1. INTIMATE PARTNER VIOLENCE DURING PREGNANCY : Oregon PRAMS 2001 Bertha Alicia Moseson, MD, MPH 10 th 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 (>2 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 <20yo 26 women did not answer question about IPVP

7. METHODS Statistical 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 <.05 considered significant Logistic regression of selected variables with significant OR based on 95% CI

8. METHODS The 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. MEHTODS Model 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

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. RESULTS Effect 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 woman’s alcohol use during pregnancy

20. DISCUSSION: Lots of bills you couldn’t pay Consistently more significant than income: Income <$15,000: Crude OR 2.48 (0.78,7.48) Being on OHP: Crude OR 2.25 (0.65,7.72) Lots of bills you couldn’t 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 don’t want to know, because so few resources available to pregnant women

22. LIMITATIONS Women < 20 yo not asked about IPVP Only women with live born baby surveyed Questionnaire mailed to woman’s 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 doesn’t want her to be pregnant,” “previous pregnancy loss,” “close to someone with drug or Etoh problem,” or “lots of bills she can’t 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