Well-Baby Care Visits Create Opportunity to Screen New Mothers for Abuse During Postpartum Period
Six percent of North Carolina mothers were physically abused during pregnancy in 1997 and 1998 and 3% were the victims of abuse during the first three and one-half months postpartum, according to the results of a statewide representative survey.1 Most of the perpetrators of that violence were the woman's husband or partner (67-76%). Women who were abused after giving birth seldom sought medical care for their injuries. Nearly all women took their infants for well-baby visits, however, which creates an opportunity for pediatricians to screen postpartum women for physical abuse.
Women who had recently had a live birth were recruited by mail or telephone between July 1997 and December 1998 to participate in a population-based survey, which used the North Carolina birth certificate data file as the sampling frame. (The data collection was part of a larger, ongoing project, the North Carolina Pregnancy Risk Assessment Monitoring System, or PRAMS.) Three-quarters of the women invited to participate in the survey responded, and nearly all of these (2,630 women) answered all questions concerning physical abuse in the year before pregnancy, during pregnancy and since delivery. On average, the women were 3.6 months postpartum when they completed the survey.
The survey instrument asked whether the woman had been physically abused (i.e., whether she had been pushed, hit, slapped or hurt in some other way) and who had perpetrated that violence (a current or former husband or partner, another family member, multiple persons, a friend or someone else). Women who had been the victim of abuse after delivery were asked whether injury had resulted and if they had sought medical care for it. The researchers calculated odds ratios to determine whether the woman's socioeconomic characteristics were related to the likelihood of abuse and whether previous physical abuse was associated with the likelihood of subsequent abuse.
The majority of women surveyed were aged 20 and older (85%), had graduated from high school (78%), were married (67%) and had had other children (57%). Overall, nearly 7% had been abused in the year before they became pregnant, 6% had been the victim of violence during their pregnancy and 3% had been physically hurt since their baby was born. The perpetrators of the violence were most commonly former or current intimate partners (67-76% of perpetrators, depending on the timing of the abuse).
Seventy-seven percent of the women who had been abused since giving birth reported that the abuse had led to physical injury. Some 73% said they had experienced pain the day after the abuse, and 57% had suffered sprains and bruises, while 6-9% reported more serious injuries (e.g., internal or permanent injuries, weapon wounds and broken bones). Only 23% of all women who were injured, however, received related medical care.
Women did take their babies for medical attention, however: Nearly all women, regardless of whether and when they had experienced abuse, had taken their infant for a well-baby visit. Women had made an average of three such visits during the postpartum period covered by the survey, and the majority (71%) had used private physicians for their baby's care.
Women who had been abused in any of the three time periods that the survey asked about were significantly more likely than those who had never been abused to be unmarried, to be poor, to be younger than 20 and to have not graduated from high school. There were no significant differences in women's socioeconomic characteristics, however, by the timing of abuse (i.e., in any of the eight categories created by the yes-no responses to abuse in each of the three times asked about).
Moreover, the researchers found that previous violence was strongly associated with subsequent violence. For example, physical abuse in the year before pregnancy significantly raised the likelihood of abuse during pregnancy (odds ratio, 67.6); similarly, women who suffered physical abuse during pregnancy had significantly increased odds of being victimized again in the first few months postpartum (odds ratio, 38.0). Conversely, the absence of physical abuse protected women from violence; that is, women who were unharmed before or during pregnancy were at significantly decreased odds of suffering physical abuse once their baby was born (odds ratios, 0.01-0.02).
The researchers acknowledge that because of several limitations, their study could underestimate the true prevalence of physical abuse during the period surrounding pregnancy and childbirth. These limitations include the significant socioeconomic differences between respondents and nonrespondents; the sensitive nature of the topic; the absence of questions on psychological abuse; and the exclusion of women whose pregnancies did not result in a live birth. The researchers assert that the encouraging finding of nearly universal well-baby care creates an important opportunity for intervention. They recommend that pediatricians be trained to screen postpartum women for abuse and that physicians be educated about the long-term nature of domestic violence.
The investigators' recommendations are seconded in a related editorial that advocates building questions on physical abuse into standard forms used in routine well-baby care.2 The editorial authors assert that pediatricians could actively prevent child abuse and further domestic violence by screening battered mothers who happen to come into their practices. They conclude that pediatricians and other health professionals involved in caring for infants should focus on filling the gap in screening for physical abuse during the immediate postpartum period, because "it is the right thing to do."--L. Remez
1. Martin S et al., Physical abuse of women before, during, and after pregnancy, Journal of the American Medical Association, 2001, 285(12):1581-1584.
2. Thompson RS and Krugman R, Screening mothers for intimate partner abuse at well-baby care visits: the right thing to do, commentary, Journal of the American Medical Association, 2001, 285(12):1628-1630.