Domestic violence is an important problem in women’s health, with many complications and associated costs. It is estimated that up to 23% (range 0.9 to 23%) of pregnant women are affected by domestic violence,1–7 and such abuse is associated with unintended pregnancy,8 increased maternal depression, suicide attempts, and tobacco, alcohol, and drug abuse.9–13 Domestic violence may even escalate during pregnancy.8,14 However, the literature remains inconclusive and primarily consists of observational studies of pregnant or postpartum women without controls and studies looking at the consequences of violent behavior on pregnancies and neonatal outcomes.15 Pregnancies affected by domestic violence have an increased incidence of low maternal weight gain, anemia, infection, first/second trimester bleeding, late entry to care, preterm labor, low birth weight, and increased admissions to the neonatal intensive care unit.13,16–19 Homicide is one of the leading causes of pregnancy-associated death, commonly resulting from intimate partner violence.20
Pregnancy, with its regular schedule of prenatal visits, is a “window of opportunity” for domestic violence screening and intervention. It has been speculated that the incidence of domestic violence may be higher in the pregnant population and that pregnant women experience a heightened concern for their health as well as that of their unborn children.21,22 Risk factors for domestic violence include young age (younger than 19 years), low education (less than 12 years of standard education), and low socioeconomic status (Women, Infants and Children’s socioeconomic program criteria).21
The military environment possesses a unique set of circumstances and stressors that may directly affect family violence. These include periods of family separation, tensions between the demands of duty and the demands of family life, stress related to the military mission, frequent relocation, perceived dangers associated with military training and combat, as well as financial stressors.23–25 Although it has been suggested that the prevalence of domestic violence may be higher in a pregnant military population, this has not been studied. In studies comparing the nonpregnant military population with the civilian population, two studies have shown higher rates of physical spousal abuse in the military,26,27 whereas another study showed similar prevalence rates of abuse between Army and civilian samples after controlling for age and race.28 However, the abuse among military service members was more severe than in their civilian counterparts.28
We conducted a search of the following databases: PubMed MEDLINE 1966–present, BIOSIS 1969–2004, EMBASE 1974–present, PsychINFO 1967–present, Social Sciences Citation Index 2001–present, Social Work Abstracts 1977–present, Federal Research in Progress 1998–present, Dissertation Abstracts Online 2004–present, FirstSearch 1994–2004, HAPI 1985–2004, using the search terms: domestic abuse, domestic violence, military, pregnancy, pregnant, spouse abuse and veterans. We found no studies looking at the prevalence of domestic violence in a pregnant military population. This study was undertaken to estimate the prevalence of domestic violence and the factor or factors correlated with domestic violence in a pregnant military population.
MATERIALS AND METHODS
This investigation was approved by the Chief, Navy Bureau of Medicine and Surgery, Washington, DC, through the local institutional review board at Naval Medical Center Portsmouth, CIP#P07–002. We conducted an anonymous survey of pregnant women presenting to Naval Medical Center Portsmouth for initial prenatal care. A convenience sample of women presenting for initial prenatal care from January 2007 to March 2008 was screened for domestic violence using the Abuse Assessment Screen. The Abuse Assessment Screen is a validated, 5-item questionnaire that assesses physical, emotional, and sexual violence. The Abuse Assessment Screen was developed by the Nursing Research Consortium on Violence, with criterion-related validity established by comparing responses on the abuse assessment screen with responses to scores on the Conflict Tactics Scale, Index of Spouse Abuse, and the Danger Assessment Scale, instruments with established psychometric properties.29,30 The survey also included a series of 19 additional questions to assess risk factors and demographics. Individual participants classified their race/ethnicity by selecting from a series of options on the survey. Race and ethnicity may be significant risk factors for pregnancy-related violence; however, studies to date have been inconclusive and inconsistent.15
For safety reasons, special care was taken to administer the survey in a private setting, separate from spouse, significant others, family members, or friends.
Patients received an envelope containing the survey and a resource card with contact information for local and national organizations for battered women. Owing to the sensitive nature of domestic violence, a waiver of signed informed consent was obtained. Informed consent was implied when patients voluntarily completed the survey. Patients completed the survey, sealed the envelope, and placed it in a locked collection box. Those who did not wish to participate were instructed to place their blank survey in the envelope and return it to the collection box. The surveys remained sealed until the completion of data collection, at which point the surveys were reviewed as a group to maintain complete anonymity.
Answers to the Abuse Assessment Screen were used to estimate the incidence of domestic violence in a pregnant military population. Patients who answered “yes” to any of the five questions (Have you ever been emotionally or physically abused by your partner or someone important to you? [Important person was defined by the respondent completing the survey and could encompass friends, intimate partners, or anyone they deemed important.] Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Within the past year, has anyone forced you to have sexual activities? Are you afraid of your partner or anyone listed above?) are considered abused. Continuous data were summarized using medians and interquartile ranges. Categorical data were summarized using frequency distributions. Univariable comparisons between groups were conducted using Mann–Whitney tests for continuous data and χ2 tests for categorical outcomes. Univariable and multivariable logistic regression analysis was implemented to investigate factors predictive of domestic violence and their effects were summarized using odds ratios (ORs) and their 95% confidence intervals (CIs). All hypothesis tests were two-sided, and P<.05 was considered statistically significant. SPSS statistical software (SPSS Inc., Chicago, IL) was used for data analysis.
A total of 1,162 surveys were collected between January 2007 and March 2008, of which 58 were blank, for a response rate of 95%. Of these, 14.5% of respondents screened positive for abuse (either current abuse or a prior history of abuse). Demographic characteristics of participants and their partners are presented in Tables 1 and 2. The majority of participants were in their 20s, white, and high school graduates with some college. Most of our participants were dependent spouses of Navy personnel, and the majority were enlisted, rank E6 (mid enlisted) and below. The prevalence of domestic violence in our population was 14.5% (95% CI 12.4–16.5%), with 160 women recording at least one positive answer on the abuse assessment screen (Table 3).
Responses to the abuse assessment screen are shown in Table 4. Most of the positive responses (144, 13%, 95% CI 11–15%) consisted of women who reported being abused physically or emotionally by a person close to them. Physical abuse in the previous year was reported by 42 women (3.8%, 95% CI 2.7–4.9%), with the majority reporting that the abuser was the current or ex-husband or boyfriend. Seventeen women (1.5%, 95% CI 0.8–2.3%) reported abuse since becoming pregnant, with the majority reporting that their boyfriend was the abuser. Of the abuse incidents since becoming pregnant, most were reported to be in the head or in multiple locations and consisted of slapping or pushing in nine (52.4%) and punching, kicking, or cutting in five (29.4%). Ten women (0.9%) reported forced sexual activities, and 19 women (1.7%) reported being afraid of their partner or someone listed on the form.
Additional questions assessed participants’ abuse history, and 114 (10.3%) reported being a victim of abuse within their family. Forty-six (4.2%) suspected friends of being abused, and 604 (54.6%) participants were aware of local abuse services.
Logistic regression of factors predicting any physical or emotional abuse by a partner or someone important (as defined by the respondent, including friends, intimate partners, or anyone they deemed important) revealed that marital status and history of abuse within the family were simultaneous factors associated with any physical or emotional abuse by a partner or an important person. Relative to married women, both single women (OR 1.81, 95% CI 1.04–3.16, P=.036) and separated or divorced women (OR 3.45, 95% CI 1.59–7.46, P=.002) were at an increased risk of physical or emotional abuse by a partner or an important person.
Logistic regression of factors predicting abuse in the previous 12 months also showed that marital status and history of abuse within the family were simultaneous factors associated with the abuse within the previous year. Compared with married women, single women (OR 2.80, 95% CI 1.35–5.78, P=.005), but not separated or divorced women (P=.172), were at increased risk of abuse in the previous 12 months. History of abuse in the family also was associated with an increased risk of abuse within the previous 12 months (OR 5.99, 95% CI 2.99–11.99, P<.001).
A total of 1,162 women were screened for domestic violence between January 2007 and March 2008. The prevalence of domestic violence in this single study of a pregnant population presenting for prenatal care at the largest U.S. military treatment facility in the Department of Defense was 14.5%. This is in the upper range of the prevalence of domestic violence in pregnancy reported in the nonmilitary literature (0.9% to 23%).1–7 Although the limited literature comparing domestic violence in nonpregnant military and civilian populations seems to suggest an increased prevalence of physical spousal abuse,25–27 we did not find a similarly increased prevalence of abuse in this single study of a pregnant military population.
We found that single and separated or divorced women compared with married women were at an increased risk of physical or emotional abuse by a partner or other important person and that single women were also at an increased risk for abuse in the previous 12 months. This is consistent with the civilian literature, which has shown that, during pregnancy, unmarried status is a significant risk factor for police-reported intimate partner violence.31 A history of abuse also was associated with an increased risk of abuse by a partner and abuse in the previous 12 months. This is again consistent with previous studies in the civilian literature, which show that the primary predictor of battering during pregnancy is a prior history of abuse.5,15,32 Because domestic violence and abuse are often cyclic, abuse in the previous 12 months may represent a new incident, ongoing violence, or a subsided incident of violence. Although it is not possible to comment on causality, this study suggests that unmarried women and women with a history of abuse may be more likely to be in strained or abusive relationships.
The advantages of our study are the large sample size and the fact that the survey was administered in an anonymous fashion. The anonymity of the survey may have encouraged more women to participate and truthfully report their circumstances, knowing that they would not suffer adverse consequences by reporting domestic violence. Studies have shown that the majority of pregnant patients (97%) are not offended when screened for domestic violence; however, they may increase disclosure if they are aware of laws precluding mandatory reporting of domestic violence against adults.33 In a telephone interview survey conducted in 2006, a majority (57%) of active-duty women supported routine screening for domestic violence, with 87% of responders saying that the military’s policy should continue to require mandatory reporting of domestic violence.34 Unfortunately, there is a paucity of evidence related to actual outcomes of screening and reporting practices.34,35
The limitations of our study are that we relied on participants’ self-report of domestic violence, which may have led to recall bias. Additionally, there may have been some selection bias between responders and nonresponders, with 58 (5%) women choosing not to complete the survey. In a previous prospective, observational study, women who declined to be surveyed about domestic violence were found to be at risk for adverse pregnancy outcomes including low birth weight neonates, preterm delivery, placental abruption, and neonatal intensive care unit admissions.36
The American College of Obstetricians and Gynecologists recommends domestic violence screening in pregnancy each trimester and at postpartum examinations.37 Because we screened only once during the pregnancy, it is possible that the prevalence of abuse would have been higher if there had been multiple screenings and if those screenings were conducted as part of a personal interview rather than a paper questionnaire. Some studies of domestic violence screening have shown a higher response rate with direct questioning,38 whereas other studies have shown that a self-report survey is an effective alternative.39,40
Often victims need to be asked about domestic violence several times before they are comfortable enough to disclose abuse or identify their experiences as abuse.41 Interestingly, the use of resources by battered women was found to correlate with severity of abuse rather than the presence or absence of an intervention program.42 Additionally, the number of women reporting abuse since becoming pregnant (17, 1.5%) may have been low because women were screened when presenting for prenatal care, with a median gestational age of 10 weeks. A previous study has shown that more women reported domestic violence during the latter part of pregnancy.7
In conclusion, our study demonstrates that the prevalence of domestic violence in a pregnant population at a large military treatment facility was 14.5%, in the upper range of the prevalence of domestic violence in pregnancy reported in the civilian literature. Additionally, in this patient population, unmarried status and prior history of abuse may indicate a higher risk of abuse. With the increased stressors and demands placed on our military service members and their families during wartime, this is an especially important area for future research.
Further studies with multiple screenings throughout pregnancy may identify a higher prevalence of abuse in the pregnant military population. This study confirms the importance of continued routine screening in pregnant women. Unmarried women and women with a history of abuse also may be at greater risk.
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