1. Intimate Partner Violence (IPV) and Women’s Health during Pregnancy Findings from the 2004-2008 Rhode Island PRAMS Hanna Kim, Samara Viner-Brown, Rachel Cain Center for Health Data and Analysis Rhode Island Department of Health

2. Background Intimate Partner Violence (IPV) occurs between two people in a close relationship – current and former spouses and dating partners. IPV includes four types of behavior: –Physical abuse –Sexual abuse –Threats of physical or sexual abuse –Psychological and emotional abuse Each year in the U.S., IPV affects approximately 1.5 million women overall and affects as many as 324,000 pregnant women.

3. Background Women experiencing IPV during pregnancy have high levels of stress, are more likely to smoke or use other drugs, deliver a preterm or low birth weight infant, have an increase in infectious complication, and are less likely to obtain prenatal care. The cost of IPV, including medical care, mental health services, and lost productivity, was estimated more than $8.3 billion in 2003. The ACOG, the AMA, and the AAFP recommend routine screening of all women for IPV.

4. Study Questions What is the prevalence of IPV before or during pregnancy among Rhode Island recent mothers? Who are at risk for IPV? Is IPV associated with maternal health during pregnancy and the health of their newborn infants?

5. Methods Data Source: 2004-2008 RI Pregnancy Risk Assessment Monitoring System (PRAMS) – Total Respondents for 5 years: 6,959 – Weighted Response Rate (5-year average): 73.2% – Average PRAMS population per year: 11,816 YearPRAMS Pop.RespondentsWeighted R.R. 200412,0641,50675.5 200512,0131,42475.1 200611,7321,36072.5 2007118021,37272.1 200811,4671,29770.4

6. What is the PRAMS? (Pregnancy Risk Assessment Monitoring System) A surveillance project of the CDC and state Health Departments to monitor the health of mothers and infants. Collects state-specific, population-based data on maternal behaviors and experiences before, during, and after pregnancy. A sample survey of recent mothers and administered 2-5 months after baby’s delivery by mail or telephone. The PRAMS sample is chosen from all women who had a live birth recently.

7. Intimate Partner Violence (IPV) Before Pregnancy During the 12 months before you got pregnant, 1) did an ex-husband or ex-partner push, hit, slap, kick, choke, or physically hurt you in any other way? 2) were you physically hurt in any way by your husband or partner? During Pregnancy During your most recent pregnancy, 1) did an ex-husband or ex-partner push, hit, slap, kick, choke, or physically hurt you in any other way? 2) were you physically hurt in any way by your husband or partner?

8. Pregnancy Complication Vaginal Bleeding Kidney or Bladder (Urinary Tract) Infection Severe Nausea, Vomiting, or Dehydration Preterm or Early Labor (labor pains > 3 weeks before baby’s due) Premature Rupture of Membranes [PROM] (water broke > 3 weeks before baby’s due) Diagnosed Depression Maternal Health

9. Newborn Health Low Birth Weight Infant (< 2,500 g) Preterm Infant (< 37 gestational weeks) NICU Staying Newborn Health

10. Maternal Age Household Income Maternal Education Ethnicity Race Marital Status Prenatal Care Smoking during pregnancy Pregnancy Intendedness Maternal Characteristics Demographic factors Behavioral factors

11. Statistical Analysis Chi-square tests for bivariate relationships between maternal characteristics (socio-demographic and behavioral factors) and IPV Multivariable logistic regression analyses to determine the effects of IPV on maternal and newborn health SUDAAN v10 software was used for statistical analysis to account for complex sample design of the survey

12. Results

13. Prevalence of IPV Rhode Island, 2004-2008 Combined

14. Prevalence of IPV by Maternal Age, RI 2004-08 P <.0001

15. Prevalence of IPV by Household Income, RI 2004-08 P <.0001

16. Prevalence of IPV by Maternal Education, RI 2004-08 P <.0001

17. Prevalence of IPV by Ethnicity, RI 2004-08 P <.01

18. Prevalence of IPV by Race, RI 2004-08 P <.001 * American Indian: n < 100

19. Prevalence of IPV by Marital Status, RI 2004-08 P <.0001

20. Prevalence of IPV by Prenatal Care Status, RI 2004-08 P <.001

21. Prevalence of IPV by Smoking Status, RI 2004-08 P <.0001

22. Prevalence of IPV by Pregnancy Intendedness, RI 2004-08 P <.0001

23. Demographic Characteristics: The prevalence of IPV before/during pregnancy was significantly higher among Teens (13.1%), Blacks (8.6%), Hispanics (8.0%), mothers with incomes <$15K (13.2%), <high school education (10.1%) and unmarried mothers (11.2%). Behavioral Characteristics: The prevalence of IPV before/during pregnancy was significantly higher among mothers having delayed/no prenatal care (8.9%), mothers smoking during pregnancy (16.4%), and mothers whose pregnancy was unintended (9.0%). Prevalence of IPV: Bivariate Analysis

24. Pregnancy Complication by IPV Status, RI 2004-08 % * P<.05; ** P<.01; *** P<.0001

25. Effect of IPV on Maternal Health Multivariable Logistic Regression To assess the independent effect of IPV on maternal health, the following logistic regression models were used. Outcome: Each Pregnancy Complication Condition Exposure: IPV before/during Pregnancy Confounders: Maternal Age, Household Income, Education, Ethnicity, Race, Marital Status, Prenatal Care, Smoking during pregnancy, and Pregnancy Intendedness

26. Vaginal Bleeding Urinary Tract Infection Nausea/ Vomiting /Dehydra tion Preterm/ Early LaborPROM Dx Depressi on Had IPV 1.5* (1.1-2.1) 1.5** (1.1-2.1) 1.8*** (1.4-2.4) 1.5* (1.1-2.0) 1.8** (1.2-2.6) 2.6*** (1.8-3.6) No IPV 1.0 Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs)# * p<.05; **p<.01; *** p<.001 Effect of IPV on Maternal Health Multivariate Logistic Regression # AORs and 95% CIs were calculated after controlling for age, race, ethnicity, marital status, household income, and educational level, smoking during pregnancy, prenatal care status, and pregnancy intendedness.

27. Newborn Health by IPV Status, RI 2004-2008 % * P<.05; ** P<.01 ns: Not Significant ns

28. To assess the independent effect of IPV on Newborn Health, the following logistic regression models were used. Outcome: Low Birth Weight Infant Preterm Infant NICU Staying Main Exposure: IPV before/during Pregnancy Control: Maternal Age, Household Income, Maternal Education, Ethnicity, Race, Marital Status, Prenatal Care, Smoking during pregnancy, and Pregnancy Intendedness Effect of IPV on Newborn Health Multivariate Logistic Regression

29. Low Birth WeightPreterm BabyNICU Stay Had IPV 1.0 (0.8-1.1) 1.2 (0.8-1.6) 1.3 (0.9-1.9) No IPV 1.0 Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs)# # AORs and 95% CIs were calculated after controlling for age, race, ethnicity, marital status, household income, and educational level, smoking during pregnancy, prenatal care status, and pregnancy intendedness. Effect of IPV on Newborn Health Multivariate Logistic Regression ns ns: Not significant

30. Conclusions One in 17 (5.7%) Rhode Island recent mothers experienced IPV before or during pregnancy. Women who are at high risk for IPV include teens, Hispanics, Blacks, unmarried, women with low household income and low education, women having delayed/no prenatal care, smoking during pregnancy, and having unintended pregnancy.

31. Conclusions Women who experienced IPV before /during pregnancy had increased odds of having complications during pregnancy, even after controlling for confounding factors. Newborn health, measured by LBW infant, Preterm infant, and NICU staying, was not significantly associated with IPV before/during pregnancy when confounding factors were controlled.

32. Limitations Pregnancy complications were determined by respondent’s self-report, not by medical records. Since IPV in this study included only physical abuse (Sexual, Threats, or Emotional abuse was not measured), its prevalence may be underestimated. Reporting Issue: IPV is considered a sensitive issue - possible under-reported.

33. Public Health Implications Since IPV before/during pregnancy is common and associated with harmful consequences, it is a significant public health concern. Routine screening for IPV by health care providers is necessary before, during and after pregnancy to identify the victims of IPV and refer them to the appropriate services.

34. THANK YOU! Contact Information: Hanna Kim, PhD: Hanna.Kim@health.ri.gov