physical abuse during pregnancy and preterm delivery
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BSTETRICS
hysical abuse during pregnancy and preterm deliveryeresa Rodrigues, MD; Lúcia Rocha, MPH; Henrique Barros, MD, PhD
BJECTIVE: This study was undertaken to assess the relationship be-ween physical abuse during pregnancy and preterm delivery.
TUDY DESIGN: We conducted a hospital-based survey on physicalbuse during pregnancy, which included 2660 women with consecu-ive live births. Women were interviewed and violence was assessedsing the Abuse Assessment Screen. Data on sociodemographic, be-avioral, and obstetric variables were also obtained. Mothers of pre-erm (�37 weeks; n � 217) were contrasted with mothers of termewborn infants (n � 2428). Logistic regression analysis was per-
ormed to estimate adjusted odds ratios.
ESULTS: Twenty-four percent of mothers of preterm newborn infants
preterm delivery.See Journal Club, page 239
f mothers of term newborn infants (P � .0001). Violence was asso-iated with preterm birth even after controlling for age, marital status,ducation, income, parity, planned pregnancy, antenatal care, smok-ng, alcohol, and illicit drugs use (odds ratio � 3.14, 95% confidencenterval, 2.00-4.93).
ONCLUSION: Women who have had physical abuse during preg-ancy present a large increase in the risk of preterm delivery,
ndependently from a large set of sociodemographic and behav-oral characteristics usually recognized as determinants of pretermirth.
ad experienced physical abuse during pregnancy compared with 8% Key words: physical abuse, pregnancy, preterm, violence
ite this article as: Rodrigues T, Rocha L, Barros H. Physical abuse during pregnancy and preterm delivery. Am J Obstet Gynecol 2008;198:171.e1-171.e6.
reterm birth remains an unsolved rel-evant public health issue.1 Knowledge
bout etiologic factors is insufficient, effec-ive prophylactic interventions are un-vailable, and in most countries, increasingates are observed.2
Only few factors were established as pre-erm birth determinants and most are notmenable to intervention, like ethnicity,ultiple pregnancy, or a previous preterm
elivery. This led to a resurgence of interestn the role of social and environmentalactors like racism, violence, poverty,
stress, and physical exertion in the occur-rence of preterm birth and the design ofpreventive strategies.1,3
Studies in Europe and North Amer-ica showed that the prevalence of vio-lence against pregnant women variedbetween 0.9% and 22.0%,4 and physi-cal abuse is increasingly reported as apotentially modifiable risk factor forpregnancy adverse outcome.5-8 Fewstudies on the association betweenphysical abuse and preterm birth havebeen reported, and those that havefound an effect were mainly conductedamong low-income and teenage moth-ers.9-12 Few population-based studieswith a large sample size and allowingcontrol for several confounding vari-ables have been conducted, and somehave not yielded a significant associa-tion between physical violence andpreterm birth.13,14 Differences in pop-ulation characteristics and sample size,varying definitions of physical violenceand birth outcome, and different studydesign and control for confoundingmay also explain the discrepant find-ings. In this study we aimed to assessand clarify the relationship betweenphysical abuse during pregnancy and
M ATERIALS AND M ETHODS
This survey included 2660 white womenconsecutively delivered of live singletoninfants, at the Department of Obstetricsof Hospital de São João, in Porto, duringa 10-month period in 1999-2000. Thislevel III teaching hospital admits almostall pregnant women from the neighbor-hood area and is a referral hospital forseveral level II units.
In the first 96 hours after delivery,women were invited to participate andasked written informed consent. Thecentral study hypothesis—the associa-tion between physical abuse and adversepregnancy outcome—was not explicitlypresented during the study descriptionto eligible participants. Information wasobtained by face-to-face interview. Allinterviews were performed by trainedsocial workers in a private setting at thehospital, and women were guaranteedconfidentiality. There was no refusal toparticipate.
Participants completed a question-naire comprising questions on sociode-mographic (age, education, employ-ment status, cohabitation status withinfant’s father, and family income), cur-rent pregnancy (parity, anthropomet-
rom the Department of Hygiene andpidemiology, University of Porto Medicalchool (Drs Rodrigues and Barros), and theepartment of Obstetrics and Gynecology,ospital S. João (Dr Rodrigues and Msocha), Porto, Portugal.
eceived Dec. 4, 2006; revised Jan. 30,007; accepted May 11, 2007
eprints: Teresa Rodrigues, Serviço deigiene e Epidemiologia, Faculdade deedicina do Porto, Al. Prof. Hernani Monteiro,200-319 Porto; [email protected]
002-9378/$34.002008 Mosby, Inc. All rights reserved.
oi: 10.1016/j.ajog.2007.05.015
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FEBRUARY 2008 America
ics, antenatal care use, and intention to
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et pregnant), and behavioral character-stics during pregnancy (tobacco smok-ng, alcohol consumption, and illicitrugs use). Concerning antenatal care,omen were classified as having no an-
enatal care visit, beginning antenatalare during pregnancy first trimester, orntering antenatal care later. Women’sxperience of abuse was assessed by us-ng the Abuse Assessment Screen.15
others were asked whether they hadeen hit, slapped, kicked, or otherwisehysically abused since they becameregnant. If so, they were asked to indi-
TABLE 1Crude association between socio-dand physical abuse during pregna
Phpre
Maternal characteristics Yes
n �...................................................................................................................
n...................................................................................................................
Maternal age (y)..........................................................................................................
�20 44..........................................................................................................
20-24 54..........................................................................................................
25-29 59..........................................................................................................
30-34 63..........................................................................................................
�35 37...................................................................................................................
Cohabitation with infant’s father..........................................................................................................
Yes 194..........................................................................................................
No 63...................................................................................................................
School education (y)..........................................................................................................
0-4 136..........................................................................................................
5-6 60..........................................................................................................
7-9 39..........................................................................................................
10-12 20..........................................................................................................
�13 2...................................................................................................................
Family income (Euros)..........................................................................................................
�600 145..........................................................................................................
600-1999 102..........................................................................................................
2000-2999 9..........................................................................................................
�3000 1...................................................................................................................
Paid job..........................................................................................................
Yes 104..........................................................................................................
No 143Rodrigues. Physical abuse and preterm delivery. Am J Obs
ate the perpetrator, the number of times t
71.e2 American Journal of Obstetrics & Gynecol
hey had been abused, the area of injury,nd the most severe incident they haduffered during pregnancy. Womenere also asked if they had ever beenhysically abused. Data on gestationalge, birthweight, and medical complica-ions during current pregnancy were col-ected from maternity clinical charts.
For this analysis, the outcome variableas preterm birth defined as birth before7 weeks’ gestation. Gestational age wasetermined according to the best clinicalstimate considering that when the dis-repancy between amenorrhea and ul-
ographic characteristics
al abuse duringncy
No P value
57 n � 2403..................................................................................................................
) n (%)..................................................................................................................
..................................................................................................................
7.1) 182 (7.6)..................................................................................................................
1.0) 489 (20.3)..................................................................................................................
3.0) 814 (34.0)..................................................................................................................
4.5) 627 (26.2)..................................................................................................................
4.4) 287 (12.0) � .0001..................................................................................................................
..................................................................................................................
5.5) 2268 (94.4)..................................................................................................................
4.5) 135 (5.6) � .0001..................................................................................................................
..................................................................................................................
2.9) 443 (18.4)..................................................................................................................
3.3) 552 (23.0)..................................................................................................................
5.2) 413 (17.2)..................................................................................................................
.8) 475 (19.8)
..................................................................................................................
.8) 520 (21.6) � .0001
..................................................................................................................
..................................................................................................................
6.4) 322 (13.4)..................................................................................................................
9.7) 1219 (50.8)..................................................................................................................
.5) 507 (21.1)
..................................................................................................................
.4) 353 (14.7) � .0001
..................................................................................................................
..................................................................................................................
2.1) 1809 (77.7)..................................................................................................................
7.9) 519 (22.3) � .0001ynecol 2008.
rasounds ascertained gestational age p
ogy FEBRUARY 2008
as higher than 1 week, the latter wasdopted. The current analysis compared17 preterm births with 2428 termirths. Fifteen births were excluded be-ause there was no reliable informationn gestational age.We used logistic regression analysis to
valuate the association between physi-al abuse during pregnancy and pretermelivery, measured by using the odds ra-io (OR) and its 95% confidence intervalCI) both crude and adjusted for otherignificant exposures. Statistical analysisas performed with Stata Statistical Soft-are (release 7.0, Stata Corp, Cary, NC).This study was approved by The Ethi-
al Committee of the Medical School oforto University.
ESULTS
n this survey, the prevalence of physicalbuse during pregnancy among womenelivered of live singleton infants was.7% (257/2660). One in 8 women re-orted a lifetime experience of physicalbuse. From women battered duringregnancy, 50% reported to suffer acts ofiolence more than 3 times during thehole pregnancy, 57.6% mentioned that
he most severe act of violence they haduffered was a slap or push but withoutnjuries or lasting pain, and 42.4% re-erred a more severe incident (39.3% actsuch as punching, kicking, bruises, cuts,nd/or continuing pain; and 3.1%eaten up, severe contusions, brokenones, head, internal, and/or permanent
njury).The prevalence of preterm birth was
.2% (217/2645 births). Preterm deliv-ry was significantly more frequentmong physically abused than non-bused pregnant women (21.4% vs.8%; P � .0001). Women reportinghysical abuse during pregnancy wereignificantly more likely to be youngerhan 20 years of age, in a noncohabitingelationship, less educated, with loweramily income, higher parity, unplannedregnancy, to have no antenatal care, tonter later into antenatal care, to gain lesseight during pregnancy, to smokeore than 10 cigarettes per day during
emncyysicgna
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.........
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(2.........
(2.........
(1.........
.........
(7.........
(2.........
.........
(5.........
(2.........
(1.........
(7.........
(0.........
.........
(5.........
(3.........
(3.........
(0.........
.........
(4.........
(5
regnancy, to use alcohol and illicit
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rugs during pregnancy, and to have nomployment (Tables 1 and 2).
The OR for the univariate associationetween physical abuse during preg-ancy and preterm delivery was 3.7295% CI, 2.59-5.33). After controllingor maternal age, cohabitation status, ed-cation level, family income, parity,lanned pregnancy, antenatal care, to-acco, alcohol, and illicit drugs use, thessociation between physical abuse dur-ng pregnancy and preterm delivery wasttenuated but remained strong and sta-istically significant (adjOR � 3.14; 95%I, 2.00-4.93). Higher ORs of pretermave been shown with increasing fre-uency of abuse experience and for moreevere aggression (Table 3). Eighty-eightercent of women experiencing physicalbuse during pregnancy had been vic-ims of intimate partner violence. Theisk of preterm delivery was higher wheniolence was inflicted either by an inti-ate partner or others (usually relatives;able 3).The association between physical
buse during pregnancy and pretermirth was similar after excluding medi-ally induced preterm cases from analy-is (adj.OR � 2.87; 95% CI, 1.69-4.87).
omen who were physically abused be-ore but not during pregnancy (n � 83)lso showed an increased risk of pretermelivery when compared with neverbused women, although the associationas weaker (adjOR � 2.1; 95% CI,.00-4.31).Abused women reported more fre-
uently genital hemorrhage during preg-ancy (16% vs 5.4%; P � .005) and thessociation was significant for everyregnancy trimester. Gestational hyper-ension was less prevalent among abusedomen (1.6% vs 5.4%; P � .005). No
tatistically significant differences wereound for preeclampsia or other severeregnancy hypertensive disorders (2.3%s 0.9%), diabetes (3.5% vs 5.3%) or uri-ary tract infections (16.0% vs 18.6%).ictims of physical abuse during preg-ancy reported more frequently the oc-urrence of unspecified pregnancy dis-ases (36.2% vs 16.3%) and they alsoelivered more frequently a small-for-estational-age newborn infant (36.5%
s 10.3%; P � .005). yOMMENThis report resulted from a cross-sec-
ional survey conducted in a Portu-uese level III hospital attendingainly urban population and deliver-
ng about 3000 newborn infants per
TABLE 2Crude association between obstetrcharacteristics and physical abuse
Maternal characteristics
...................................................................................................................
...................................................................................................................
Parity..........................................................................................................
1..........................................................................................................
2..........................................................................................................
3 or more...................................................................................................................
Planned pregnancy..........................................................................................................
Yes..........................................................................................................
No...................................................................................................................
Antenatal care..........................................................................................................
No visits..........................................................................................................
First visit after first trimester..........................................................................................................
First visit during the firsttrimester
...................................................................................................................
Body mass index (kg/m2)..........................................................................................................
�20.0..........................................................................................................
20.0-24.9..........................................................................................................
25.0-29.9..........................................................................................................
�30.0...................................................................................................................
Weight gain during pregnancy (g/wk)..........................................................................................................
�225..........................................................................................................
�225...................................................................................................................
Smoking during pregnancy..........................................................................................................
Did not smoke..........................................................................................................
1-9 cigarettes per day..........................................................................................................
�10 cigarettes per day...................................................................................................................
Ethanol intake during pregnancy..........................................................................................................
Yes..........................................................................................................
No...................................................................................................................
Illicit drugs use during pregnancy..........................................................................................................
Yes..........................................................................................................
NoRodrigues. Physical abuse and preterm delivery. Am J Obs
ear. Unlike other studies that have p
FEBRUARY 2008 America
ound a relationship between violencegainst pregnant women and pretermelivery, our study has not been con-ucted in a generally indigent or low-
ncome population. From a search inedline, no previous report on the
l, anthropometric and behavioraluring pregnancysical abuse duringgnancy
No P value
257 n � 2403..................................................................................................................
(%) n (%)..................................................................................................................
..................................................................................................................
(34.2) 1254 (52.2)..................................................................................................................
(24.5) 765 (31.8)..................................................................................................................
(41.2) 384 (16.0) � .0001..................................................................................................................
..................................................................................................................
(18.7) 1862 (77.5)..................................................................................................................
(81.3) 541 (22.5) � .0001..................................................................................................................
..................................................................................................................
(14.6) 23 (1.0)..................................................................................................................
(40.5) 244 (10.2)..................................................................................................................
(44.9) 2123 (88.8) � .0001
..................................................................................................................
..................................................................................................................
(11.9) 278 (11.7)..................................................................................................................
(55.7) 1335 (56.0)..................................................................................................................
(23.4) 579 (24.3)..................................................................................................................
(9.0) 193 (8.1) .956..................................................................................................................
..................................................................................................................
(33.9) 476 (20.1) � .0001..................................................................................................................
(66.1) 1896 (79.9)..................................................................................................................
..................................................................................................................
(72.4) 2065 (86.0)..................................................................................................................
(12.1) 230 (9.6)..................................................................................................................
(15.6) 107 (4.4) � .0001..................................................................................................................
..................................................................................................................
(24.1) 162 (6.7) � .0001..................................................................................................................
(75.9) 2239 (93.3)..................................................................................................................
..................................................................................................................
(6.6) 8 (0.3) � .0001..................................................................................................................
(93.4) 2395 (99.7)ynecol 2008.
icad
Phypre
Yes
n �.........
n.........
.........
88.........
63.........
106.........
.........
48.........
209.........
.........
36.........
100.........
111
.........
.........
29.........
136.........
57.........
22.........
.........
74.........
144.........
.........
186.........
31.........
40.........
.........
62.........
195.........
.........
17.........
240
revalence of physical abuse during
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regnancy was found for Portugueseomen. We estimated that about 10%f pregnant women are physicallybused during pregnancy, a rate that isithin the range of prevalence esti-ates in other countries.4
This study disclosed a significant as-ociation between physical abuse dur-ng pregnancy and preterm birth, evenfter controlling for many sociodemo-raphic and behavioral factors. Therude association between physicalbuse during pregnancy and pretermas only slightly attenuated after ad-
ustment for the potential confound-rs. This means that low socioeco-omic status, behavioral factors suchs smoking, alcohol or drug use, andnadequate antenatal care use do notargely explain the association betweenhysical abuse during pregnancy andreterm delivery. We also have not
ound any interaction between physi-al abuse and social class (assessed
TABLE 3Crude and adjusted odds ratios be
...................................................................................................................
...................................................................................................................
Physical abuse during pregnancy..........................................................................................................
No..........................................................................................................
Yes...................................................................................................................
Frequency of physical abuse during pregnan..........................................................................................................
0..........................................................................................................
1-3..........................................................................................................
4-6..........................................................................................................
�7...................................................................................................................
Severity of physical abuse..........................................................................................................
No abuse..........................................................................................................
Less severe..........................................................................................................
More severe...................................................................................................................
Physical abuse perpetrator..........................................................................................................
No physical abuse..........................................................................................................
Partner..........................................................................................................
Other than a partner...................................................................................................................
Adjusted for other violence characteristics, maternal age, cohand illicit drugs use.a Logistic regression models used to calculate adjusted odds
Rodrigues. Physical abuse and preterm delivery. Am J Obs
hrough maternal education or family l
71.e4 American Journal of Obstetrics & Gynecol
ncome), marital status, maternal age,r parity. Therefore, we only enteredhese factors in the multivariable mod-ls as potential confounders.
The mechanisms linking violence withreterm birth are yet unknown. Someuthors found that women admitteduring pregnancy after sustaining an as-ault, experienced higher rates of pre-erm delivery, whether they delivered athe assault hospitalization or were dis-harged after the assault.16 According toetersen et al,17 the relationship betweeniolence during pregnancy and adverseregnancy outcomes must take into ac-ount two potential etiologic pathways,hysical trauma, and stress. Severe directbdominal trauma may cause adverseregnancy outcome, but minor abdom-
nal trauma seems less likely to be asso-iated with perinatal results. Womenbused during pregnancy are more likelyhan nonabused women to experienceigher levels of other types of stressful
een violence characteristics and prePreterm Term Crud
n � 217 n � 2428.........................................................................................................................
n (%) n (%).........................................................................................................................
.........................................................................................................................
164 (75.6) 2234 (92.0) 1.........................................................................................................................
53 (24.4) 194 (8.0) 3.72.........................................................................................................................
.........................................................................................................................
164 (75.6) 2234 (92.0) 1.........................................................................................................................
23 (10.6) 92 (3.8) 3.41.........................................................................................................................
16 (7.4) 58 (2.4) 3.76.........................................................................................................................
14 (6.4) 44 (1.8) 4.33.........................................................................................................................
.........................................................................................................................
164 (75.6) 2234 (92.0) 1.........................................................................................................................
28 (12.9) 117 (4.8) 3.26.........................................................................................................................
25 (11.5) 77 (3.2) 4.42.........................................................................................................................
.........................................................................................................................
164 (75.6) 2234 (92.0) 1.........................................................................................................................
45 (20.7) 172 (7.1) 3.56.........................................................................................................................
8 (3.7) 22 (0.9) 4.95.........................................................................................................................
tion status, education level, family income, planned pregnancy, a
os included 2613 observations.
ynecol 2008.
ife events18 and more likely to have de- O
ogy FEBRUARY 2008
ression and anxiety.19 There is increas-ng evidence that psychosocial stress maye associated with preterm delivery viaoth behavioral and neuroendocrineathways. Women who had been sub-
ected to violence are more likely tomoke, drink alcohol, and use illegalrugs, and these unhealthy behaviorsay be associated with preterm delivery.n the other hand, emotional stress may
ctivate the neuroendocrine axis, caus-ng the release of catecholamine andther vasoconstrictors that lead to fetalypoxia or fetal growth restriction andredispose to induced preterm or pro-oke the release of prostaglandins con-ributing to preterm labor. Nevertheless,ccording to McLean et al,20 besidestressors, there are effect modifiers likeersonal dispositions (coping behaviorsnd responses, perceived control of situ-tions) and social support and networks,nd these factors may interfere with theffect of violence on pregnancy outcome.
rm deliveryR (95% CI) Adjusted OR (95% CI)a
..................................................................................................................
..................................................................................................................
..................................................................................................................
1..................................................................................................................
59-5.33) 3.14 (2.00-4.93)..................................................................................................................
..................................................................................................................
1..................................................................................................................
04-5.65) 2.97 (1.72-5.12)..................................................................................................................
03-6.89) 3.06 (1.50-6.24)..................................................................................................................
22-8.36) 3.75 (1.80-7.81)..................................................................................................................
..................................................................................................................
1..................................................................................................................
04-5.17) 2.84 (1.68-4.80)..................................................................................................................
66-7.30) 3.69 (2.03-6.72)..................................................................................................................
..................................................................................................................
1..................................................................................................................
43-5.21) 2.98 (1.86-4.76)..................................................................................................................
99-11.92) 4.59 (1.74-12.09)..................................................................................................................
atal care, parity, tobacco smoking, alcohol consumption,
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ot been adequately investigated areigh physical demanding activity, sexu-lly transmitted diseases, and nutritionaleprivation.We have found that victims of violence
uring pregnancy reported vaginalleeding in every pregnancy trimesterore frequently than nonabusedomen. These findings favor the hy-othesis that choriodecidual hemor-hage and abruption placenta are mech-nisms through which physical abuseuring pregnancy may increase the riskf preterm delivery. It is commonly ac-epted that intentionally inflicted ab-ominal trauma may lead directly to pla-ental dysfunction. However, vaginalleeding may be a sign of threatenedbortion or preterm labor resulting fromnother causal pathway. Moreover, inur study, too few women referred directrauma to the abdominal area duringregnancy.It has been supposed that the association
etween physical abuse and preterm birthould partially be explained by an in-reased frequency of pregnancy complica-ions, such as preeclampsia and fetalrowth restriction among abused preg-ant women. In our study, we have foundsignificantly higher prevalence of small-
or-gestational-age, but not preeclampsiamong abused women. A lower prevalencef gestational hypertension among abusedomen may be explained by less antenatal
are use and gestational hypertensionnderdiagnosis.We also have found an association be-
ween physical abuse and preterm deliv-ry when abuse exposure only occurredefore pregnancy. This finding supportshe presence of mechanisms other thanirect maternal physical trauma. The ex-erience of violence before pregnancyay result in posttraumatic stress, whichay lead to preterm delivery.In this study, intimate partners repre-
ented the largest single category of perpe-rators of violence against pregnantomen, but preterm risk was also in-
reased among women battered by othershan intimate partners, usually the father.
e may hypothesize that violence inflictedy relatives other than an intimate partneray happen in a context of high depen-
ency and psychosocial stress. M
We used the Abuse Assessment Screenecause its reliability and validity havelready been established and it is easy todministrate. This is also the most com-only used research tool to measure vi-
lence in hospital samples. Bias in expo-ure status ascertainment cannot bexcluded in our study. Although the usef structured questionnaires by trainedtaff significantly improves detectionate,21 it is still possible that domestic vi-lence has been underidentified givenhe reluctance of women to report it.owever, if a nondifferential bias had
ccurred, the true association wouldven be higher than the reported one. Al-hough, in data analysis, we have madefforts to control for all confounding fac-ors, the possibility of residual con-ounding still exists, but it is unlikely toe relevant given the magnitude of thebserved effect even after adjustment.The main strengths of this study are
ts large sample size, the high partici-ation rate; the inclusion of women
rom virtually all social and economictrata and a broad range of pregnancynd delivery risk profiles. Assessmentf violence exposure took place withuaranteed privacy, through face-to-ace interviews that used highly trainedersonnel. Evaluation and control forany potential confounding factors,
ncluding smoking, alcohol intake, andllicit drug abuse; with accurate infor-
ation on gestational age and preg-ancy complications were essential toata quality analysis. Although thetudy setting was a public maternity ofgeneral university hospital, the exter-al validity of the results can be in-
erred because more than 90% of deliv-ries occur in public hospitals.
In Portugal, like in many other devel-ped countries, pregnant women are notoutinely screened for domestic vio-ence. Besides uncertainties in the causalathways, it seems to be consensual thatealth professionals should recognizehysical abuse as a risk factor for pretermelivery and inquire pregnant womenbout it. f
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