Intimate Partner Violence During Pregnancy

Diana Filipa da Costa Marques Intimate Partner Violence During Pregnancy 2011/2012 março, 2012 Diana Filipa da Costa Marques Intimate Partner Violence During Pregnancy Mestrado Integrado em Medicina Área: Medicina Legal Trabalho efetuado sob a Orientação de: Professora Doutora Teresa Magalhães E sob a Coorientação de: Professora Dra. Ana Clara Grams Trabalho organizado de acordo com as normas da revista: Journal of Forensic and Legal Medicine março, 2012 Projeto de Opção do 6º ano - DECLARAÇÃO DE INTEGRIDADE Eu, Diana Filipa da Costa Marques, abaixo assinado, nº mecanográfico 060801220, estudante do 6º ano do Mestrado Integrado em Medicina, na Faculdade de Medicina da Universidade do Porto, declaro ter atuado com absoluta integridade na elaboração deste projeto de opção. Neste sentido, confirmo que NÃO incorri em plágio (ato pelo qual um indivíduo, mesmo por omissão, assume a autoria de um determinado trabalho intelectual, ou partes dele). Mais declaro que todas as frases que retirei de trabalhos anteriores pertencentes a outros autores, foram referenciadas, ou redigidas com novas palavras, tendo colocado, neste caso, a citação da fonte bibliográfica. Faculdade de Medicina da Universidade do Porto, 21/03/2012 Assinatura: _________________________________________________________ Projeto de Opção do 6º ano – DECLARAÇÃO DE REPRODUÇÃO Nome: Diana Filipa da Costa Marques Endereço eletrónico: med062[email protected].pt Telefone ou Telemóvel: 937481679 Número do Bilhete de Identidade: 13006596 Título da Dissertação: Intimate Partner Violence During Pregnancy Orientador: Professora Doutora Teresa Magalhães Ano de conclusão: 2012 Designação da área do projeto: Medicina Legal É autorizada a reprodução integral desta Dissertação para efeitos de investigação e de divulgação pedagógica, em programas e projetos coordenados pela FMUP. Faculdade de Medicina da Universidade do Porto, 21/03/2012 Assinatura: _________________________________________________________ INTIMATE PARTNER VIOLENCE DURING PREGNANCY AUTHORS Diana Filipa da Costa Marques (corresponding Author) Faculty of Medicine of Porto University, Al. Prof. Hernâni Monteiro 4200 - 319 Porto, Portugal e-mail address: [email protected]; Tel: +(351) 937481679 ABSTRACT Introduction: Intimate partner violence is an important worldwide problem. During pregnancy this phenomenon can start or exacerbate with serious implications for the pregnancy outcome. This type of violence can also have serious consequences in the physical and mental health of both, mother and child. The aim of this study is to characterize women who are victims of intimate partner violence during pregnancy to contribute to promote the development of early intervention strategies as soon as the risk factors are recognized. Material and methods: This study is a retrospective analysis of selected medico-legal reports of victims of intimate partner violence, submitted for forensic assessment at the north services of the National Institute of Legal Medicine of Portugal, during the period between 2005 and 2010. It includes two groups with 49 cases each: one group with women who were pregnant at the moment of the abuse and another group with non pregnant women (control). Results: Over this period, 11263 suspected female victims of intimate partner violence were examined; 0.44% (n=49) of them were pregnant. In the pregnant group most women were single (67.3%), while in the non pregnant group most were married (51%) at the time of the abuse; statistical significant differences have been found (p=0.025). Regarding the professional status, the majority of victims of the pregnant group were unemployed (38.8%). With respect to the number of children, significant statistical differences were found between the two groups (p=0.003). In the pregnant group it was found that a larger number of women had no previous children. The pregnant group also showed a higher number of women with only one previous pregnancy (p=0.022). The non pregnant group showed significant differences for the duration of abuse: “less than one year” when compared with “more than one year” (p=0.02). The majority of the victims reported multiple mechanisms of abuse. They were mainly punching, pushing, slapping and kicking (49%, 40.8%, 36.7% and 34.7%, respectively) in the pregnant group case. For the non pregnant group, the same mechanisms were the most frequents (53.1%, 32.7%, 26.5% and 28.6%, respectively). Both in the pregnant group and in non pregnant group face and limbs are the anatomical areas more frequently injured, with no significantly statistical differences, but in pregnant group there is description of injuries at the torso in 14.3% of the cases, while in non pregnant group only the thorax has been involved. No significant statistical differences were found between both groups with regard to demands for medical care after abuse (p=0.539). Conclusions: Intimate partner violence in pregnancy is probably underreported. Women victims of intimate partner violence during pregnancy are mostly unmarried compared with non pregnant and there seems to be a predominance of abuse in women who are pregnant for the first time. Further studies are necessary to better characterize the medico-legal aspects in this kind of situations. KEYWORDS: Intimate partner violence; female victims; pregnancy; Portugal INTRODUCTION Violence, which includes abuse, is a very serious and complex social issue, with harmful physical and psychological consequences for victims. Besides, it also has important implications for their families and society in general.1 According to the World Health Organization (WHO), the most common form of abuse suffered by women is perpetrated by an intimate partner.2, 3 This intimate partner violence (IPV) is defined as actual or threatened physical, sexual, psychological, and emotional abuse by a current or former intimate partner, regardless of the involved genders and cohabitation.4 Consequences are always very severe in terms of psychological and physical health and in socioeconomic aspects; furthermore, each year, at least 1400 women die in the United States of America as a result of IPV.3 Pregnancy is a high-risk period during which violence can start or exacerbate,3, 4, 5, 6, 7, 8, 9 usually resulting on adverse outcomes for the newborn.3, 4, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17 According to a study developed at the Obstetrics Department of São João Hospital, in Porto, preterm delivery was significantly more frequent among physically abused than non-abused pregnant women (21.4% vs 6.8%; p<0.0001).10 Studies show that the prevalence of violence from a man to a woman in an intimate relationship at any time ranges from 9.7% to 29.7%,5 and the overall prevalence of IPV during pregnancy varies between 0.9% and 20.1%.5, 9, 11, 12, 18, 19, 20, 21 In Portugal the estimated value is around 10%.10 Violence during pregnancy deserves special attention because it affects women at a moment of great vulnerability. Moreover, it may potentiate an increase in morbidity and mortality of the mother as well as the newborn. This violence may influence the evolution of the perinatal period by the interference of two mechanisms: (a) the first is the trauma itself, capable of promoting lesions that affect women during pregnancy; (b) the second is based on the theory of continuous stress.2, 10, 18 This kind of abuse may have serious consequences for the women’s physical and mental health.11 Direct health effects include the increase likelihood of miscarriage, premature labour or delivery, low birth weight as well as higher levels of depression. An indirect health effect described in several studies is substance abuse by women who suffer violence in order to diminish feelings of shame and humiliation.3, 5, 13 Hedin et al. found that physical abuse during pregnancy occurred mostly in cases were it was already happening during the period of time preceding the pregnancy, suggesting that it is important to consider previous history of abuse.5 Some risk factors have been associated with IPV during pregnancy.4, 6, 8, 9, 11, 12, 13, 18, 17, 22, 23, 24, 25, 26, 27, 28, 29, 30 Risk factors refer to aspects that increase the probability of occurrence or maintenance of abuse. They may be related to the individual characteristics of the victim or the abuser, their family background and socio-cultural environment. The presence of a risk factor does not mean, by itself, the presence of abuse. It is known, however, that the combination of several risk factors could significantly increase the likelihood of abuse.1 Risk factors for violence during pregnancy include: socioeconomic status,11, 22, 25 a young age,5, 6, 8, 9, 11, 12, 15, 18, 22, 23, 25, 27, 29, 30 ethnicity,11, 12, 18, 22 marital status (single),5, 12, 17, 18, 22, 25, 28 low level of education,4, 6, 12, 18, 22, 25 unemployment,18 parity,6,18 absence of prenatal care,18, 25 low level of social support,11, 25, 26 unintended pregnancy,9, 30 smoking, alcohol and drug abuse by women partners.3, 4, 5, 11, 12, 13, 15, 17, 31 Another factor often associated with increased risk for IPV is witnessing or being a victim of violence during childhood.11, 12, 17 OBJECTIVES The general objective of this study was to characterize women who are victims of IPV during pregnancy to contribute to promote the development of early intervention strategies as soon as the risk factors are recognized. The specifics objectives were to characterize household’s situation, including victims, alleged perpetrators and couple’s situation, as well as physical abuse and legal outcomes of the cases. MATERIALS AND METHODS The present study is a retrospective review of selected medico-legal reports of victims of IPV, submitted for forensic assessment at the north services of the National Institute of Legal Medicine of Portugal (INML), during the period between 2005 and 2010. It includes two groups. For the group of pregnant women (n=49), the inclusion criteria were: a) Women in reproductive age (15-49 years old); b) Presenting a claim of IPV; c) Perpetrated during the pregnancy; d) Observed at the north services of the INML; e) Between 2005 and 2010. For control, a group of non pregnant women was randomly selected (n=49); the inclusion criteria were: a) Women in reproductive age (15-49 years old); b) Presenting a claim of IPV; c) Not pregnant at the time of the alleged abuse; d) Observed at the north services of the INML; e) Between 2005 and 2010. For data collection, a form, previously developed for collecting data from abused women, was adapted and applied to medico-legal reports of selected women. Variables studied included the characterization of the: (a) household at the moment of the forensic assessment (victim, alleged abuser, couple relationship and previous pregnancies); (b) current episode of violence; (c) physical abuse that led to medico-legal observation; (d) legal outcomes. In order to evaluate the judicial outcome for the pregnant group, judicial decisions were requested by mail to the respective the Public Prosecutor Offices and Courts; only in 19 cases the information was sent to us. Statistical analysis was performed using SPSS (Statistical Package for Social Sciences), version 17.0; including descriptive statistics and correlation tests using Pearson’s Chi-square, due to sample sizes. The significance level considered was p<0.05. the resulting small size of the sample might impair the results. We acknowledge that prevalence obtained by us is thus probably much lower than real, since many women victims of abuse were not questioned about the presence or absence of episodes of aggression during pregnancy and some, even having been asked about this had denied by shame or embarrassment about the subject. Another limitation has to do with the fact that this is a retrospective study based on the analysis of medico-legal reports that have not been performed in order to participate in this kind of study, therefore do not include all items that we tried to analyze. In Portugal, it was already conducted a study with the aim of understanding the relationship between IPV during pregnancy and preterm birth. They have concluded that women abused during pregnancy had an increased risk of preterm birth regardless of presence of another factors related to the higher incidence of preterm delivery.10 However there is still a gap with respect to the forensic characterization of this phenomenon. Therefore, it would be interesting to conduct a longitudinal study in order to better characterize the medico-legal aspects of cases of IPV during pregnancy. The health sector has an important role in combating this type of violence by means of research, case notifications, organization of reference services for victims as well as other proposals involving intervention.11 In fact, studies show that women abused during pregnancy frequently continue to suffer abuse after child birth, so both the safety of the mother and child are at risk.36 The emotional consequences for children who witness violence between their parents can be even worse than when they become targets themselves.25, 35 Therefore it would be important to implement standardized screening measures to be applied at the primary health care centre in order to timely detect cases of violence during pregnancy, making it safer for the women and their baby. The American Medical Association recommends that health care providers routinely ask patients about IPV37 and in fact, most women agree to IPV screening.26 CONCLUSIONS This study allows us to conclude that: a) IPV in pregnancy is probably underreported by the victims and the health care professionals, taking into account the low prevalence of women who were undergoing forensic evaluation during the study period when compared to the values found in international studies; b) Women victims of IPV during pregnancy are mostly unmarried compared with non pregnant; c) There seems to be a predominance of abuse in women who are pregnant for the first time when compared with those who already have children; d) The majority of women, pregnant and non pregnant, seek for medical help after abuse; e) Most of the victims is achieved by multiple mechanisms of aggression whereas punching, pushing, slapping and kicking are revealed the most commons regardless the women are pregnant or not; f) The affected body areas are mostly the face and upper limbs in both pregnant and non pregnant women. Further studies are necessary to better characterize the medico-legal aspects in this kind of situations. It is important to evaluate these cases in terms of sequelae (temporary and permanent) as well as in terms of life-threatening. Another important forensic aspect that needs to be better known is if there is a preference for abdominal attaining which in this study could not be statistically analyzed due to missing data. ETHICAL APPROVAL Despite we do not require the approval from the Ethics Committee, since it is a retrospective study in which the identity of women involved was preserved, the development of the study was conducted according to high ethical standards. REFERENCES 1. L. Magalhães T. Violência e Abuso Respostas Simples para Questões Complexas. Imprensa da Universidade de Coimbra; 2010. 2. Lourenço MA, Deslandes SF. Experiência do cuidado materno e amamentação sob a ótica de mulheres vítimas de violência conjugal. Rev Saúde Pública 2008; 42(4): 615-21. 3. Linda R. 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TABLES Table 1: Characterization of the victims PG (n=49) NPG (n=49) p n % n % Resident type National 46 93.9 46 93.9 Immigrant 3 6.1 3 6.1 Marital status Single 33 67.3 22 44.9 0.025 Other condition 16 32.6 27 55.1 Married 8 16.3 25 51.0 Divorced 7 14.3 2 4.1 Widow 1 2.0 0 0 Education level 1st to 4th grade 0 0 1 2.0 5th to 6th grade 1 2.0 0 0 7th to 9th grade 3 6.1 2 4.1 10th to 12th grade 2 4.1 2 4.1 University 2 4.1 0 0 No information 41 83.7 44 89.8 Profession Unemployed 19 38.8 15 30.6 0.355 Other condition 29 58.9 34 69.4 Scientific occupation, technical, artistic or similar 3 6.1 1 2.0 Director or senior 0 0 1 2.0 Admnistrative or similar 1 2.0 0 0 Industry worker 1 2.0 2 4.1 Protection services, security, personal, domestic services or similar 11 22.4 18 36.7 Trade and sellers 6 12.2 4 8.2 “Housewife” 3 6.1 3 6.1 Student 3 6.1 2 4.1 Other 1 2.0 3 6.1 No information 1 2.0 0 0 Psychiatric history Yes 2 4.1 1 2.0 No 4 8.2 0 0 No information 43 87.8 48 98.0 History of childhood abuse Yes 1 2.0 1 2.0 No 4 8.2 2 4.1 No information 44 89.8 46 93.9 Table 2: Mechanisms of the current physical abuse Mechanism PG (n=49) NPG (n=49) n % n % Pushing 20 40.8 16 32.7 Pressing 8 16.3 12 24.5 Pinching 1 2.0 0 0 Scratching 1 2.0 1 2.0 Pulling hair 7 14.3 10 20.4 Slapping 18 36.7 13 26.5 Punching 24 49.0 26 53.1 Kicking 17 34.7 14 28.6 Biting 1 2.0 3 6.1 Strangling 5 10.2 5 10.2 Blunt instrument 3 6.1 4 8.2 Sharp instrument 1 2.0 1 2.0 Mixed instrument 0 0 1 2.0 Others 9 18.4 7 14.3 Table 3: Anatomical distribution of the injuries Anatomical distribution PG (n=49) NPG (n=49) n % n % Cranium 4 8.2 8 16.3 Face 12 24.5 15 30.6 Neck 2 4.1 1 2.0 Rachis 1 2.0 0 0 Thorax 5 10.2 5 10.2 Abdomen 2 4.1 0 0 Perineum 0 0 0 0 Right Upper Limb 11 22.4 14 28.6 Left Upper Limb 12 24.5 17 34.7 Right Lower Limb 8 16.3 9 18.4 Left Lower Limb 8 16.3 9 18.4 ANEXOS Anexo 1: Regras de publicação (Revista de referência: Journal of Forensic and Legal Medicine) INTRODUCTION Types of paper The following types of articles will be considered for publication: Original Communication: new research, previously unpublished. 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