More research is needed on violence and reproduction

On average, one out of every 15 pregnant women experiences violence, one study shows.

By Lisa Rabasca
Monitor staff

At the first-ever conference on the relationship between violence against women and reproductive health, researchers, advocates and practitioners began chipping away at the invisible barriers that often prevent them from collaborating on research and prevention methods.

More than 200 members of the women's health community--including experts in reproductive health, maternal and child health and family planning, many of them psychologists--attended the June 14-16 meeting in Atlanta.

Sponsored by the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Health and Human Services, the meeting also brought together representatives of programs aimed at preventing family violence, teen pregnancy, HIV and sexually transmitted diseases (STDs). APA's Women's Program Office was one of the conference partners.

"By holding the conference, CDC affirmed in a very public way something that we've worked for years to get people to recognize--that violence against women is a public health issue," said Nancy Felipe Russo, PhD, Regents Professor of Psychology and Women's Studies at Arizona State University in Tempe. "We have these myths about pregnancy that it's an ideal time for women, that they're on a pedestal and 'glowing,' but in reality many are being beaten and abused."

Many women also have brawls with their partners when they discuss using birth control, particularly condoms. The conference set the foundation for developing more comprehensive research programs on violence and pregnancy, said Russo, and it brought together researchers from numerous disciplines and providers from different settings.

Such a disparate group doesn't often have an opportunity to exchange information because women's health services are so compartmentalized, said Patricia O'Campo, PhD, of The Johns Hopkins School of Hygiene and Public Health in Baltimore. And this lack of collaboration often leads to fragmented research and services. For instance, she said, the definition of alcohol abuse frequently varies in separate studies of HIV-positive women, adolescents and pregnant women.

Service delivery is also disjointed, and women who have a variety of health concerns may not receive comprehensive help, O'Campo said. Substance-abuse programs, for instance, often don't accept pregnant women, and domestic violence shelters often don't accept women with substance-abuse problems.

More common than diabetes

The most recent study of violence against pregnant women found that on average one of every 15 pregnant women whose pregnancies end in a live birth experience violence, and that women with unplanned pregnancies have two to four times more risk of violence than women whose pregnancies were planned.

The study, published in the June 1996 Journal of the American Medical Association (Vol. 275, No. 24, p. 1915-1920), further suggests that women in abusive relationships are less likely to use condoms and more likely to experience verbal abuse or threats of violence when they discuss the use of condoms.

"Violence is a more common risk for pregnant women than high blood pressure, diabetes or any other ailment they are routinely screened for," said Lynne Wilcox, MD, director of the division of reproductive health in CDC's National Center for Chronic Disease Prevention and Health Promotion.
APA has recognized the need to support research, prevention and interventions to stop violence against women by their partners. The association is exploring ways to better train psychologists to recognize and treat victims of violence, and to conduct research on prevention and intervention methods with the women, their children and their perpetrators.

While a link between violence and reproductive health has been established, it is unclear whether there is a greater risk for violence during pregnancy, what the long-term consequences are, whether the potential for violence coerces women into having riskier sex that could lead to HIV or STD infection and, ultimately, how women may be protected.

More research is needed, but clinicians say that collecting data on violence during pregnancy has been difficult.

"We need to increase the specificity of the data that we collect," said Linda Koenig, PhD, assistant chief for behavioral science in CDC's HIV/AIDS division. "We need to know more about what we mean by violence and what the people we are studying mean by violence and find ways to capture that meaning, including what people mean by threats of violence and fears of threats."

CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) provides the largest source of data about violence during pregnancy, but only surveys women who had live births and excludes women who had miscarriages or abortions. Further, only 14 states participate in PRAMS. Large states such as California and Texas do not participate.

In addition to broadening the scope of the data collected, researchers need to consider whether the way they collect data influences how women disclose issues around violence and reproductive health.

"Researchers are often worried that if you know a woman's name and ask her personal information, she won't be honest with you, so sometimes there's a feeling we should do this anonymously," said Sandra Martin, PhD, associate professor in the department of maternal and child heath at the University of North Carolina at Chapel Hill.

However, preliminary studies have found that face-to-face interviews conducted during pregnancy may yield more accurate information. Higher rates of violence were reported when questions were repeated and asked later in the pregnancy, said Julie Gazmararian, PhD, director of scientific research at the Prudential Center for Health Care Research in Atlanta.

In addition, clinicians conducting the interviews need to be sensitive to cultural differences, said O'Campo of Baltimore. Asian Americans, for instance, often aren't asked about violence during pregnancy because they're not perceived as being at risk. Diversity within ethnic groups also must be recognized when conducting research, said O'Campo, because outreach efforts tailored to Latina women, in general, might not reach Puerto Rican women in the same way they reach Mexican women.

Another piece of the puzzle is figuring out how women make decisions about contraceptions because, as the 1996 study shows, women in abusive relationships are more likely to experience verbal abuse or threats of violence when they discuss the use of condoms.

African-American women, for instance, are more likely to decide which contraception to use without their partners. They tend either to use no birth control or a method that prevents pregnancy but not HIV or STDs, said Gail Wyatt, PhD, professor of psychiatry and biobehavioral sciences and associate director of the AIDS Institute at the University of California, Los Angeles.

"They tend to make decisions alone because they are less likely to be married and they're making this decision to take the issue out of the interaction between themselves and their partners," she said.

The need to study partners and develop interventions for them was a refrain heard throughout the conference.

"No matter how well we study, screen and treat women during the reproductive years around the issues of partner violence and sexual assault," said Martin of North Carolina, "these problems aren't going away if we ignore the perpetrators."



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