Journal of the American Medical Association, Vol. 267, No. 17, May 6, 1992, 2370-2372.
Abuse of Pregnant Women and Adverse Birth Outcome
Current Knowledge and Implications for Practice
Eli H. Newberger, MD, Susan E. Barkan, PhD, Ellice S. Lieberman, MD, DrPH, Marie C. McCormick, MD, ScD, Kersti Yllo, PhD, Lisa T. Gary, MSW, Susan Schechter, MSW
ABUSE of pregnant women is not rare. The prevalence of physical assault of women during pregnancy has been estimated at 8% in a random sample drawn from public and private prenatal clinics,1 and between 7% and 11% in nonrandom samples drawn from university obstetric clinic services.2,3 Rates of overall violence against pregnant women gathered by the Second National Family Violence Survey4 were as follows: 154 acts of violence per 1000 during the first 4 months of pregnancy and 170 acts of violence per 1000 women during the fifth through ninth months. (Pregnant women’s risk of what was characterized as “abusive violence” was 60.6% greater than that of nonpregnant women in this national probability sample of 6002 households, but this was interpreted as an artifact of age because women under 25 years of age were more likely both to be pregnant and to be abused by husbands and partners.)
Nevertheless, the assault of women during pregnancy occurs with sufficient frequency to pose a significant concern for the possible threat to the health of the pregnant woman and her developing fetus.
There has been little study of or focused clinical effort on the risks to mother and fetus associated with physical or sexual abuse during pregnancy. Only a single, small study has addressed the issue of adverse birth outcome in association with abuse of pregnant women. The results of that study suggest an increased risk of low birth weight in women abused during pregnancy.5
An Institute of Medicine committee6 examined the causes of low birth weight and pointed to the need for more systematic and rigorous examination of the risk of low birth weight. The report did not mention maternal injury, either intentional or unintentional, but did include a discussion of psychological factors that impinge on pregnant women.
Methodologic Problems.– The few clinical studies on abuse of pregnant women contain numerous methodologic problems that limit the extent to which these studies can inform clinical practice and guide future research. These methodologic problems include (1) small selected samples7; (2) limited descriptions of the timing, severity, locus, and treatment given for injuries1,8; (3) absence of corroboration with specific neonatal findings5; (4) confounded inferences of cause and effect with spurious variables5; (5) inability to generalize results of the findings to specific populations because of selected samples and study designs that do not use stratification on major social and demographic variables1,9; (6) possible recall biases both with regard to violence and to other risk exposures in pregnancy1,7,8; (7) poor validity and reliability due to underdeveloped study instruments1,5,7,8,10,11; and (8) statistical methods with little power to exclude type I and type II errors and to examine hypothesized effects of mediating variables.1,7,8
These methodologic difficulties result, implicitly, from the nature of the issue of family violence and the challenges it poses to investigators. Family violence is inherently multifactorial in nature. Practice and instrumentation in this area are far from standardized. Many risks and obstacles prevent accurate measurement of exposure and outcome. Rigorous study design involving large samples is needed but funding in this area has been limited.
Postulated Etiology.– While the association between abuse and adverse pregnancy outcome has not been extensively studied, several causal mechanisms can be postulated. The postulated relationship between victimization of battered pregnant women and their children’s low birth weight can be understood as direct or indirect.
The direct causal pathway between physical and sexual victimization of a pregnant woman and adverse birth outcome could operate through a variety of biologic mechanisms. A physical or sexual assault involving abdominal trauma can cause abruptio placentae, which, depending on the gestational age of the fetus, could lead to fetal loss or early onset of labor and the delivery of a live, low-birth-weight or preterm infant.12 Other consequences of abdominal trauma during pregnancy may include fetal fractures, rupture of the mother’s uterus, liver, or spleen, pelvic fractures, and antepartum hemorrhage.13 Additionally, trauma may cause uterine contractions, premature rupture of membranes, and infection leading to early onset of labor and possible fetal loss.12 Finally, the victimization of a woman may lead to the exacerbation of chronic illnesses such as hypertension, diabetes, or asthma, which may have deleterious effects on the fetus. An indirect causal pathway can be derived by considering the meaning of the victimization experience for a woman as realized in our and other research and clinical experiences. These experiences focus on the relationship between a woman and her victimizer, in which the victimizer uses a variety of strategies and methods to coerce and to exert control over the woman in the relationship. Victimization in this perspective may be defined in terms of particular assaultive acts,14 by control techniques that include verbal intimidation, emotional abuse, and challenges to the woman’s competency as a person, including, for example, her capacity to care for her children.15 Therefore, physical or sexual victimization might also lead to one or more of the following intermediate risks: (1) elevated physical and psychological stress; (2) isolation and inadequate access to prenatal care and other health care services; (3) behavioral risks such as cigarette smoking, alcohol use, and illegal drug use in reaction to the psychological distress of victimization; and (4) inadequate maternal nutrition as a consequence of financial privation or denial of nutrients as part of the victimization pattern.
The literature associating these indirect risks with diminished fetal growth and with the early onset of labor culminating in the delivery of a low-birth-weight and/or preterm infant is fairly extensive.
Although in general the literature linking stress and anxiety to obstetric outcome has been equivocal, there is a sound basis for the notion that maternal emotional distress may be linked to poor reproductive outcome. Animal research has demonstrated that exposing animals to stressors during gestation is associated with low birth weight, smaller litter size, and decreased neonatal survival.16
Maternal psychological stress has been associated with depression in both pregnant and nonpregnant women.17,18 Stress and/or depression may have direct or indirect effects on the fetus. Direct effects have been hypothesized to involve the release of catecholamines resulting in precipitation of preterm delivery or placental hypoperfusion resulting in delayed fetal growth.19 Stressful events and depression have been linked to pregnancy and birth complications.2O Emotional distress may also increase the frequency of behavioral risks associated with neonatal or obstetric problems such as cigarette smoking, alcohol consumption, and decreased utilization of prenatal care.16,19 A recent study confirmed the association between maternal depression and psychological stress, and between maternal depression and substance use and low weight gain during pregnancy.17 Another study postulated that the relationship between maternal psychological stress and low birth weight may result from the effect of psychological stress on maternal weight gain.21
Current data suggest that the negative effects of maternal psychological stress and depression on neonatal outcome are ameliorated by social support.22 Studies of work-related stress, both physical and psychological, suggest a link to low birth weight23,24 and preterm delivery.23-27
Well-substantiated evidence links maternal alcohol consumption with miscarriage28,29 and low birth weight.3O-32 The impact of marijuana use on decreased fetal growth has been suggested,33-35 and the impact of cocaine use has been more convincingly documented.33,36
In the United States, maternal cigarette smoking is one of the most important risk factors for fetal growth retardation.37-39 Smoking has been reported to slow fetal growth, double the risk of low birth weight, and increase the risk of stillbirth.40,41
Numerous studies have examined the relationship between adequacy of prenatal care and low birth weight and preterm delivery. These studies fairly consistently show that lack of or inadequate prenatal care is associated with an increased incidence of low birth weight even after controlling for important confounding variables.42-46
Impacts on Women.- The impact of abuse on women is extensive and embraces medical and psychological effects that may increase risks during pregnancy. The physical impacts can affect every organ system, and abuse may escalate in frequency and severity, especially during pregnancy.7 In the absence of studies that systematically compare the risks and the nature of violence against pregnant women with those of other abused women, no clear patterns of vulnerability and trauma have been discerned. Apart from the substantial direct effects on pregnant women’s physical safety (ie, abuse of the most vulnerable organ systems such as the central nervous system, integument, reproductive organs, facial organs, and abdominal viscera), such abuse by these women’s partners appears to conform to a pattern of coercive control that includes restricting access to preventive and curative health care.15
The psychological effects of victimization include shame, fear, diminished self-esteem, self-blaming, and depression (in response to the continued sense of terror and need to mollify and contain the violence of the partner), and a sense of diminished personal instrumentality, because of few available resources to protect herself or to extricate herself from the relationship.47 (Although this phenomenon has also been characterized as “learned helplessness,” we, among other students of woman abuse, note that many women are indeed quite resourceful in protecting themselves and in seeking options, even in the face of continued threats and harmful actions and limited resources as part of the pattern of victimization.48)
Psychological impacts may also be associated with a reluctance to disclose one’s status as a victim to friends or to providers of health, social, and other services. They also appear to be associated with expressing psychosomatic and emotional complaints when seeking medical care, denying victimization when responding to direct questions about abuse, avoiding service contacts that might inflame the rage of their abusers, and exhibiting a vulnerability to use and abuse alcohol and illicit drugs.3,47,49
Implications for Practice
The burden of these posited associations for the clinical practice that considers the effect of the abuse of pregnant women on birth outcome is clear: direct and indirect causal relationships must be postulated and attention to multiple causal pathways must be considered. In the absence of a corpus of systematic research on the abuse of pregnant women and its consequences, clinicians should consider a range of possible physical and psychological consequences to a victimized woman and act to address them in a thoughtful and comprehensive fashion.
Interview Approach.-We believe that all women should have the opportunity to expand beyond the confines of the usual medical history to relate their life circumstances before and during the pregnancy and their experiences of victimization. Most women will not volunteer information about abuse experiences unless they are asked specifically about them. This interview effort should also try to gather insights into their relationships with the battering partners, the women’s fears, and their perceptions of professional responses to their efforts to seek help and protection in the past, as well as the women’s concerns about their pregnancies, deliveries, and the evolving condition of their babies. Interviewing must always be done apart from their male partners.
Sometimes women will deny to professional personnel that they are victimized, even when questions are posed to them directly. Victimized women appear more likely to disclose the circumstances of their victimizations to other women and to personnel who offer protection and who are sympathetic to the plight of battered women and can provide support and access to help.
Although the amount of time women spend in the hospital after delivering is decreasing, especially because of efforts to reduce the costs of hospitalization, aggressive efforts can be made in the obstetric service to identify and to protect battered women. This work has been pioneered by Prof McFarlane and her colleagues at the Texas Women’s University School of Nursing, Houston. They have developed, in association with the Metropolitan Houston Chapter of the March of Dimes Birth Defects Foundation, a Protocol of Care for the Battered Woman.50 They suggest the use of a schematic body map to guide interview questions on specific loci of trauma.
Linkages to Battered Women’s Services.-Based on our experience at Children’s Hospital, Boston, Mass, we propose that all medical and surgical services for women construct linkages to the battered women’s service movement. Programs now exist in many communities. Such connection would provide access to protection, crisis intervention, and support for battered women. Ideally, after a disclosure of victimization to a physician, nurse, or social worker, the woman would be seen as quickly as possible by an advocate or the social worker, who would provide her with information about protection, legal rights, and when needed, shelter. In the course of the initial contact, an assessment would be made of the level of violence in the home, the availability of weapons, and the woman’s previous experience with court and police interventions. A safety plan would be developed with the woman. There would be collaboration with medical and nursing staff to provide care for the woman and her children, including attending all case conferences and participating in hospital discharge planning. Services provided would include the following: (1) housing advocacy with shelter and emergency housing transfers; (2) court accompaniment; (3) referrals for legal and medical care; and (4) referrals to counseling support groups. The goals of such an effort are to empower women to better protect themselves and their children and to develop networks of support in the community.
Eli H. Newberger, MD
Susan E. Barkan, PhD
Ellice S. Lieberman, MD, DrPH
Marie C. McCormick, MD, ScD
Kersti Yllo, PhD
Lisa T. Gary, MSW
Susan Schechter, MSW
This work was supported in part by a grant from the Noonan Memorial Fund of the Medical Foundation, Boston, Mass, and grant MH18265-08 from the National Institute of Mental Health, Bethesda, Md.
1. Helton A, McFarlane J, Anderson E. Battered and pregnant: a prevalence study. Am J Public Health. 1987;77:1337-1339.
2. Hilliard P. Physical abuse in pregnancy. Obstet Gyncecol. 1985;66:185-190.
3. Amaro H, Fried L, Cabral H, Zuckerman E. Violence during pregnancy and substance abuse. Am J Public Health. 1990;80:575-579.
4. Gelles R. Violence and pregnancy: are pregnant women at greater risk of abuse? J Marriage Fam. August 1988:841-847.
5. Bullock L, McFarlane J. The birthweight/battering connection. Am J Nurs. 1989; 1153-1155.
6. Institute of Medicine. Preventing Low Birthweight. Washington, DC: National Academy Press; 1985:72.
7. Gelles R. Violence and pregnancy: a note on the extent of the problem and needed services. Fam Coordinator. 1975;24:81-86.
8. Helton A, Snodgrass F. Battering during pregnancy: intervention services. Birth. 1987;14:142-147.
9. Hawkins D. Devalued racial stereotypes: ideological barriers to the prevention of family violence among blacks. In: Hampton R, ed. Violence in the Black Family: Correlates and Consequences. Lexington, Mass: Lexington Books; 1987.
10. Sorenson S, Stein J, Seigal J, Golding J, Burnam A. The prevalence of adult sexual assault. Am J Epidemiol. 1987;126:1154-1163.
11. Russell DEH. The prevalence of wife rape. In: Russell D, ed. Rape and Marriage. New York, NY: Collier Books; 1982:57-72.
12. Pearlman MD, TintinalliJE, Lorenz RP. Blunt trauma during pregnancy. N Engl J Med. 1990;323:1609-1613.
13. Sammons MN. Battered and pregnant. Am J Maternal Child Nurs. 1981;6:246250.
14. Gary LT. Feminist practice and family violence. In: Bricker-Jenkins M, Hooyman NR, Gottlieb N, eds. Feminist Social Work Practice in Clinical Settings. Newbury Park, Calif: Sage Publications; 1991:19-32.
15. McKibben L, De Vos E, Newberger E. Victimization of mothers of abused children: a controlled study. Pediatrics. 1989;84:531-535.
16. Istvan J. Stress, anxiety, and birth outcomes: a critical review of the evidence. Psychol Bull. 1986;100:331-348.
17. Zuckerman B, Amaro H, Bauchner H, Cabral H. Depressive symptoms during pregnancy: relationship to poor health behaviors. Am J Obstet Gynecol. 1989;160: 1107-1111.
18. Brown GW, Harris TO. Social Origins of Depression. New York, NY: Free Press; 1978.
19. McAnarney ER, Stevens-Simon C. Maternal psychological stress/depression and low birth weight: is there a relationship? AJDC. 1990;144:789-792.
20. NorbeckJS, Tilden VP. Life stress, social support, and emotional disequilibrium in complications of pregnancy: a prospective, multivariate study. J Health Soc Behav. 1983;24:30-46.
21. Picone TA, Allen LH, Schramm MM, Olsen PN. Pregnancy outcome in North American women, I: effects of diet, cigarette smoking, and psychological stress on maternal weight gain. Am J Clin Nutr. 1989;6:1205-1213.
22. Boyce WT, Schaefer C, Vitti C. Permanence and change: psychological factors on the outcome of adolescent pregnancy. Soc Sci Med. 1985;11:1279-1287.
23. Homer CJ, James SA, Siegal E. Work-related psychological stress and risk of preterm, low birthweight delivery. Am J Public Health. 1990;80:173-177.
24. Homer CJ, Beresford SA, James SA, Siegal E, Wilcox S. Work related physical exertion and risk of pre term, low birthweight delivery. Paediatr Perinat Epidemiol. 1990;4:161-174.
25. Mammelle N, Laumon B, Lazar P. Prematurity and occupational activity during pregnancy. Am J Epidemiol. 1984;119:309-322.
26. Zuckerman BS, Frank D, Hingson R, et al. Impact of maternal work outside the home during pregnancy on neonatal outcome. Pediatrics. 1986;77:459-464.
27. Teitehnan AM, Welch LS, Hellenbrand KG, Bracken ME. Effect of maternal work activity on preterm birth and low birth weight. Am J Epidemiol. 1990;131:104-114.
28. Harlap S, Shiono P. Alcohol, smoking, and incidence of spontaneous abortions in the first and second trimester. Lancet. 1980;2:173-176.
29. Kline J, Shrout P, Stein Z, Susser M, Warburton D. Drinking during pregnancy and spontaneous abortion. Lancet. 1980;2:176-180.
30. Ouellette EM, Rosett HL, Rosman NP, Weiner L. Adverse effects on offspring of maternal alcohol abuse during pregnancy. N Engl J Med. 1977;297:528-530.
31. Mills JL, Graubard BI, Harley EE, Rhoads GG, Berendes HW. Maternal alcohol consumption and birth weight: how much drinking during pregnancy is safe? JAMA. 1984;252:1875-1879.
32. Little RE. Moderate alcohol use during pregnancy and decreased infant birth weight. Am J Public Health. 1977;67:1154-1156.
33. Zuckerman B, Frank DA, Hingson R, et al. Effects of maternal marijuana and cocaine use on fetal growth. N Engl J Med. 1989;320:762-768.
34. Hatch EE, Bracken ME. Effect of marijuana use in pregnancy on fetal growth. Am J Epidemiol. 1986;124:986-993.
35. Linn S, Schoenbaum SC, Monson RR, Rosner R, Stubblefield PC, Ryan KJ. The association of marijuana use with outcome of pregnancy. Am J Public Health. 1983; 73:1161-1164.
36. ChasnoffIJ, Burns WJ, Schnoll SH, Burns KA. Cocaine use in pregnancy. N Engl J Med. 1985;313:666-669.
37. Simpson WJ. A preliminary report of cigarette smoking and the incidence of prematurity. Am J Obstet Gynecol. 1957;73:808-815.
38. Butler NR, Goldstein H, Ross EM. Cigarette smoking in pregnancy: its influence on birth weight and prenatal mortality. BMJ. 1972;2:127-130.
39. Abel EL. Smoking during pregnancy: a review of effects on growth and development of offspring. Hum Biol. 1980;52:593-625.
40. Public Health Service. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. Washington, DC: Public Health Service; 1979: 24-25. US Dept of Health, Education, and Welfare publication PHS 79-55071.
41. Stein Z, Kline J. Smoking, alcohol and reproduction. Am J Public Health. 1983; 73: 1154-1156.
42. Gortmaker SL. The effects of prenatal care upon the health of the newborn. Am J Public Health. 1979;69:653-660.
43. Eisner V, Brazie JV, Pratt MW, Hexter AC. The risk of low birthweight. Am J public Health. 1979;69:887-893.
44. Elster AE. The effect of maternal age, parity and prenatal care in perinatal outcome in adolescent mothers. Am J Obstet Gynecol. 1984;149:845-847.
45. Showstack JA, Budetti PP, Minkler D. Factors associated with birthweight: an exploration of the roles of prenatal care and length of gestation. Am J Public Health. 1984;74:1003-1008.
46. Donaldson DJ, BHry JOG. The impact of prenatal care on birthweight: evidence from an international data set. Med Care. 1984;22:177-188.
47. Walker L. The Battered Woman Syndrome. ‘New York, NY: Springer Publishing Co Inc; 1984.
48. Gondolf E, Fisher E. Battered Women as Survivors: An Alternative to Treating Learned Helplessness. Lexington, Mass: Lexington Books; 1988.
49. Goldberg W, Tomlanovich M. Domestic violence in the emergency department: new findings. JAMA. 1984;251:3259-3264. .
50. Helton A, Anderson E, McFarlane J. Protocol of Care for the Battered Woman. Houston, Tex: Metropolitan Houston Chapter of the March of Dimes Birth Defects Foundation; 1986.
This article is one of a number of articles on violence that will appear in upcoming issues of THE JOURNAL. The reader is referred to the June 10,1992, issue, which will be dedicated to studies of violence.