Associations Between Intimate Partner Abuse and Reproductive Outcomes Among Women of African Descent

African-Caribbean & African- American Women’s Study

Desiree Bertrand, MSN, RNDoris Campbell, PhD, ARNP, FAANAshley Chappell, BS, RN

Jamila Stockman, PhD Phyllis Sharps, PhD, RN, FAAN Jacquelyn Campbell, PhD, RN, FAAN

Mary T. Paterno, PhD(c), MSN, CNM

Acknowledgements

This research supported by a subcontract with the Caribbean Exploratory NIMHD Research Center of Excellence (CERC),  University of the Virgin Islands, Grant # P20MD002286, National Institutes of Health

ACAAWS Team MembersUnited StatesJacquelyn Campbell, PhD, RN, FAANPhyllis Sharps PhD, RN, FAANRichelle Bolyard, MHSJamila Stockman, PhD, MPHMarguerite B. Lucea, PhD, MSN, MPH, RNBushra Sabri, PhD, LMSW, ACSWAkosoa McFadgion, MS, MSW, PhD studentKaitlan Gibbons, PsyD(c) Mary Paterno, MSN, CNM, RN, PhD (c)Sharon O’Brien, PhDSachi Mana-ay, BSN studentJessica Draughon, MSN, RN, PhD (c)Charmayne M. Dunlop-Thomas, MSCallie Simkoff, BSN, RNGyasi Moscou-Jackson, MHS, BSN, RNChris KunselmanAyanna Johnson, MPHAshley Chappell, BSN, RNLucine Francis, BSN, RNNaa Ayele Amponsah, MPHHossein Yarandi, PhD

US Virgin IslandsDoris Campbell, PhD, ARNP, FAANGloria Callwood, PhD, RN, FAANDesiree Bertrand, MSN, RNLorna Sutton, MPATyra DeCastroAlexandria Bradley, RNSally Browne, RNEdris Evans, RNYvonne Francis, RNNaomi Joseph, BSN studentJennifer King, RNSuzette Lettsome, MSPHN, RNJulie Matthew, RNKenice Pemberton, ASN studentJ'Nique Smith, BSN studentJaslene Williams, MSW

IntroductionIntimate partner abuse

- increased risk for:Adverse neonatal

outcomesAdverse maternal

outcomesSexually transmitted

infections (STI)

(Coker, 2007; Sarkar, 2008; Seth et al., 2010; Sharps et al., 2007; Shah & Shah, 2010; Silverman et al., 2006; Wu et al., 2003)

African heritage – increased risk for:Adverse neonatal

outcomesAdverse maternal

outcomesSexually transmitted

infections

(CDC, 2010, 2011; Curry et al., 1998; Hogue & Silver, 2011; Martin et al., 2011; McFarlane et al., 1996)

Study Purpose

Examine differences in maternal and neonatal reproductive outcomes comparing women with history of intimate partner abuse (IPA) to never-abused women

MethodsComparative case-control study (randomly

selected controls)Study period 2009-2011

Eligibility criteriaWomen aged 18-55 yearsSelf-identify as Afro Caribbean or African

AmericanReport intimate partner in the past two years

Women recruited from primary care, prenatal or family planning clinics

Questionnaire administered on a touch screen computer with optional headphones

Medical record abstraction for health outcomes

CASES = Intimate Partner Abuse (IPA) Intimate Partner Violence (IPV - physical/sexual abuse) & psychological

abuse (threats/emotional abuse/controlling behavior ) IPV assessed using the Abuse Assessment Screen (AAS, McFarlane & Helton -

www.nnvawi.org) Pushed, slapped, hit, kicked, or physically hurt &/OR Forced sex

Psychological abuse: <19 on WEB (Women’s Experiences of Battering – Hall-Smith) Controlled, in fear of current/former intimate partner

Any of the above by current or former intimate partner

Past 2 Year and Lifetime IPV (Physical/Sexual)—subgroups within cases Exclusive of emotional/controlling abuse Reported as Lifetime and Past-two-year

CONTROLS = Women never abused by anyone in their lifetime

Not eligible (if meeting age, race, and language requirements) Women experiencing abuse only from someone other than an intimate partner or ex-partner. Women reporting no partner within 2 years prior to survey

Study Definitions

Final Participants

1579 screened from both sites

n=486 n=1059

169controls

159cases

189 controls

n=553

n=461 n=963

384cases

US Virgin IslandsBaltimore City, MD

n=348

34 ineligible race; duplicates

No partner past 2 yrs= 96

No partner past 2 yrs= 25

Didn’t meet case /control criteria = 70

Didn’t meet case /control criteria= 39

Non-selected control =329

Non-selected control = 74

Screened as case; no full survey=11

Lifetime IPA

Total 621/1545=40%B’more 179/488=37%USVI 442/1059=42%

Past 2-year IPV

Total 382/1424= 27%B’more 119/461= 26%USVI 263/963= 26%

1315 fully eligible women

Sub-Sample PopulationBaltimore City, MD US Virgin

Islands

Pregnant at Survey42

cases

64 control

s

98 cases

54 control

sn=258

28 cases

49 control

s

16 cases

8 control

s

Medical Record

Abstractionn=101

Final Participants169

controls159

cases189

controls

n=553

384cases

n=348

VariablesDependent Variables

Pregnancy outcomesMaternal antenatal outcomesMaternal infectionsMaternal behaviorsNeonatal outcomes

Independent VariableLifetime experience of IPA

Analysis

Descriptive analysisChi-square , Fisher’s exact, and t-tests

Regression analysisGeneralized linear modelAIC valuesMediation test

Table 1. Demographic Characteristics of Sub-Sample, n(%)Overall(n=101)

Cases(n=44)

Controls(n=57)

P-value†

Age, years < 20 20-24 25-29 30+

23 (22.8)42 (41.6)21 (20.8)15 (14.8)

10 (22.7)21 (47.7)8 (18.2)5 (11.4)

13 (22.8)21 (36.8)13 (22.8)10 (17.4)

0.66

Education Level < High School High School Some College Completed College

34 (34.4)41 (41.4)13 (13.1)11 (11.1)

12 (27.3)21 (47.7)8 (18.2)3 (6.8)

22 (40)20 (36.4)5 (9.1)8 (14.5)

0.19

Marital Status Single Partnered Married Other

49 (48.5)37 (36.6)12 (11.9)

3 (3)

24 (54.5)12 (27.3)5 (11.4)3 (6.8)

25 (43.9)25 (43.9)7 (12.2)

0

0.10

Income, monthly < $400 $400-$1200 ≥ $1201

42 (43.3)41 (42.3)14 (14.4)

19 (43.2)19 (43.2)6 (13.6)

23 (43.4)22 (41.5)8 (15.1)

0.98

Health Insurance 86 (85) 35 (79.6) 51 (89.5) 0.16

Employed 33 (32.7) 17 (38.6) 16 (28.1) 0.26

† Chi-square or Fisher’s exact test

41 (93.2%)

21

Figure 1. Cases (n=44)

Live BirthMiscarriageFetal Demise

53 (93%)

3 1

Figure 2. Controls (n=57)

Pregnancy Outcomes

Gesta

tiona

l Dia

bete

s

Diabe

tes M

elitu

s

Gesta

tiona

l HTN

Chron

ic H

TN

Pre-

ecla

mps

ia*

PROM

PPRO

M

Plac

enta

l Abr

uptio

n

Pre-

term

Lab

or02468

1012

CasesControls

Figure 3. Maternal Antenatal Outcomes (%)

HTN = hypertensionPROM = premature rupture of membranesPPROM = pre-term premature rupture of membranes

p <0.05

Chyla

mdi

a

Gonor

rhea

HPV

Genita

l Her

pes

Syph

ilis

Tricho

mon

iasis

Any S

TI

Bacte

rial V

agin

osis

Abnor

mal

Pap

Sm

ear

Yeas

tUTI

Smok

ing

Hx

Positiv

e Urin

e To

x05

101520253035

CasesControls

Figure 4. Maternal Infection and Behavioral Outcomes (%)

Table 2. Neonatal Outcomes, n(%)

Overall(n=101)

Cases(n=44)

Controls

(n=57)

P-value†

Gestation at Delivery < 32 32-36 37+

2 (2.1)11 (11.6)82 (86.3)

1 (2.4)5 (12.2)

35 (85.4)

1 (1.9)6 (11.1)

47 (87.0)

1.0

Pre-Term Birth 13 (13.7) 6 (14.6) 7 (13.0) 0.81

Birth Weight in grams (mean, SD)

3075 (610)

3028 (562)

3112 (646)

0.51

Low Birth Weight 12 (13) 5 (12.5) 7 (13.5) 0.74

Very Low Birth Weight

2 (2.2) 1 (2.5) 1 (1.9) 0.72

Small Gestational Age

9 (9.7) 6 (15) 3 (5.7) 0.11

NICU Admission 7 (7.3) 5 (11.9) 3 (3.7) 0.13† Chi-square ,Fisher’s exact test, or t-test; SD=standard deviation

Table 3. Odds Ratio for Select Outcomes, Baltimore cases vs. controls (n=74)

Variable Odds Ratio(95% CI)

Adjusted Odds Rati0*

(95% CI)

Small for Gestational Age

6.3 (1.2-33.8) 7.5 (1.2-46.6)

Smoking 3.4 (1.2-9.6) 3.2 (1.1-9.2)

NICU Admission 5.1 (0.9-28.5) 4.0 (0.66-24.4)† Adjusted for education, martial status, and income

DiscussionNo significant difference found for most

variables

IPA associated with higher smoking and SGA infants

SGA may result in serious neonatal complications

Nurses should focus on smoking reduction among women of childbearing age experiencing IPA

Intervention research studies should test approaches to smoking cessation for women with IPA

Limitations

Small sample sizeUnable to differentiate based on type/timing

of abuseHomogenous populationLimited to participants who gave permission

for medical record review

Strengths

ACASI technologyIncluded participants from USVILongitudinal dataIncluded SGA as an outcome

References Centers for Disease Control and Prevention. (2011). HIV

surveillance report, 2009. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/resources/reports/

Centers for Disease Control and Prevention. (2010). Sexually transmitted disease surveillance 2009. Retrieved from http://www.cdc.gov/std/stats

Coker, A. L. (2007). Does physical intimate partner violence affect sexual health?: A systematic literature review. Trauma, Violence, & Abuse, 8, 149-177. doi:10.1177/1524838007301162

Curry, M. A., Perrin, N., & Wall, E. (1998). Effects of abuse on maternal complications and birth weight in adult and adolescent women. Obstetrics & Gynecology, 92, 530-534.

Hogue, C. J. R., & Silver, R. M. (2011). Racial and ethnic disparities in United States: Stillbirth rates: Trends, risk factors, and research needs. Seminars in Perinatology, 35, 221-233. doi:10.1053/j.semperi.2011.02.019

MacFarlane, J., Parker, B., & Soeken, K. (1996). Abuse during pregnancy: Associations with maternal health and infant birth weight. Nursing Research, 45(1), 37-42.

ReferencesMartin, J. A., Hamilton, B. E., Ventura, S. J., Osterman, M. J.

K., Kirmeyer, S., Mathews, T. J., … Wilson, E. C. (2011). Births: Final data for 2009. National Vital Statistics Reports, 60(1), 1-72.

Parker, B., & McFarlane, J. (1991). Identifying and helping battered pregnant women. MCN. The American Journal of Maternal Child Nursing, 16(3), 161-164.

Sarkar, N. N. (2008). The impact of intimate partner violence on women’s reproductive health and pregnancy outcome. Journal of Obstetrics and Gynaecology, 28(3), 266-271.

Seth, P., Raiford, J. L., Robinson, L. S., Wingood, G. M., & DiClemente, R. J. (2010). Intimate partner violence and other partner-related factors: Correlates of sexually transmissible infections and risky sexual behaviors among young adult African American women. Sexual Health, 7, 25-30. doi:10.1071/SH08075

Shah, P. S., & Shah, J. (2010). Maternal exposure to domestic violence and pregnancy and birth outcomes: A systematic review and meta-analyses. Journal of Women’s Health, 19(11), 2017-2031. doi:10.1089=jwh.2010.2051

ReferencesSharps, P. W., Laughon, K., & Giangrande, S. K. (2007).

Intimate partner violence and the childbearing year. Trauma, Violence & Abuse, 8(2), 105-116. doi:0.1177/1524838007302594

Silverman, J. G., Decker, M. R., Reed, E., & Raj, A. (2006). Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: Associations with maternal and neonatal health. American Journal of Obstetrics & Gynecology, 195, 140-148. doi:10.1016/j.ajog.2005.12.052

Smith, P. H., Earp, J., & DeVellis, R. (1995). Measuring battering: Development of the women’s experience with battering (WEB) scale. Women’s Health: Research on Gender, Behavior, and Policy, 1(4), 273-288.

Wu, E., El-Bassel, N., Witte, S. S., Gilbert, L., & Chang, M. (2003). Intimate partner violence and HIV risk among urban minority women in primary health care settings. AIDS and Behavior, 7(3), 291-301. doi:1090-7165/03/0900-0291/0