Intimate Partner Violence During Pregnancy and the Risk for Adverse Infant Outcomes: A Systematic Review and Meta-Analysis Donovan BM, Spracklen CN, Schweizer M, Ryckman KK, Saftlas AF

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Clinical Scenario A nulliparous woman visits her midwife at weeks with her partner. She is a healthy non-smoker. Her dating ultrasound scan was normal. She works as a shop assistant and lives with her partner. This is an unplanned but wanted pregnancy. She reports no concern. You notice small circular burn marks on her forearm, which the woman described as accidental burn by an iron. How would you counsel this woman?

The Clinical Question Are women who experience intimate partner violence (IPV) during pregnancy at higher risks of having adverse birth outcomes, than women who do not experience IPV during pregnancy?

Background IPV during pregnancy has been shown to increase a woman’s risk of having adverse birth outcomes Previous meta-analyses found significantly increased unadjusted odds of low birth weight among infants of women exposed to IPV compared to women who did not (Murphy et al, 2001; Shah and Shah, 2010) Previous meta-analyses did not evaluate the effects of specific types of violence on adverse birth outcomes

Structured Question ParticipantsPregnant women InterventionWomen who experienced IPV during pregnancy Included studies used different exposure scales to ascertain this exposure ComparisonWomen who did not experience IPV during pregnancy Outcomes Preterm birth (PTB): infants born before 37 weeks gestation Low birth weight (LBW): infants born <2500g Small-for-gestational age (SGA): birth weight <10 th percentile for a given gestational age Study DesignSystematic review and meta-analysis of observational studies

Background In your practice, how prevalent is IPV during pregnancy? How does this prevalent compared to the global prevalence of IPV during pregnancy? (see WHO Information Sheet)WHO Information Sheet Which additional factors would you consider when you counsel the woman in the scenario?

Figure 1. PRISMA flow chart of the search strategy

Methods (1) Critical appraise this study using the critical appraisal worksheet on systematic review by the Centre for Evidence-based Medicine (see suggested reading) How was IPV identified in the included studies of this meta-analysis? How was quality of the included studies assessed? (See Table 1 and S1)

Methods (2) What are the different factors leading to heterogeneity in a systematic review? How did the authors assess heterogeneity in this systematic review? (See suggested reading) How did the authors subsequently address the identified heterogeneity of the included studies?

Summary of pooled effect estimates of PTB, LBW, and SGA

Graphical representation of pooled effect estimates of PTB, LBW, and SGA stratified by violence type

Result and discussions Which interventions aimed at preventing IPV have been tested? Are they effective? (See Van Parys et al 2014) How would the results of this study influence your daily practice?

Authors’ summary Pooled odds ratios for PTB and LBW were significantly increased, even after adjusting for potential confounders, in women who experienced IPV. Multiple types of IPV exposure yielded larger effect estimates than just one type alone Significant heterogeneity was present in the included studies Understanding the underlying biological mechanism of the observed association between IPV and SGA is needed Future research should focus on the effectiveness of interventions to prevent violence during pregnancy and support women post- disclosure

Suggested reading Shah PS, Shah J; Knowledge Synthesis Group on Determinants of Preterm/LBW Births. Maternal exposure to domestic violence and pregnancy and birth outcomes: a systematic review and meta-analyses. J Womens Health (Larchmt) Nov;19(11): Murphy CC, Schei B, Myhr TL, Du Mont J. Abuse: a risk factor for low birth weight? A systematic review and meta-analysis. CMAJ May 29;164(11): World Health Organisation. Intimate partner violence during pregnancy: Information sheet. The Centre for Evidence-based Medicine. Critical appraisal worksheet on systematic review. Available from: National Institute for Health and Care Excellence. Guideline PH50. Domestic violence and abuse: multi- agency working. February Available from: The Cochrane Collaboration. Part 2 Section 9.5: Heterogeneity. Cochrane Handbook for Systematic Reviews of Interventions Version Available from Van Parys A-S, Verhamme A, Temmerman M, Verstraelen H. Intimate Partner Violence and Pregnancy: A Systematic Review of Interventions. Vermund SH, ed. PLoS ONE. 2014;9(1):e85084.

Authors’ Affiliations Brittney M. Donovan, MS 1 Cassandra N. Spracklen, MS PhD 2 Marin Schweizer, PhD 1,3,4 Kelli K. Ryckman, MS PhD 1,5 Audrey F. Saftlas, MPH PhD 1 1.Department of Epidemiology, College of Public Health, University of Iowa, USA 2.Department of Genetics, University of North Carolina, USA 3.Department of Internal Medicine, Carver College of Medicine, University of Iowa, USA 4.Iowa City VA Health Care System, USA 5.Department of Pediatrics, Carver College of Medicine, University of Iowa, USA There are no conflicts of interest to declare. Corresponding to: