Abstract
The aim of this study was to determine if the effects of intimate partner violence (IPV) in the previous 12 months (current IPV) on newborn’s health, pregnancy outcomes and couple’s reproductive behaviours were different for postpartum (PP) women as compared to women who had undergone an elective abortion (EA) in Trieste (Italy). This study is part of an unmatched case–control study. The major findings are that current IPV was positively associated with previous stillbirth among both groups of women, but the association was only marginally significant. Among EA women only, current IPV was significantly associated with previous miscarriages (adjusted odds ratio, 2.41; 95 %CI, 1.13–5.14). In both groups of women, current IPV was associated with a lack of joint couple decision making about contraception; however, the magnitude of this effect was higher among PP women. This study reveals that IPV was associated with poor obstetrical history among both groups of women. But the associations of current IPV with previous EA and couple reproductive behaviours were stronger among PP women.
Keywords: Domestic violence, Induced abortion, Spontaneous abortion, Stillbirth, Contraceptive behaviours
Introduction
Violence against women by male intimate partners (IPV) is recognised as one of the most common forms of gender-based violence and represents a significant public health concern. A recent review of studies examining the prevalence of physical domestic abuse before or during pregnancy in developing countries reported estimated prevalence that range from 3.5 % to 24.5 %.1 Studies undertaken in Europe have shown a lower prevalence (1.3–5.8 %).2–7 The reproductive years represent a particularly vulnerable period for women regarding susceptibility to potential health hazards, both for her own health (including injuries, unwanted pregnancies, and other sexual and reproductive health problems) and for the development of the foetus.
Moreover, recent evidence suggests that abused women suffer from compromised decision making regarding contraceptive use and family planning, and have little control in their reproductive choices.8–11 IPV affects women’s reproductive lives when men manipulate contraception and force sex. Violent partners may use tactics to get women pregnant; then, they may stop them from having an abortion or, conversely, force them to undergo one.11,12 However, the relationship between IPV, including physical and psychological violence, and women’s ability to control their fertility has not been adequately explored; especially understudied is the question whether there are any differences in these relationships between women who continue their pregnancy and those who terminate it.
Furthermore, IPV prior to or during the pregnancy is associated with adverse outcomes related to pregnancy (preterm labour, hypertension, oedema, vaginal bleeding, placental problems, premature rupture of membranes, caesarean delivery and hospitalisation not associated with delivery);13,14 as well as to foetal development and newborn health (miscarriage, premature birth, low birth weight, abruptio placentae, chorioamnionitis, neonatal death, etc.).13–20
Women who have an elective abortion (EA women) tend to be different from those who continue their pregnancy (postpartum (PP) women): they are more often poorly educated, without a job, without a stable relationship and at the extremes of what are usually considered the ‘appropriate’ reproductive ages in their societies (very young and older women).14–16,21–24 Moreover, several studies have shown that they are also more likely to experience IPV.12,20,24,25
Until now, no one has tackled the issue of whether the impact of IPV on reproductive health is similar in these two groups of women. Given that EA may be associated with other social and economic problems,14–16,21–24 these problems may compound or interact with the effects of IPV in these women, resulting in worse outcomes. On the other hand, it is possible that PP women may suffer more adverse health effects of IPV, especially if they were forced to go forward with the pregnancy by a violent partner.11 If the effects of IPV on reproductive health are more pronounced in one group as opposed to the other, it may make sense to tailor the timing and locations of IPV screening and interventions specifically for each group.
The aim of this study was to determine if the associations of IPV in the previous 12 months (current IPV) with newborn’s health, pregnancy outcomes and couple’s reproductive behaviours were different for postpartum women and women that underwent an elective abortion among patients in an Italian hospital.
Methods
Study Design and Setting
This study is part of an unmatched case–control study that was carried out in the only maternity hospital in Trieste (Italy), where the vast majority of all the births and abortions in the city take place.24 The cases comprised all consecutive elective abortions (445) occurring from March 2006 to July 2007, performed at less than 12 weeks of pregnancy (therefore excluding ‘therapeutic’ abortions, performed after the 12th week of pregnancy). The unmatched control group included all consecutive live births (438), occurring from March 2006 to August 2006 in the same hospital.
Data Collection
In Trieste Maternity Hospital, EAs are performed on an out-patient basis. The information was collected from women by means of an anonymous, self-administered questionnaire, during their stay in the maternity unit, 2 days after giving birth (controls), and in the afternoon after the EA (cases). All eligible women were approached in their hospital room at a time when they did not have visitors and asked to participate. The study was presented as research on the health of women during pregnancy and confidentiality of the responses was assured. Verbal informed consent was obtained from each participant, and each was given a letter explaining the purposes of the study and information about support resources for women (telephone hotlines, shelters, other health and social services). The response rate was 93 % among cases and 93 % among controls. The study was approved by the ethics committee of the hospital.
Measures
Dependent Variables
We included six indicators of newborn health and pregnancy outcomes (obstetrical history): previous stillbirth, previous miscarriage, previous elective abortion, hospital admission during pregnancy (all categorised as no/yes), and type of birth, categorised as spontaneous or not spontaneous. Furthermore, four indicators of couple reproductive behaviours were used. (1) All women were asked about couple decision making on contraception before the pregnancy. Possible answers included: contraception was (a) mostly decided by the woman, (b) mostly decided by the man, (c) decided together, (d) disagreed on, or (e) unnecessary because they wanted a baby. The question was recoded into two categories: “couple concurrency on contraception” included answers c and e, and the category “other” included all the other answers. (2) PP women were asked whether the pregnancy was (a) wanted in the same way by the woman and her partner, (b) unwanted in the same way, (c) she wanted it more, (d) he wanted it more, (e) she had almost forced the pregnancy on him, or (f) he had almost forced the pregnancy on her. The question was recoded into two categories: “Couple concurrence on pregnancy intendedness,” including the first answer; and “other,” including all the other responses. (3) EA women were asked if “it was the partner who wanted her to become pregnant” (i.e., the partner imposed the pregnancy on her). (4) In another question, EA women were asked if the partner had pressured her not to have an abortion, as an indicator of lack of partner support for the EA decision. The response categories for the last two questions were: no (reference) or yes.
Predictor Variable
Current IPV
We included three questions to evaluate psychological, physical and sexual violence in the previous 12 months,24 adapted from the Abuse Assessment Screen Questionnaire.26 Women who responded affirmatively to any of these three questions were considered to have ‘current IPV exposure’.
Statistical Analysis
After a descriptive analysis of the sample, multivariate procedures were carried out with the statistical software SPSS version 15.0. A logistic regression model was fitted for each outcome variable, separately in each of the sub-samples (EA and PP women). Odds ratios were adjusted (AOR) by socio-demographic factors (age, education and native country) and by having had previous life births, as previous studies have shown a relationship between newborn’s health, pregnancy outcomes, and women’s sexual health behaviours and these factors.15,16,21,23,24,27
Results
Description of the Sample
The distribution of current IPV, social characteristics, obstetrical factors and couple’s reproductive behaviours is shown in Table 1. The proportion of women reporting current IPV was higher among EA women (12.0 %) than among PP women (2.8 %). Concerning social characteristics, women seeking abortion were younger, had lower educational levels and were more likely to have been born outside of Italy than PP women. The percentage with previous live births was higher among PP women, while the percentage with previous EA was higher among EA women. Regarding couple reproductive behaviours, the percentage with lack of couple concurrence on contraception was higher among EA women.
Table 1.
Distribution of intimate partner violence in the previous 12 months, social characteristics, obstetrical factors and reproductive behaviours among postpartum women and women with an elective abortion
| Postpartum womena (n = 438) | Elective Abortion womena (n = 445) | ||||
|---|---|---|---|---|---|
| N | % | N | % | p valueb | |
| IPV previous 12 months | |||||
| No | 424 | 97.2 | 383 | 88.0 | <0.001 |
| Yes | 12 | 2.8 | 52 | 12.0 | |
| Social characteristics | |||||
| Age | |||||
| 36+ | 124 | 28.3 | 123 | 27.6 | <0.001 |
| 26–35 | 284 | 64.8 | 189 | 42.5 | |
| 13–25 | 30 | 6.8 | 133 | 29.9 | |
| Education | |||||
| University | 137 | 31.3 | 54 | 12.2 | <0.001 |
| Secondary | 199 | 45.4 | 198 | 44.7 | |
| Primary | 102 | 23.3 | 191 | 43.1 | |
| Native country | |||||
| Italy | 391 | 89.3 | 328 | 73.7 | <0.001 |
| Other | 47 | 10.7 | 117 | 26.3 | |
| Obstetrical factors | |||||
| Number of previous live births | |||||
| 0 | 257 | 59.1 | 299 | 67.6 | 0.008 |
| 1+ | 178 | 40.9 | 143 | 32.4 | |
| Number of previous stillbirths | |||||
| 0 | 424 | 97.5 | 430 | 97.9 | 0.636 |
| 1–2 | 11 | 2.5 | 9 | 2.1 | |
| Number of miscarriages | |||||
| 0 | 338 | 77.5 | 358 | 82.1 | 0.092 |
| 1–4 | 98 | 22.5 | 78 | 17.9 | |
| Number of previous elective abortions | |||||
| 0 | 426 | 97.9 | 304 | 69.4 | <0.001 |
| 1+ | 9 | 2.1 | 134 | 30.6 | |
| Type of current birth | |||||
| Spontaneous | 281 | 64.3 | |||
| No spontaneous | 156 | 35.7 | |||
| Hospital admission during pregnancy | |||||
| No | 320 | 73.1 | |||
| Yes | 118 | 26.9 | |||
| Reproductive decision making | |||||
| Couple concurrence on contraception | |||||
| No | 329 | 76.0 | 272 | 62.1 | <0.001 |
| Yes | 104 | 24.0 | 166 | 37.9 | |
| Couple concurrence on pregnancy | |||||
| No | 67 | 15.3 | |||
| Yes | 371 | 84.7 | |||
| The partner imposed the pregnancy on her | |||||
| No | 423 | 97.2 | |||
| Yes | 12 | 2.8 | |||
| Partner’s support for the EA decision | |||||
| No | 327 | 74.5 | |||
| Yes | 112 | 25.5 | |||
aTotal number differs because of missing data
bChi square
Current IPV and Obstetrical History
Current IPV was associated with a higher probability of previous stillbirth among both groups of women but the association was marginally significant (p = 0.056). Among EA women, current IPV was significantly associated with a higher probability of previous miscarriages (AOR, 2.41; 95 %CI, 1.13–5.14); among PP women, we found the same tendency. Among PP women, current IPV was significantly associated with previous elective abortion (AOR, 7.36; 95 %CI, 1.92–27.62; Table 2).
Table 2.
Associations between IPV in the previous 12 months and obstetrical factors
| Stillbirths | Miscarriages | Previous elective abortions | Hospital admission during current pregnancy | Type of current birth | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| % (N) | AOR (95 %IC)a | % (N) | AOR (95 %IC)a | % (N) | AOR (95 %IC)a | % (N) | AOR (95 %IC)a | % (N) | AOR (95 %IC)a | |
| Post-partum women | ||||||||||
| IPV previous 12 months | ||||||||||
| No | 2.1 (421) | 1 | 22.3 (422) | 1 | 11.4 (421) | 1 | 25.9 (424) | 1 | 35.2 (423) | 1 |
| Yes | 16.7 (12) | 6.04 (0.96–38.09) | 33.3 (12) | 2.21 (0.57–8.52) | 50.0 (12) | 7.36 (1.92–27.62) | 66.7 (12) | 5.81 (1.62–20.83) | 58.3 (12) | 3.26 (0.95–11.16) |
| p value | 0.002 | 0.055 | 0.250 | 0.124 | <0.001 | 0.003 | 0.002 | 0.007 | 0.100 | 0.060 |
| Elective abortion women | ||||||||||
| IPV previous 12 months | ||||||||||
| No | 1.6 (379) | 1 | 16.7 (377) | 1 | 30.1 (379) | 1 | ||||
| Yes | 5.9 (51) | 4.68 (0.96–22.79) | 28.0 (50) | 2.41 (1.13–5.14) | 33.3 (51) | 1.23 (0.62–2.43) | ||||
| p value | 0.044 | 0.056 | 0.051 | 0.023 | 0.635 | 0.557 | ||||
aAdjusted for age, education, native country and previous live births
Current IPV and the Current Pregnancy
In PP women, current IPV was also associated with increased risk of antenatal hospitalisation and of assisted delivery, but the association was marginally significant (p = 0.060; Table 2).
Current IPV and Couple’s Reproductive Decision-Making
Among both groups of women, current IPV was associated with a lack of couple concurrence on contraception, but the magnitude of the effect was higher among PP women. Among PP women, current IPV was significantly associated with lack of couple concurrency on the pregnancy. Among EA women, current IPV was associated with the pregnancy having been forced on the woman by the partner, and the man’s lack of support for the EA decision (Table 3).
Table 3.
Associations between IPV in the previous 12 months and reproductive decision making
| Lack of couple concurrence on contraception | Lack of couple concurrence on pregnancy | The partner imposed the pregnancy on her | Lack of partner support for the EA decision | |||||
|---|---|---|---|---|---|---|---|---|
| % (N) | AOR (95 %IC)a | % (N) | AOR (95 %IC)a | % (N) | AOR (95 %IC)a | % (N) | AOR (95 %IC)a | |
| Post-partum women | ||||||||
| IPV previous 12 months | ||||||||
| No | 23.2 (419) | 1 | 14.4 (421) | 1 | ||||
| Yes | 58.3 (12) | 6.24 (1.65–23.65) | 50.0 (12) | 7.95 (2.01–31.44) | ||||
| p value | 0.005 | 0.007 | 0.001 | 0.003 | ||||
| Elective abortion women | ||||||||
| IPV previous 12 months | ||||||||
| No | 35.4 (376) | 1 | 1.9 (377) | 1 | 22.3 (377) | 1 | ||
| Yes | 53.8 (52) | 2.39 (1.31–4.37) | 9.8 (51) | 4.95 (1.47–16.68) | 48.1 (52) | 3.60 (1.94–6.69) | ||
| p value | 0.010 | 0.005 | 0.001 | 0.010 | <0.001 | <0.001 | ||
aAdjusted for age, education, native country and previous live births
Discussion
The literature shows that women who have an EA tend to be different from those who continue their pregnancy, with respect to several socio-demographic characteristics (number of births, age, education, social class, etc.)14–16,21–24 and with respect to the experience of abuse.12,20,24,25 Consequently, the data analyses of this study on the impact of current IPV on pregnancy outcomes and couple’s reproductive behaviours were carried out independently for each of the sub-samples (EA and PP women). The study thus made it possible to further identify similarities and differences in these two sub-samples.
With respect to similarities, in both groups of women current IPV was positively associated with poor obstetrical history (previous stillbirths and miscarriages), notwithstanding the fact that Trieste (Italy) is a region situated in the European Union, with a good universal health system.28 On the other hand, this study found differences between the two groups of women. Generally, among PP women, the relationships between current IPV and poor obstetric history and lack of couple agreement on reproductive behaviour were stronger. PP women were more likely to report previous elective abortions than women with an EA. Moreover, while in both groups of women, current IPV had a negative relationship with joining couple contraceptive decision making, the magnitude of AOR was higher among PP women.
With respect to the associations of current IPV with previous stillbirths, our results are congruent with those found in the literature.15–18,23 In this study, current IPV (physical or psychological) was associated with previous stillbirth, but the association was marginally significant. It is important to take into account that in Italy, the rate of stillbirth was very low29 and also in this study, the prevalence of IPV (physical or psychological) around pregnancy was also relatively low (7.3 %). Thus, it is possible that this association would reach a statistical significance with a larger sample. Moreover, consistent with the findings of other authors,18,20,23 among women with an EA current IPV was significantly associated with previous miscarriages. The same trend was found among PP women. Only Nelson et al.30 did not find an association between physical violence and spontaneous abortion in a case–control study.
In our study, only among PP women was current IPV significantly associated with increased probability of previous EAs. This contrasts with the findings of other authors25,31 who found that a history of abuse was associated with induced abortion.
On the other hand, similar to other authors19,32,33 among PP women, we found that current IPV was associated with antenatal hospitalisation and of assisted delivery for the current pregnancy.13,14,23,34
The scientific literature has highlighted that victimised women face compromised decision making regarding contraceptive use and family planning.11,35,36 Our results are congruent with the literature: in both groups of women, we found a lack of joint couple decision making on contraception, but interestingly the magnitude of the effect on outcomes was higher among PP women. This could indicate that EA women with a violent partner may have more agency than PP women who are in the same situation.
Moreover, among PP women, current IPV was associated with a greater probability of a lack of couple concurrency on pregnancy intendedness. As found also by other authors9–11 in the EA group, abused women reported more often than non-abused women that the partner had imposed the pregnancy on them and that he did not support her in the abortion decision.
It is important to point out some possible limitations of this study. The cross-sectional nature of the data means that it is not conclusive as to the causal direction of the association of current IPV with obstetrical history. However, reverse causality (i.e., stillbirth causing previous or current IPV) does not seem plausible. Also, the consistency of our results with those of previous studies makes reverse causality an unlikely alternative explanation. Another possible shortcoming of our study is the fact that we did not control for medical or obstetrical factors when examining the association between current IPV and stillbirth. Women reporting any partner violence during pregnancy were significantly more likely than women without reported partner violence to have a poor obstetrical history. However, if some causes of stillbirth (e.g., placental abruption, intrauterine growth restriction) are pathways by which women who are victims of spousal abuse could lose their foetus, adjustment for these factors on the causal pathway would actually mask the relationship between IPV and stillbirth.
In conclusion, the current findings confirm that in an industrialised country with good perinatal health indicators,29 partner violence against woman is negatively associated with poor obstetrical history (previous stillbirth and miscarriage) among both groups of women (PP and EA). But surprisingly, the impact of current IPV on previous elective abortions and on and couple’s reproductive behaviours appears to be worse among PP women. Therefore, further research should be carried out in developed countries with low prevalence of partner abuse, combining qualitative and quantitative research, to explain these possible differences between the two groups of women.
Our results highlight the need to design interventions and prevention measures adapted to the different characteristics and life histories of EA and PP women. For many women, pregnancy is the first point to entry into the healthcare system and perhaps the first contact with a helping profession. Thus, it is a good opportunity for screening and intervening in IPV. It is crucial for maternity care and abortion providers to be trained in working effectively with patients who have experienced IPV. Training should be incorporated in all phases of professional education, from undergraduate curricula (e.g., medical or nursing school curriculum) to in-service training and continuing education.37–39
Acknowledgments
We would like to thank all the women who gave their time to complete the questionnaire and shared their experiences with us. Without them, this study would have not been possible. We gratefully acknowledge Laura Pomicino and Chiara Luchetta, the research assistants who collaborated in this study, working with dedication and commitment to ensure its successful completion.
Funding
The study was funded by a research grant from Istituto di Ricovero e Cura IRCCS “Burlo Garofolo”, Trieste (Italy). The analyses and the preparation of the manuscript were partially financed by two research grants from the “Fondo de Investigaciones Sanitarias” (Ministry of Health): FIS-FEDER PI06/1565, FIS-FEDER PS09/00523 and a specific action (PD08_010) of the CIBER en Epidemiología y Salud Pública (CIBERESP), Spain. Janet Molzan Turan’s work on this study was supported by NIH grant 5K01MH81777.
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