Physical Abuse During Pregnancy

Fact sheet
February 2004

Health Surveillance and Epidemiology Division at Health Canada's Public Health Agency of Canada has been working to establish the Canadian Perinatal Surveillance System (CPSS). The development of the CPSS is guided by a Steering Committee comprising expert representatives of health professional organizations, consumer and advocacy groups, and the provincial and territorial governments, as well as Canadian and international specialists in perinatal health and epidemiology. The CPSS is part of Health Canada's efforts to strengthen Canada's national health surveillance capacity. There are three main components to the CPSS: collection of data related to perinatal health, analysis and interpretation of these data, and response. The aim is to acquire data on all recognized pregnancies, regardless of their outcome: abortion, ectopic pregnancy, stillbirth or live birth. If the pregnancy results in a live birth, the long-term plans for the CPSS include surveillance of the infant's health during the first year of life. One of the CPSS's response vehicles is the fact sheet, for which the objective is to disseminate perinatal health information to a broad audience of interested persons.  Members of the CPSS Steering Committee review all CPSS fact sheets before their publication.

Introduction

Abuse of women during pregnancy is a health problem that is receiving increased attention in both research and clinical practice. The Canadian Perinatal Surveillance System (CPSS) has identified the proportion of pregnant women reporting physical abuse as an important perinatal health indicator.¹ Physical abuse during pregnancy has been associated with adverse maternal and fetal health outcomes. A better understanding of the epidemiology of physical abuse during pregnancy, including its frequency, risk factors, adverse maternal conditions and birth outcomes, could have important clinical and public health implications.² Early identification and intervention to prevent abuse of pregnant women may reduce these adverse outcomes. 

This fact sheet presents information on the frequency, risk factors and clinical outcomes of physical abuse during pregnancy. While other forms of abuse during pregnancy exist, they are less well documented than physical abuse.

Definitions of key terms 

Violence - measures of violence in the 1993 Violence Against Women Survey were restricted to the Criminal Code definitions of assault and sexual assault in order to capture violence as it is legally understood.³ Violence by marital partners was measured on the basis of a series of violent acts similar to those contained in the Conflict Tactics Scale (CTS).⁴ 

Physical abuse - physical abuse can include, but is not limited to, kicking, pushing, shoving, throwing, grabbing, biting, choking, slapping, punching and hitting. Physical abuse also includes the use of a weapon or other object to threaten or injure another person, and it may result in death.^{3, 5-8} 

Preterm birth - birth at a gestational age of < 37 completed weeks (< 259 days). 

Low birth weight - a birth weight < 2500 grams. 

Adverse pregnancy outcomes - negative fetal health or maternal physical or mental health outcomes as a result of abuse during pregnancy. 

Epidemiology of physical abuse during pregnancy 

The frequency of abuse during pregnancy is equal to or greater than that of other complications of pregnancy that are major foci of prenatal care.⁹ 

In the 1993 Violence Against Women Survey, 12,300 Canadian women > 18 years of age were randomly selected and interviewed by telephone about their experiences of violence. The primary objective of this nationwide survey was to provide reliable estimates of the nature and extent of male violence against women in Canada. Overall, the survey found that of those women who had ever been married or had lived with a man in a common-law relationship, 29% reported having been physically or sexually abused by their partner at some point during the relationship. Twenty one percent of these women had been assaulted by their partners during pregnancy.³ Forty percent of the women who were abused during pregnancy reported that the abuse began during pregnancy.¹⁰ Women abused during pregnancy were four times as likely as other abused women to report having experienced very serious violence, including being beaten up, choked, threatened with a gun/knife or sexually assaulted.¹¹ Of the women who were abused during pregnancy, approximately 18% reported that they had suffered a miscarriage or other internal injuries as a result of the abuse.¹¹ 

Two Canadian studies have estimated the prevalence of physical abuse during pregnancy to be 5.7% and 6.6%.^7,8 The sample in the first study consisted of pregnant women attending a publicly funded, community-based health program in Saskatoon;⁷ in the second, by Stewart and Cecutti, the women surveyed were receiving prenatal care from family physicians and obstetricians working in either community settings or university teaching hospitals in Toronto.⁸ The rates reported in these two studies are similar to rates reported from other countries, including the United States,¹² South Africa¹³ and Sweden.¹⁴ 

Stewart and Cecutti's results showed that among those physically abused during pregnancy, the first episode of physical abuse occurred during the pregnancy in 14% of cases, 86% reporting previous abuse. In addition, 64% of the abused women reported increased abuse during pregnancy.⁸ Subsequently, Stewart found that 95% of women who were physically abused in the first trimester of their pregnancy were also physically abused in the three-month period after delivery.¹⁵ 

The most common body parts affected by physical abuse during pregnancy appear to be the head, neck and abdominal region.^16,17 Stewart and Cecutti found that the most common area struck during pregnancy was the abdomen (63.9%), followed in frequency by the buttocks (13.9%), head and neck (11.1%), and extremities (11.1%). Sixty-seven percent of the women were struck on more than one body part.⁸ 

Risk factors and outcomes 

There has been limited investigation of the risk factors for physical abuse during pregnancy and the maternal and fetal health outcomes associated with it. Stewart and Cecutti⁸ and others^16,18 found that a past history of abuse is one of the strongest predictors of abuse in pregnancy. Stewart and Cecutti identified other risk factors, including social instability (young, unmarried, failed to complete high school, unemployed and having an unplanned pregnancy); an unhealthy lifestyle (including unhealthy diet, alcohol use, illicit drug use and emotional problems); and physical and psychological health problems (including prescription drug use). As well, studies in the United States report that physical abuse during pregnancy is associated with delayed entry into or inadequate prenatal care.^19-22

In Canada, the 1999 General Social Survey (GSS) reported that the risk of spousal violence against women in general is higher among women who are younger, are living in common- law relationships, have a lower household income, have a partner who drinks heavily and have a partner who was exposed to violence against his mother in his childhood.²³ Greater understanding of the risk and protective factors for physical abuse during pregnancy may allow targeting of interventions and prevention strategies.²⁴ 

A review of the literature by Peterson et al found that for the fetus, severe blunt trauma to a maternal abdomen has been shown to lead to spontaneous abortion, fetal death, placental abruption, preterm labour and delivery, and fetal injuries, such as skull fractures, intracranial hemorrhage and bone fractures.²⁴ For the woman, potential adverse pregnancy outcomes include rupture of the uterus, spleen, liver and diaphragm.²⁴ 

In some studies of low birth weight and physical abuse during pregnancy, preterm birth and low birth weight have not been described as separate outcomes. It has been suggested that direct mechanisms, such as trauma to the pregnant abdomen, could lead to preterm labour.²⁵ In addition, indirect mechanisms found in the abusive environment could be associated with low birth weight, even at term. Examples are the use of nicotine or alcohol, low socio-economic status, poor maternal weight gain, stress and lack of social support.⁸ 

Screening practices and tools 

It is important that health care providers be knowledgeable about and screen for abuse in all obstetric patients. The Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists and the American Medical Association recommend that screening for abuse during pregnancy should be a routine part of prenatal care.^26-28 An awareness of the frequency and risk factors may help caregivers and health professionals in their approach to the history taking and physical examination of pregnant women in their care. For those who wish to explore this issue further, there are many abuse screening tools available to health care providers. However, the optimal method of screening for abuse during pregnancy remains uncertain. Examples of possible tools are as follows: 

• Index of Spousal Abuse (ISA)²⁹ 
• Abuse Assessment Screen (AAS)²¹ 
• WAST (Woman Abuse Screening Tool).³⁰ The WAST has been incorporated into the Antenatal Psychosocial Health Assessment (ALPHA) form.^31,32 
• Partner Violence Screen (PVS)³³ 

Data limitations 

Canadian data on physical abuse during pregnancy are limited. Furthermore, there is no standard definition of physical abuse, therefore comparing international and regional study findings is challenging. The Violence Against Women Survey is a useful national data source for information on the frequency of violence in pregnancy, but it does not provide information on clinical outcomes. Additionally, incorrect recall is a concern, as pregnancy- related questions can correspond to events several years or months before the interview. Women may also hesitate to report experiences of violence to survey interviewers because of shame or embarrassment.³⁴ 

The Canadian Perinatal Surveillance System (CPSS), Health Canada, is designing and implementing a Maternity Experiences Survey that will document Canadian women's knowledge, experiences and practices during pregnancy, birth and the early postpartum months as well as their perceptions of perinatal care. This survey will be an integral component of national perinatal health surveillance and will provide data for monitoring important perinatal health indicators, such as abuse during pregnancy.

Summary 

Evidence indicates that, in some cases, physical abuse may be initiated when a woman becomes pregnant, but in most cases it is a continuation of physical abuse that began before pregnancy. Overall, the literature indicates that severe physical abuse of the pregnant woman can lead directly and indirectly to adverse maternal and fetal health outcomes. Further surveillance and research are needed to enhance our understanding of physical abuse during pregnancy and the mechanisms through which it affects pregnancy outcomes.

For further information 

Women in abusive situations are encouraged to seek help and support from care providers in hospitals, community/ public health agencies, women's health clinics, mental health agencies and social service agencies. 

For health professional guidelines on screening for violence during pregnancy, please refer to the following: 

Society of Obstetricians and Gynaecologists of Canada. Healthy Beginnings: Guidelines For Care During Pregnancy and Childbirth. Clinical Practice Guidelines Policy Statement, No.71, 1998. http://sogc.org/SOGCnet/sogc_docs/common/guide/pdfs/healthybegeng.pdf 

Society of Obstetricians and Gynaecologists of Canada Violence Against Women. Clinical Practice Guidelines Policy Statement, No.46, 1996. http://sogc.org/SOGCnet/sogc_docs/common/guide/pdfs/ps46.pdf 

American College of Obstetricians & Gynecologists. Domestic Violence. Educational Bulletin, No.257, 1999. 

The College of Family Physicians of Canada. Discussion paper January 28, 2000. The Effect of Domestic Violence on Pregnancy and Labour. Commissioned by the CFPC's Maternity and Newborn Care Committee. Prepared by Lent B, Morris P and Rechner S. http://www.cfpc.ca/programs/patcare/maternity/matviolence.asp 

For other fact sheets, for information on the CPSS, or to be added to the CPSS mailing list, please contact 

The Maternal and Infant Health Section
Health Surveillance & Epidemiology Division
Centre for Healthy Human Development
Public Health Agency of Canada
Health Canada
Jeanne Mance Building #19, 10th Floor, A.L. 1910C
Tunney's Pasture
Ottawa, Ontario  K1A 0K9
Tel: (613) 941-2395
Fax: (613) 941-9927
e-mail: cpss@hc-sc.gc.ca

For further information on violence and pregnancy, please contact 

National Clearinghouse on Family Violence
Family Violence Prevention Unit
Healthy Communities Division
Centre for Healthy Human Development
Public Health Agency of Canada
Health Canada
7th Floor, Jeanne Mance Bldg
Tunney's Pasture, A.L. 1907D1
Ottawa, Ontario  K1A 1B4
Tel: 1-800-267-1291 or (613) 957-2938
Fax: (613) 941-8930

Bureau of Women's Health and Gender Analysis
4th Floor, Jeanne Mance Building
200 Eglantine Driveway
Address Locator: 1904C
Tunney's Pasture
Ottawa, ON
K1A 0K9
e-mail: women_femmes@hc-sc.gc.ca

References

1. Health Canada. Perinatal Health Indicators for Canada: A Resource Manual.Ottawa: Minister of Public Works and Government Services Canada, 2000.

2. Cokkinides VE, Coker AL, Sanderson M, Addy C, Bethea L. Physical violence during pregnancy: maternal complications and birth outcomes. Obstet Gynecol 1999;93(5):661-6.

3. Statistics Canada. The Violence Against Women Survey. The Daily, catalogue number 11-001-XIE, Nov 18, 1993.

4. Straus MA, Gelles RJ. Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families. New Jersey: Transaction Publishers, 1990.

5. Health Canada. A Handbook for Health and Social Service Professionals Responding to Abuse During Pregnancy. Prepared by Jamieson, Beals, Lalonde and Associates, Inc. Ottawa: Minister of Public Works and Government Services Canada, 1999.

6. National Clearinghouse on Family Violence. Wife Abuse: Information from the National Clearinghouse on Family Violence. Prepared by Linda Macleod. Ottawa: Health Canada, 1995. 

7. Muhajarine N, D'Arcy C. Physical abuse during pregnancy: prevalence and risk factors. Can Med Assoc J 1999;160(7):1007-11. 

8. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc J 1993;149(9):1257-63. 

9. Campbell JC. Addressing battering during pregnancy: reducing low birth weight and ongoing abuse. Semin Perinatol 1995;19(4):301-6. 

10. Statistics Canada. Violence Against Women Survey: Survey Highlights 1993. Shelf Tables 1-25. 1993. 

11. Johnson H. Dangerous Domains: Violence Against Women in Canada. Scarborough: Nelson Canada, 1996. 

12. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA 1996;275(24):1915-20. 

13. Jewkes R, Penn-Kekana L, Levin J, Ratsaka M, Schrieber M. "He must give me money, he musn't beat me": Violence Against Women in Three South African Provinces. Pretoria (South Africa): CERSA (Women's Health), Medical Research Council, 1999. 

14. Hedin LW, Grimstad H, Möller, A, Schei B, Janson PO. Prevalence of physical and sexual abuse before and during pregnancy among Swedish couples. Acta Obstet Gynecol Scand 1999;78(4):310-15. 

15. Stewart DE. Incidence of postpartum abuse in women with a history of abuse during pregnancy. Can Med Assoc J 1994;151(11);1601-04. 

16. McFarlane J. Abuse during pregnancy: the horror and the hope. AWHONNS Clin Issues Perinat Womens Health Nurs 1993;4(3):350-62. 

17. Purwar MB, Jeyaseelan L, Varhadpande U, Motghare V, Pimplakute S. Survey of physical abuse during pregnancy GMCH, Nagpur, India. J Obstet Gynaecol Res 1999;25(3):165-71. 

18. Campbell JC, Oliver C, Bullock L. Why battering during pregnancy? AWHONNS Clin Issues Perinat Womens Health Nurs 1993;4(3):343-9. 

19. Dietz PM, Gazmararian JA, Goodwin MM, Bruce FC, Johnson CH, Rochat RW. Delayed entry into prenatal care: effect of physical violence. Obstet Gynecol 1997;90:221-4. 

20. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and birth weight in adults and teenage women. Obstet Gynecol 1994;84:323-8. 

21. 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. 

22. Campbell JC, Poland ML, Waller JB, Ager J. Correlates of battering during pregnancy. Res Nurs Health 1992;15:219-26. 

23. Pottie Bunge V, Locke D (eds.). Family Violence in Canada: a Statistical Profile 2000. Ottawa: Statistics Canada, Canadian Centre for Justice Statistics. Catalogue. 85-224-X1E. 

24. Petersen R, Gazmararian J, Spitz A, Rowley D et al. Violence and adverse pregnancy outcomes: a review of the literature and directions for further research. Am J Prev Med 1997;13(5):366-73. 

25. Newberger EH, Barkan SE, Lieberman ES, McCormick MC, Yllo K, Gary LT et al. Abuse of pregnant women and adverse birth outcomes: current knowledge and implications for practice. JAMA 1992;267:2370-3. 

26. Society of Obstetricians and Gynaecologists of Canada (SOGC). Healthy Beginnings: Guidelines for Care During Pregnancy and Childbirth. Clinical Practice Guidelines Policy Statement No.71, 1998. 

27. Jones RF 3^rd, Horan DL. The American College of Obstetricians and Gynecologists: a decade of responding to violence against women. Int J Gynaecol Obstet 1997;58:43-50. 

28. American Medical Association. Diagnostic and Treatment Guidelines on Domestic Violence. Chicago, Il: American Medical Association, 1992. 

29. Hudson WW, McIntosh SR. The assessment of spouse abuse: two quantifiable dimensions. J Marriage Fam 1981;43:873-88. 

30. Brown JB, Lent B, Brett PJ, Sas G, Pederson LL. Development of the woman abuse screening tool for use in family practice. Fam Med 1996;28(6):422-8. 

31. Midmer D, Biringer A, Carroll JC, Reid AJ, Wilson L, Stewart D, Tate M, Chalmers B. A Reference Guide for Providers: The ALPHA Form - Antenatal Psychosocial Health Assessment Form, 2^nd ed. Toronto: University of Toronto, Faculty of Medicine Department of Family and Community Medicine, 1996. 

32. Reid AJ, Biringer A, Carroll JD, Midmer D, Wilson LM, Chalmers B, Stewart DE. Using the ALPHA form in practice to assess antenatal psychosocial health. Can Med Assoc J 1998;159(6):677-84.

33. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277(17):1357-61. 

34. Smith MD. Enhancing the quality of survey data on violence against women: a feminist approach. Gend Soc 1994;8(1):109-27.