Timing of intimate partner violence and alcohol and cigarette use across the perinatal period among American Indian and Alaska Native women

Abstract

Background

Intimate partner violence (IPV) and substance use are closely linked and pose significant risks during the perinatal period. American Indian and Alaska Native (AI/AN) women experience disproportionately high rates of IPV and inequities related to perinatal substance use outcomes, yet research is limited regarding timing of IPV exposure and how it relates to perinatal substance use. This study examined associations between IPV exposure before and during pregnancy and patterns of alcohol use and cigarette smoking across the perinatal and postpartum periods among AI/AN women.

Methods

We analyzed pregnancy risk assessment monitoring system (PRAMS) data from 2016 to 2022 in a cross-sectional design. IPV exposure was categorized as occurring before pregnancy, during pregnancy, or both. Outcomes included alcohol use frequency, heavy drinking (≥ 8 drinks per week), and cigarette smoking before pregnancy, during pregnancy, and postpartum. Survey-weighted ordinal logistic and logistic regression models were used, adjusting for sociodemographic and pregnancy-related factors. Predicted probabilities were calculated. Exploratory analyses examined associations between partner race and IPV.

Results

AI/AN women reported higher prevalence of IPV before and during pregnancy (p < 0.001). In adjusted models, IPV before pregnancy was not associated with alcohol use frequency but was associated with higher odds of heavy drinking (aOR = 1.75, 95% CI 1.07–2.85). AI/AN women had higher odds of heavy drinking compared with Non-Hispanic White (NHW) women (aOR = 1.80, 95% CI 1.31–2.46), with the highest predicted probabilities observed among AI/AN women experiencing IPV (12.1%). IPV before pregnancy was also associated with higher odds of cigarette smoking before pregnancy, during late pregnancy, and postpartum (aORs 1.45–1.89), while IPV during pregnancy was associated with postpartum smoking (aOR = 2.82, 95% CI 1.23–6.44). Predicted probabilities indicated higher smoking across periods among those with IPV exposure, particularly among AI/AN women. In exploratory analyses, partner racial concordance was associated with lower odds of reported IPV among AI/AN women.

Conclusions

IPV exposure was associated with more severe and persistent patterns of perinatal substance use, with the highest predicted probabilities of heavy drinking and persistent smoking observed among AI/AN women experiencing IPV. These findings underscore the importance of trauma-informed, culturally grounded harm reduction approaches that address both IPV and substance use across the perinatal period. Efforts should be situated within the broader context of structural and historical inequities while recognizing Indigenous communities strengths and resilience.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12954-026-01506-x.

Introduction

American Indian and Alaska Native (AI/AN) women experience disproportionately high rates of intimate partner violence (IPV) in the United States, while also facing substantial inequities in maternal health and substance use outcomes. IPV encompasses a continuum of coercive and violent behaviors by a current or former intimate partner, including intimidation, physical and sexual assault, psychological abuse, and homicide [1]. Population-based estimates consistently show elevated IPV exposure among AI/AN women; for example, the 2010 National Intimate Partner and Sexual Violence Survey indicated that 46% of AI/AN women reported lifetime experience of rape, physical violence, or stalking compared with 36% of women in the general U.S. population [2]. More recent race and ethnicity specific estimates are limited, as such disparities are no longer reported by the Centers for Disease Control and Prevention (CDC) [3] and AI/AN individuals are frequently underrepresented in maternal health research, including studies examining IPV, substance use, and pregnancy-associated morbidity and mortality [2–4].

Elevated rates of IPV among AI/AN women must be understood within the context of historical and ongoing oppression. Historical trauma (HT) describes the cumulative and intergenerational impacts of colonization policies that disrupted kinship, cultural practices, and land stewardship such as boarding school policies and forced displacement [5, 6]. The effects of these policies have been associated with increased vulnerability to IPV, psychological distress, and high-risk alcohol use among AI/AN communities [7]. These historical and structural forces extend into contemporary inequities experienced by AI/AN communities, including poverty, discrimination, erosion of traditional support systems, and the devaluation of women [8–10].

Prior scholarship has noted that many Indigenous communities historically maintained relational systems in which women held important social, political, familial, and spiritual roles, with some tribal nations organized around matrilineal or matriarchal traditions [9, 11]. Colonization imposed patriarchal gender roles and Western family structures that disrupted these systems, contributing to shifts in power dynamics, diminished status of women, and increased vulnerability to gender-based violence [9, 11, 12]. Pregnancy may further heighten vulnerability to IPV through shifts in relational power dynamics and increased maternal demands during the perinatal period [13, 14]. These historical and ongoing experiences have contributed to distrust of formal institutions and may influence how IPV and substance use are reported, screened, and addressed within healthcare systems [10].

At the same time, Indigenous communities have long advanced culturally grounded, community-driven approaches to supporting maternal and family wellbeing that center relationality, cultural continuity, and collective care. These strengths include extended kinship networks, intergenerational caregiving practices, and community accountability structures that support women and families across the perinatal period [10, 12]. Indigenous women have historically held important roles as caregivers, knowledge keepers, and community leaders within many tribal communities, contributing to resilience and healing across generations [9, 12]. Interventions grounded in Indigenous values provide concrete examples of how cultural and community-based approaches to wellbeing are operationalized in practice. For example, the Family Spirit program, a culturally grounded home-visiting intervention delivered by Indigenous paraprofessionals, has been shown to improve maternal and child outcomes [15, 16]. Tribal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs similarly support culturally adapted, tribally implemented care, often integrating substance use and IPV-related services [17, 18]. Other family-strengthening initiatives, such as the Native American Fatherhood and Families Association’s “Fatherhood Is Sacred®” program, emphasize relational accountability and healthy relationships. Similarly, culturally grounded, family-based interventions, such as the Tiwahe Wicagwicayapi Program, have demonstrated reductions in intimate partner violence, alongside improvements of family wellbeing [19]. Together, these approaches highlight how Indigenous knowledge systems and community-defined practices actively promote resilience, healing, and prevention, underscoring the importance of centering Indigenous strengths alongside structural inequities.

Acknowledging structural roots of violence alongside Indigenous community strengths is essential for interpreting current patterns of IPV and substance use. The perinatal period for AI/AN women is particularly concerning given persistently high rates of pregnancy-associated mortality in the U.S. [20]. More broadly, IPV remains a major public health concern in the U.S., with approximately 1 in 3 women experiencing IPV in their lifetime [2]. Additionally, mortality during pregnancy and up to one year postpartum remains alarmingly high in the U.S., including both pregnancy-related deaths and unintentional or incidental causes of death [6, 21]. Recent work highlights homicide and substance-use–related mortality as contributors to pregnancy-associated deaths, underscoring the need for harm-reduction–oriented perinatal care [22–25]. Together, this framing foregrounds the relevance of timing (preconception, pregnancy, postpartum) and racial disparities in shaping maternal health.

IPV and substance use are also closely interconnected, with evidence showing a complex and reciprocal relationship. Survivors may use substances to cope with trauma from abuse [26], while substance use initiation or escalation can increase IPV risk [27–29]. Prior research also suggests that IPV may begin, increase in severity, or persist across pregnancy and postpartum periods [1, 30]. IPV exposure prior to pregnancy is strongly associated with IPV during pregnancy, suggesting that preconception IPV may represent an important marker of ongoing relational violence during the perinatal period [30, 31]. This intersection is particularly critical during pregnancy. Pregnant women with substance use disorders are more likely to report experiences of IPV [32, 33], with one study reporting nearly half of the participants experiencing pregnancy-related IPV [34]. Population-based analysis from the CDC Pregnancy Risk Assessment and Monitoring System (PRAMS) has further shown that perinatal IPV is associated with a higher likelihood of cigarette smoking before and during pregnancy, as well as reduced likelihood of cessation [35, 36]. Additional PRAMS studies have found that violence was more prevalent among women using substances [37]. Together, this literature supports a nuanced understanding of violence and substance use as mutually reinforcing patterns across the perinatal period.

Despite the broad recognition of IPV and substance use as drivers to pregnancy related morbidity and mortality, AI/AN communities remain underrepresented in the literature. Most population-based studies examining the relationship between IPV and substance use around the perinatal period do not include AI/AN individuals [4, 22], limiting the understanding of perinatal IPV-substance use dynamics in these communities. Critical gaps include understanding the timing of IPV exposure relative to pregnancy (preconception vs during pregnancy) and how IPV relates to patterns of alcohol and tobacco use across the perinatal period. While PRAMS analyses have examined prenatal alcohol use among AI/AN women and found regional differences by state and rurality [38], these studies did not evaluate IPV exposure or the timing of violence in relation to alcohol use patterns. Addressing these gaps is essential to inform culturally responsive harm reduction, screening, and prevention strategies for AI/AN communities.

Using population-based data from PRAMS, this study examines the relationship between IPV exposure before and during pregnancy and perinatal alcohol use and cigarette smoking across pregnancy and early postpartum periods among AI/AN women. Non-Hispanic White (NHW) respondents were included as a comparison group to contextualize patterns within broader population-level distributions, while recognizing that observed differences reflect structural inequities rather than inherent group differences. This study addresses a critical gap by examining how the timing of IPV exposure relates to the severity and persistence of substance use across the perinatal period. Clarifying how the timing of IPV exposure relates to substance use may help identify critical opportunities for early intervention and inform more effective, culturally responsive perinatal care strategies for AI/AN women.

Methods

Study design and data source

This study used a serial cross-sectional study of stratified, weighted data from the CDC PRAMS. PRAMS uses a sampling framework based on state-issued birth certificates to identify women who have recently given birth within the U.S., selecting participants approximately 2–6 months postpartum. The survey collects data on experiences across the pre-pregnancy, prenatal, and postpartum periods, in addition to information on obstetric history, infant health and development, substance use, and maternal stress. Each participating jurisdiction samples between 1000 and 3000 women annually, oversampling individuals from smaller sociodemographic populations, including racial and ethnic minorities, and assigns sample weights to responses to ensure representativeness of the jurisdiction’s demographics. All analyses were conducted using Stata 18.5 (StataCorp, College Station, TX). Further methodological details can be found in previous literature [39].

Study sample

For this study, the 41 states participating in the CDC’s Automated Research File (ARF) were used. Additionally, PRAMS data from Oklahoma was obtained, given the state’s substantial AI/AN population, which has one of the largest AI populations in the United States [40]. This aligns with the study’s focus on racial and ethnic disparities. PRAMS Phase 8 data from 2016 to 2022 was used. The analytic sample was limited to respondents who completed the PRAMS items assessing intimate partner violence in the 12 months prior to pregnancy and during pregnancy. PRAMS refers to respondents as “women,” as it does not collect gender identity beyond this term. This study received an exemption from the Yale University Institutional Review Board in 09/03/2025.

Measures

The two primary outcomes of the study were alcohol and cigarette use. Alcohol use was assessed with a screener (“Have you had any alcoholic drinks in the past 2 years?”) and if yes, followed by: “During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week?” Analyses used the 3-month item to classify frequency into ordered categories: none, < 1/week, 1–3/week, 4–7/week, 8–13/week, and ≥ 14/week. Additionally, we examined a binary heavy-drinking outcome (yes = 1, no = 0) defined as ≥ 8 drinks/week (combining the 8–13/week and ≥ 14/week categories).

Cigarette use was assessed at three timepoints and coded as binary indicators (smoked vs did not smoke): the three months before pregnancy, the last three months of pregnancy, and at the time of the postpartum survey. Respondents who reported any cigarette use in the past two years were asked, “During the 3 months before you got pregnant, how many cigarettes did you smoke on an average day?” Pre-pregnancy smoking was coded “yes = 1” if the reported number was > 0 and “no = 0” if the response was “I didn’t smoke then.” During-pregnancy smoking was based on, “In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day?” and coded “yes = 1” for values > 0 and “no = 0” for “I didn’t smoke then.” Postpartum smoking was based on, “How many cigarettes do you smoke on an average day now?” and coded “yes = 1” for values > 0 and “no = 0” for “I don’t smoke now.” Missing values were coded missing and excluded from the corresponding analysis.

IPV before pregnancy was assessed with: “In the 12 months before you got pregnant with your new baby, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way?” Responses were coded as binary outcome “yes = 1, no = 0” for IPV before pregnancy if the respondent selected “my husband or partner” or “my ex-husband or ex-partner.” IPV during pregnancy was assessed with the parallel item: “During your most recent pregnancy, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way?” and was coded as binary variable “yes = 1, no = 0” using the same partner/ex-partner criterion. If both periods were endorsed, a “pre- and during-pregnancy IPV” category was created. If multiple perpetrator types were selected on a question, IPV was considered present if any partner/ex-partner was indicated. Missing responses were excluded from the corresponding analysis.

Several covariates were included in our analyses, including maternal sociodemographic characteristics that were derived from birth certificate data. A race and ethnicity variable was created in accordance with federal guidelines for standardized reporting of race and ethnicity [37] and included AI/AN and NHW for both mother and father. Maternal age was categorized into 6 age groups (< 19 years, 20–24 years, 25–29 years, 30–34 years, 35–39 years, and 40 and older). Educational attainment was collapsed into less than high school diploma, high school graduate, some college, or college degree and above. Marital status was dichotomized as married or not. Pre-pregnancy insurance was divided into 6 categories (no insurance, Medicaid, private insurance, government insurance, Indian Health Service, and other/unknown). Income was categorized into 6 categories (< 20 k, 20,001-40 k, 40,001-60 k, 60,001-85 k, above 85 k, and not reported). Parity was included as a reproductive covariate given its potential association with both perinatal health and relationship context. Rural residence was included based on prior PRAMS research that showed differences in IPV in those AI/AN women who live in rural areas [41]. For descriptive purposes, participating jurisdictions were grouped into broader geographic regions (e.g., South, Southwest, Midwest, West Coast, Northeast, and Alaska) to characterize the geographic distribution of the sample and contextualize generalizability. Pre-pregnancy depression was included as a covariate as a marker of pre-existing psychosocial stress and mental health burden in the months preceding pregnancy, which may be associated with both relationship context and IPV exposure. Pre-pregnancy depression was assessed using a PRAMS item asking, “During the 3 months before you got pregnant with your new baby, did you have any of the following health conditions?” with depression listed as a response option. Responses were coded as yes (= 1) or no (= 0).

Statistical analysis

All analyses incorporated survey weights and accounted for the complex sampling design. Frequency of alcohol consumption was modeled using ordinal logistic regression. Heavy drinking and each smoking outcome were analyzed and modeled with logistic regression. The association between cigarette use at three distinct timepoints (pre-pregnancy, during pregnancy, postpartum) and IPV was evaluated using logistic regression where IPV at the preceding time point was the exposure. All models were adjusted for age, education, marital status, parity, income, rural residence, depression and pre-pregnancy insurance.

To contextualize the primary outcome analyses, additional models examined crude and adjusted associations between race and smoking, as well as between partner race and IPV, to assess the contribution of sociodemographic factors. Initial analysis included tested for interaction effects and subsequently examined whether partner race was associated with IPV. In a model restricted to AI/AN respondents, the primary exposure was partner race (AI/AN vs non-AI/AN); the outcome was any IPV reported in the 12 months before pregnancy or during pregnancy.

Results

Sample characteristics

Table 1 presents sample characteristics by race (AI/AN vs NHW). Compared with NHW women, AI/AN women had significantly higher prevalence of IPV before and during pregnancy, as well as higher reported use of alcohol and cigarettes across all perinatal periods. AI/AN respondents less frequently reported any pre-pregnancy health care visit (49.6% vs 74.6%); however, among those with health care contact, AI/AN respondents more frequently reported being asked whether someone was hurting them emotionally or physically (73.0% vs 50.3%). AI/AN women were significantly younger, more often unmarried, had lower educational attainment and household income, and more frequently resided in rural areas. Insurance coverage patterns also differed, with AI/AN women more frequently covered by Medicaid, Indian Health Service, or other public programs compared to NHW women. AI/AN women also had a significantly higher prevalence of self-reported pre-pregnancy depression. Geographic representation differed across groups, with substantial representation of AI/AN participants from Alaska, the South (primarily Oklahoma), the Midwest (including North Dakota, South Dakota, Minnesota, and Wisconsin), and the Southwest (primarily Arizona and New Mexico).

Table 1.

Sociodemographic characteristics, experiences of intimate partner violence, substance use patterns, and health care contact before and around pregnancy among Non-Hispanic White and American Indian/Alaska Native respondent

	NHW n (%)	AI/AN n (%)	Total (%)	p-value
Total N	104, 802 (91.7)	9480 (8.3)
IPV exposure*				< 0.001
None	104,131 (99.4)	9197 (97.6)	99.3
Before pregnancy only	281 (0.3)	97 (0.8)	0.3
During pregnancy only	85 (0.1)	42 (0.4)	0.1
Before and during pregnancy	305 (0.3)	144 (1.2)	0.3
Alcohol use frequency during the 3 months before pregnancy				< 0.001
None	11,495 (13.9)	1209 (20.8)	13.9
< 1/wk	31,011 (38.6)	2008 (35.6)	38.6
1–3 /wk	23,915 (29.6)	1381 (23.2)	29.6
4–7/wk	10,857 (13.2)	713 (12.7)	13.2
8–13/wk	2726 (3.3)	254 (4.5)	3.3
14+/wk	1153 (1.3)	211 (3.3)	1.4
Heavy alcohol use (≥ 8 drinks/week)				< 0.001
No	77,278 (95.3)	5311 (92.3)	95.3
Yes	3879 (4.7)	465 (7.7)	4.7
Commercial cigarette use				< 0.001
Before pregnancy	19,774 (18.9)	3095 (35.0)	19.1
During pregnancy	10,180 (9.2)	1971 (17.6)	9.3
Postpartum	13,028 (12.1)	2681 (23.2)	12.3
Age				< 0.001
< 19 yrs	2988 (2.8)	739 (8.8)	2.9
20–24	15,738 (15.7)	2205 (24.3)	15.8
25–29	30,120 (29.1)	2509 (32.9)	29.2
30–34	34,497 (33.1)	1839 (21.9)	33.0
35–39	16,976 (16.1)	858 (9.7)	16.1
40+	3351 (3.1)	179 (2.4)	3.1
Education				< 0.001
No diploma	6496 (6.6)	2125 (21.2)	6.8
HS graduate	20,390 (20.9)	3357 (37.4)	21.2
Some college	28,970 (26.2)	3078 (32.2)	26.2
College or more	48,429 (46.4)	854 (9.2)	45.8
Marital status (married)				< 0.001
No	27,521 (27.1)	6669 (68.9)	27.7
Yes	77,208 (72.9)	2797 (31.1)	72.3
Insurance during pregnancy				< 0.001
No Insurance	4980 (1.4)	455 (0.7)	1.4
Medicaid	23,630 (31.6)	3801 (74.5)	32.2
Private	64,254 (62.2)	944 (16.5)	61.6
Gov Insurance	5448 (2.9)	202 (1.6)	2.9
Indian Health Service	21 (0.0)	980 (5.6)	0.1
Other	5348 (1.8)	3005 (1.1)	1.8
Income				< 0.001
< 20,000 k	16,050 (15.7)	4047 (47.7)	16.1
20,001–40,000 K	16,269 (15.9)	1614 (21.8)	15.9
40,001–60,000 k	13,851 (13.4)	700(9.3)	13.3
60,001–85,000 k	13,934 (13.2)	426 (5.6)	13.1
above 85,000 k	34,859 (36.6)	473 (6.1)	36.2
not reported	5168 (5.3)	883 (9.5)	5.3
Rural location				< 0.001
Yes	26,227 (20.8)	4657 (49.8)	21.2
No	75,495 (79.2)	3277 (50.2)	21.2
Region				< 0.001
Northeast	23,489 (25.7)	93 (3.4)	25.4
South	25,627 (26.5)	1234 (24.4)	26.5
Midwest	28,108 (31.8)	3496 (23.1)	31.7
Southwest	15,835 (8.4)	939 (24.6)	8.7
West coast	9671 (7.2)	2186 (14.7)	7.3
Alaska	2075 (0.04)	1532 (9.8)	0.5
Parity				< 0.001
0	43,029 (40.1)	2,790 (30.6)	40.0
1	34,520 (34.0)	2,381 (26.5)	33.9
2+	27,029 (25.9)	4,282 (42.9)	26.1
Pre-pregnancy depression				< 0.001
Yes	18,858 (17.2)	2306 (20.2)	17.3
No	85,278 (82.8)	7371 (79.8)	83.7
Healthcare contact in the 12 months before pregnancy				< 0.001
≥ 1 healthcare visit
Yes	78,205 (75.9)	4701 (52.5)	75.6
No	26,597 (24.1)	4779 (47.5)	24.4
Asked about emotional or physical harm by a health care provider**				< 0.001
Yes	39,340 (48.0)	3431 (71.1)	48.3
No	38,865 (52.0)	1270 (28.9	51.7

Frequencies are presented as unweighted counts and weighted percentages to account for the complex PRAMS survey design

*Intimate partner violence reflects self-reported emotional or physical harm by a current or former partner in the 12 months before pregnancy and/or during pregnancy

**Items assessing whether a health care provider asked about emotional or physical harm were only administered to respondents reporting at least one health care visit in the 12 months before pregnancy; percentages are calculated among those with documented health care contact

Alcohol use outcomes

In adjusted models, IPV before pregnancy was not associated with the frequency of alcohol use in the three months before pregnancy (aOR = 1.13, 95% CI 0.80–1.61; Table 2). IPV before pregnancy was significantly associated with higher odds of heavy drinking (aOR = 1.75, 95% CI 1.07–2.85). The interaction between IPV and race was not significant; therefore, we presented main effects. AI/AN women had significantly higher odds of heavy drinking compared with NHW women (aOR = 1.80, 95% CI 1.31–2.46).

Table 2.

Adjusted associations between intimate partner violence timing and perinatal substance use outcomes

Outcome	Predictor	aOR	95% CI	p-value
Any alcohol use	IPV before pregnancy	1.13	0.80–1.61	0.489
	AI/AN vs. NHW	1.06	0.88–1.27	0.509
Heavy drinking	IPV before pregnancy	1.75	1.07–2.85	0.025
	AI/AN vs. NHW	1.80	1.31–2.46	< 0.001
Pre-pregnancy smoking	IPV before pregnancy	1.45	1.06–1.98	0.019
	AI/AN vs. NHW	0.72	0.63–0.82	< 0.001
Late pregnancy smoking	IPV before only	1.89	1.25–2.87	0.003
	IPV during only	1.91	0.82–4.45	0.135
	IPV before + during	1.41	0.91–2.18	0.127
	AI/AN vs. NHW	0.53	0.44–0.63	< 0.001
Postpartum smoking	IPV before only	1.78	1.20–2.65	0.005
	IPV during only	2.82	1.23–6.44	0.014
	IPV before + during	1.21	0.79–1.85	0.375
	AI/AN vs. NHW	0.61	0.52–0.70	< 0.001

Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) derived from survey-weighted regression models adjusted for sociodemographic and pregnancy-related covariates

Predicted probabilities indicated that heavy drinking was highest among AI/AN women with IPV exposure (12.1%), followed by NHW women with IPV exposure (7.7%). Among women without IPV, probabilities were 7.9% for AI/AN and 4.6% for NHW. Average marginal effects showed a small, non-significant increase in heavy drinking associated with IPV among NHW (3.1 percentage points; 95% CI − 0.3 to 6.5; p = 0.072) and AI/AN (4.2 percentage points; 95% CI − 2.8 to 11.2; p = 0.239) (Fig. 1).

Fig. 1.

Predicted probabilities of heavy alcohol use before pregnancy by race/ethnicity and intimate partner violence (IPV) exposure before pregnancy. Points represent adjusted predicted probabilities estimated from logistic regression models. Error bars indicate 95% confidence intervals. Heavy drinking was defined as ≥ 8 drinks per week in the three months before pregnancy

Cigarette use outcomes

Cigarette smoking differed by IPV exposure timing. In adjusted logistic regression models, IPV before pregnancy was associated with significantly higher odds of smoking before pregnancy (aOR = 1.45, 95% CI 1.06–1.98), during late pregnancy (aOR = 1.89, 95% CI 1.25–2.87), and postpartum (aOR = 1.78, 95% CI 1.20–2.65; Table 2). IPV during pregnancy alone was also associated with increased odds of postpartum smoking (aOR = 2.82, 95% CI 1.23–6.44). IPV before and during pregnancy was not significantly associated with smoking outcomes.

Predicted probabilities indicated that AI/AN women without IPV had smoking probabilities of 15.4% before pregnancy, 5.7% during late pregnancy, and 8.5% postpartum. With IPV exposure, probabilities among AI/AN women increased to 26.9% before pregnancy, 9.1–10.3% in late pregnancy, and 11.0–16.1% postpartum depending on timing. Among NHW women without IPV, predicted probabilities were 19.2% before pregnancy, 9.3% during late pregnancy, and 12.2% postpartum, compared with 24.0%, 14.4–14.5%, and 17.9–23.3% with IPV exposure (Fig. 2).

Fig. 2.

Predicted probabilities of cigarette smoking across the perinatal period by race/ethnicity and timing of intimate partner violence (IPV) exposure. Panel A shows predicted probabilities of smoking before pregnancy by IPV exposure before pregnancy. Panel B shows predicted probabilities of smoking during late pregnancy by IPV timing (none, before pregnancy only, during pregnancy only, or both before and during pregnancy). Panel C shows predicted probabilities of smoking postpartum by IPV timing. Points represent adjusted predicted probabilities from logistic regression models and error bars indicate 95% confidence intervals

Contextual analyses of race, smoking, and IPV

A sequence of covariate-adjusted models was used to examine how sociodemographic factors contributed to racial differences in pre-pregnancy smoking. In unadjusted models, AI/AN women had more than twice the odds of pre-pregnancy smoking compared with NHW women (OR = 2.32, 95% CI 2.14–2.52; Supplementary Table 1). However, this association was strongly attenuated when adjusting for individual covariates. Adjustment for education reduced the odds to 1.26 (95% CI 1.15–1.37), marital status to 1.17 (95% CI 1.07–1.29), and rural residence to 1.85 (95% CI 1.69–2.03). Income adjustment had the greatest impact, reducing the odds to 1.07 (95% CI 0.97–1.18), essentially eliminating the disparity. Adjustment for pre-pregnancy depression alone did not attenuate the unadjusted association (aOR = 2.34, 95% CI 2.15–2.54). In the fully adjusted models, AI/AN women had significantly lower odds of smoking compared with NHW women (aOR = 0.72, 95% CI 0.63–0.82).

Partner race and IPV

Partner race analyses among AI/AN women showed that having an AI/AN partner was associated with lower odds of IPV (aOR 0.44, 95% CI 0.29–0.66) compared with having a non-AI/AN partner. This association remained after adjustment for sociodemographic factors, including education, income, and insurance status.

Discussion

This study examined associations between IPV and substance use among AI/AN women, a population that experiences disproportionately high rates of violence. It is critical that these findings are interpreted within the context of historical and ongoing colonial oppression that AI/AN communities experience. Using population-based data from PRAMS, we assessed how IPV exposure at different time points surrounding pregnancy was associated with cigarette smoking and alcohol use. We observed significantly higher reported IPV exposure among AI/AN individuals compared to NHW individuals both prior to and during pregnancy. IPV exposure was associated with heavy drinking, rather than overall alcohol use frequency, and with persistent cigarette smoking across the perinatal period among AI/AN women.

Understanding the elevated IPV exposure observed in this study requires situating these findings within the historical and structural violence experienced by AI/AN people. AI/AN families and communities have been exposed to sustained forms of violence since the onset of colonization, including forced removal from ancestral lands, suppression of cultural practices, and the implementation of boarding schools [5, 6]. These colonial policies disrupted Indigenous kinship networks, parenting practices, and community-based systems of care, contributing to intergenerational trauma and elevated vulnerability to IPV. Research suggests that the boarding school era and related assimilationist policies undermined the transmission of Indigenous caregiving and relational knowledge, while exposing generations of children to neglect and abuse [42–44]. Among AI/AN women who experience IPV, childhood exposure to violence is common and has been associated with increased rates of adverse mental health outcomes and high-risk substance use in adulthood [45, 46]. These patterns reflect the enduring impacts of historical and structural violence in contemporary relationships.

At the same time, it is important to avoid deficit-based interpretations of these findings. Despite enduring the ongoing impacts of colonization, violence, and structural inequities, Indigenous women have demonstrated remarkable resilience through cultural continuity, caregiving, leadership, and community engagement [10–12]. Many AI/AN women draw upon extended kinship networks, cultural practices, spiritual traditions, and community relationships as sources of strength and healing [10–12]. Indigenous women have long served as caregivers, knowledge keepers, and leaders within their families and communities, and these strengths continue to support wellbeing across generations [9–12]. Recognizing these strengths is essential for understanding IPV within AI/AN communities and for developing prevention and intervention approaches that build upon existing sources of resilience rather than focusing solely on risk [10–12, 19].

In addition to historical trauma shaping IPV exposure, differences in healthcare contact and screening practices may influence opportunities for IPV identification and disclosure. Although AI/AN participants reported less frequent contact with a healthcare provider in the 12 months prior to pregnancy, they were more likely than NHW participants to report being asked about emotional or physical harm when accessing care. Greater screening may increase opportunities for IPV disclosure, whereas lower screening frequency may contribute to underidentification in some populations.

At the same time, experiences of discrimination, historical mistreatment, and culturally unsafe care may affect healthcare engagement and willingness to disclose sensitive experiences among AI/AN individuals. Prior research has identified trust, respectful patient-provider relationships, and culturally responsive care as important facilitators of healthcare engagement among Indigenous communities [47–49]. Thus, patterns of IPV disclosure likely reflect both opportunities for screening and broader experiences within healthcare systems.

Importantly, differences in screening alone are unlikely to explain the consistently elevated IPV prevalence observed among AI/AN women in this study. Prior research has documented substantial variation in IPV prevalence across Indigenous communities, reflecting differences in social conditions, cultural contexts, and methodological approaches to measurement [50–52]. Taken together, these findings suggest that higher observed IPV prevalence likely reflects a true underlying burden while also being influenced by factors that shape opportunities for disclosure.

IPV exposure was associated with persistent patterns of substance use among AI/AN women, particularly with respect to heavy alcohol use and cigarette smoking. Interpretation focused on predicted probabilities within racial groups (AI/AN and NHW), allowing characterization of absolute differences in substance use associated with IPV exposure. AI/AN women who reported IPV exposure prior to and/or during pregnancy consistently demonstrated higher levels of heavy drinking compared with those without IPV exposure, whereas associations with any alcohol use were not significant. IPV exposure was also associated with cigarette smoking across multiple time points. These findings highlight the importance of addressing substance use intensity and persistence, rather than focusing solely on cessation during pregnancy.

The observed associations have important implications for infant health and early development. Both prenatal cigarette smoking and heavy alcohol use have been associated with adverse birth and developmental outcomes, including preterm birth, low birth weight, fetal alcohol spectrum disorders, and infant neurodevelopmental risks [53, 54]. IPV exposure during pregnancy has additionally been associated with adverse infant outcomes, including poor fetal growth, neonatal complications, and disruptions in early caregiving environments [36]. The persistence of substance use observed among women experiencing IPV in this study therefore underscores the potential for compounded maternal and infant health disparities across the perinatal period.

Contextual analyses further indicated that observed racial disparities in pre-pregnancy smoking were substantially attenuated after adjustment for sociodemographic factors, particularly income. While AI/AN women initially had substantially higher odds of pre-pregnancy smoking compared with NHW women, these differences largely disappeared after accounting for socioeconomic factors, suggesting that structural inequities play a major role in shaping observed smoking disparities. In fully adjusted models, AI/AN women had lower odds of smoking compared with NHW women. Prior research has similarly found that socioeconomic factors such as income and education substantially explain observed smoking disparities between AI/AN and NHW populations [55]. These findings highlight the importance of avoiding deficit-based interpretations of substance use disparities among AI/AN populations and instead recognizing the role of structural determinants in shaping health behaviors.

Findings related to partner race should be interpreted within broader relational and structural contexts rather than as evidence of inherent differences. For example, until relatively recently, federally recognized tribes lacked criminal jurisdiction over non-Indigenous perpetrators, limiting accountability and contributing to increased vulnerability to violence by non-Indigenous partners [56]. Prior research has also documented high rates of violence perpetrated by non-Indigenous individuals against AI/AN people, underscoring the importance of interpreting partner characteristics within historical, social, and jurisdictional contexts [56]. Among AI/AN women, partner racial concordance may reflect a constellation of social, economic, and community-level factors that shape relationship dynamics and exposure to violence. Shared AI/AN identity may be associated with greater embeddedness in Indigenous communities, including access to extended kinship networks, cultural continuity, and community accountability structures that support relationship functioning [10]. In contrast, relationships involving non-AI/AN partners may differentially reflect exposure to structural stressors, social isolation, or reduced access to culturally grounded support, though these mechanisms cannot be directly assessed in the current data. These findings should not be interpreted as indicating that shared AI/AN racial identity between partners is inherently protective or that partner race is a causal determinant of IPV. Rather, partner race in this analysis likely functions as a proxy for unmeasured relational, social, and structural conditions, including community connectedness, cultural engagement, and broader socioeconomic context. Given the heterogeneity across AI/AN communities, these patterns may vary substantially across settings. Future research using community-engaged and qualitative approaches is needed to better understand how relationship context, cultural factors, and structural conditions interact to shape IPV risk among AI/AN women.

These findings are consistent with prior PRAMS-based analyses, demonstrating that women experiencing IPV are significantly more likely to smoke before and during pregnancy and are less likely to quit once pregnant [35]. By examining AI/AN women specifically and evaluating the timing of IPV exposure in relation to substance use patterns, this study extends this literature by highlighting racial disparities and contextual factors that may shape persistence of substance use across the perinatal period. While prior PRAMS analyses reported lower overall prevalence of pre-pregnancy alcohol use among AI/AN women compared to NHW women [38], the estimates observed in the current study differ, likely reflecting differences in states, years of data, and analytic sample restrictions. Importantly, our study extends this work by incorporating IPV exposure and modeling alcohol use severity across the perinatal period.

These results have important implications for harm reduction approaches to perinatal and postpartum care for AI/AN women. The observed associations between IPV exposure and more severe and persistent substance use suggest that substance use in this context may reflect adaptive responses to ongoing violence, trauma, and constrained structural conditions rather than isolated individual behaviors. Interventions that prioritize abstinence without addressing safety, relational context, or material conditions may therefore be insufficient and, in some cases, may exacerbate harm. In particular, abstinence-focused approaches implemented within systems that rely on monitoring and reporting of substance use during pregnancy may heighten risks associated with disclosure, including child welfare involvement, criminalization, and loss of autonomy, particularly within broader systems of family surveillance and separation [57, 58]. These findings also underscore the importance of culturally safe and trauma-informed systems of care that recognize the historical and ongoing harms experienced by AI/AN communities within medical and child welfare systems and support disclosure without increasing surveillance or punishment.

Harm reduction frameworks offer an alternative approach that prioritizes safety, trust, and incremental change, while recognizing the broader social and relational contexts in which substance use occurs [59]. Within prenatal and postpartum care settings, harm reduction approaches may include non-punitive substance use counseling, smoking cessation interventions such as nicotine replacement therapy when clinically appropriate, medications for substance use disorders, trauma-informed prenatal care, flexible treatment engagement, and integrated behavioral health and social support services [60]. For AI/AN communities, harm reduction must also be aligned with tribal sovereignty and culturally grounded models of care. This includes integrating IPV screening with safety planning, offering flexible and non-punitive substance use support across the perinatal period, and centering Indigenous knowledge systems, relational accountability, and community-defined pathways to wellness. Such approaches move beyond individual behavior change to address the intersecting structural and relational conditions that shape both violence exposure and substance use and are critical to improving perinatal health outcomes for AI/AN women.

This study has several strengths, including the use of a large, population-based dataset with standardized measures across multiple states, enabling robust, race-stratified analyses among AI/AN women, a population that is frequently underrepresented in maternal health research. The use of PRAMS data also allowed for the examination of IPV exposure and substance use across multiple time points spanning the preconception, pregnancy, and postpartum periods. In addition, the study distinguished IPV exposure before and during pregnancy, allowing for a more nuanced assessment of how the timing of violence relates to substance use patterns across the perinatal period. The inclusion of adjusted predicted probabilities further helped contextualize findings across racial groups and IPV exposure categories.

Several limitations should also be considered. First, cigarette and alcohol use were self-reported and may be subject to recall bias and social desirability bias, particularly in the postpartum period. Although we refer to “postpartum smoking,” the survey captures cigarette use in the prior three months, and respondents completed the survey between 2 and 6 months postpartum; therefore, some reported smoking classified as postpartum smoking may reflect cigarette use occurring during late pregnancy. Second, the IPV measure was limited to physical violence and did not capture emotional abuse, severity, or chronicity. As such, IPV prevalence and its associations with substance use may be underestimated. Third, while this study leverages a national sample of AI/AN women, substantial heterogeneity exists across tribal nations with respect to substance use patterns and IPV prevalence. Because PRAMS participation varies across jurisdictions, the AI/AN sample was disproportionately represented by several states with larger AI/AN populations, including Alaska, Oklahoma, North Dakota, South Dakota, New Mexico, Montana, and Washington. Therefore, these findings should not be interpreted as generalizable to all AI/AN communities. Fourth, findings related to partner racial concordance should be interpreted as exploratory, as partner race likely reflects unmeasured relational and structural factors, such as community connectedness, social support, and cultural engagement, that were not captured in the dataset. Finally, the cross-sectional design limits our ability to determine temporality or directionality between IPV exposure and substance use outcomes. Future research should incorporate longitudinal designs, more comprehensive IPV measurement, and community-engaged frameworks to better elucidate causal pathways and culturally specific factors influencing substance use in AI/AN women.

Conclusion

This study advances the understanding of the connection between IPV and perinatal substance use among AI/AN women using a large, population- based sample. Consistent with prior findings, AI/AN women experienced higher IPV before and during pregnancy compared to NHW women. Descriptive analyses demonstrated differences in alcohol and cigarette use patterns across the perinatal period; however, differences in smoking were substantially attenuated after accounting for sociodemographic factors, highlighting the role of broader social and structural conditions in observed disparities. For both groups, IPV before pregnancy was associated with heavier alcohol use and elevated odds of cigarette smoking across the preconception, pregnancy, and postpartum periods, with the strongest associations observed for smoking in late pregnancy and postpartum. Predicted probabilities further illustrate that AI/AN women experiencing IPV had the highest estimated probabilities of heavy drinking and persistent smoking, underscoring the compounded exposures that violence and substance use may pose across the perinatal timeline. These findings support the importance of trauma-informed, culturally responsive harm reduction strategies that integrate IPV screening, substance use support, and Indigenous community strengths to promote safety and wellbeing across the perinatal period.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

SG: Conceptualization, data curation, formal analysis, prepared all figures/tables, and drafting of the manuscript. MC: Formal analysis, methodology, and critical revision of the manuscript. AR: Conceptualization and critical revision of the manuscript for important intellectual content. C.S. critical revision of manuscript. KS: Critical revision of the manuscript for important intellectual content.

Funding

This study was funded by NIDA K12 DA033312, P50DA058619.

Data availability

The data that support the findings of this study are available from the Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS). Restrictions apply to the availability of these data, which were used under data use agreements with participating states and are therefore not publicly available. Data may be requested from the CDC PRAMS program and individual state PRAMS programs, subject to approval.

Code availability

All analyses were performed using Stata version 18 (StataCorp, College Station, TX). Custom Stata.do files used for data management and analysis are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Yale IRB exception. Not applicable.

Consent for publication

Oklahoma PRAMS provided consent.

Competing interests

Ariel Richer is a Guest Editor for the special issue at the Journal of Harm Reduction.