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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.
Current Knowledge
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.
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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.
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