+/-0.9)     9.1   (+/-1.5)     6.6   (+/-0.9)

Planning status of pregnancy
  Intended                     4.0   (+/-0.5)      2.5   (+/-0.5)     3.3   (+/-0.7)     3.5   (+/-0.6)
  Unintended ***               9.3   (+/-1.0)      5.6   (+/-1.0)    10.7   (+/-1.4)     7.6   (+/-1.0)

Total                          6.1   (+/-0.5)      3.8   (+/-0.5)     6.9   (+/-0.8)     5.1   (+/-0.5)
-------------------------------------------------------------------------------------------------------
  * Percentages are weighted to account for survey design and nonresponse and reflect
    state-based population estimates. The weighted sample size for Alaska was 19,012; for
    Maine, 31,123; for Oklahoma, 88,215; and for West Virginia, 40,560.
  + The 3 months before and 9 months during pregnancy.
  & Standard error.
  @ Sample size was too small for meaningful analysis.
 ** In Alaska, 93% of mothers categorized as "other" were Alaskan Native; in Oklahoma, 86%
    of mothers characterized as "other" were American Indian.
 ++ Determined by dividing the total number of persons living in the household by the total
    number of rooms in the house. Women were classified as living in crowded conditions if
    the calculation was more than one person per room.
 && Special Supplemental Food Program for Women, Infants, and Children.
 @@ Comprises women who initiated prenatal care during the second or third trimester or who
    did not receive any prenatal care.
*** A pregnancy that, at the time of conception, the woman never wanted or did not want
    until later in life.
=========================================================================================================

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