For pregnant women, silence on domestic violence speaks loudly.

Pregnant women reporting abuse are at increased risk for certain adverse pregnancy outcomes: When compared with women who report no abuse, those reporting verbal abuse are more likely to deliver an infant of low birth weight, and those reporting physical abuse bear infants with a higher neonatal death rate, according to an observational study conducted from December 2000 to March 2002. (1) But pregnant women who do not wish to discuss domestic violence may be at greater risk for pregnancy complications and adverse infant outcomes than those who consent to such discussions.

Because there are few data to support the common belief that abuse during pregnancy increases the likelihood of complications, researchers at the University of Texas Southwestern Medical Center in Dallas sought to examine the associations between domestic violence and adverse pregnancy outcomes. Women presenting at the labor and delivery unit were asked if they would answer some questions "about physical or emotional trauma." Each woman who agreed was asked, in a face-to-face interview, the four questions that make up the HITS survey, a validated questionnaire for assessing domestic violence: whether a partner or family member had physically hurt her, insulted her or talked down to her, threatened her with harm, or screamed or cursed at her during this pregnancy Women answering yes to any of the questions were offered the phone number of a 24-hour domestic violence intervention center. The results of the survey were matched to delivery data using the facility's database containing information on all obstetric and neonatal outcomes. The Wilcoxon rank-sum test, Student t test and chi-square were used for the statistical analyses.

Women were eligible for participation if they were carrying a single fetus of greater than 24 weeks' gestation, but were excluded if they required immediate care or were about to deliver, among other factors. In all, 16,041 women were asked to be interviewed about abuse they had experienced during their pregnancy The vast majority of women (93%) denied any abuse; 1% reported physical abuse, 5% reported verbal abuse and 1% declined to be interviewed. Most of the participants were Hispanic (64-85%) and young (mean ages of 23.4-24.9 years), and had received prenatal care (96-97%); only 90% of those who declined to be interviewed had received prenatal care. Across all groups, 29-39% had never given birth before.

There were striking differences in regard to adverse pregnancy outcomes among the four study groups. Infants born to women who reported verbal abuse only had a significantly increased incidence of low birth weight, compared with those born to women in the no-abuse group (8% vs. 5%). Infants born to women in the physical-abuse group were at greater risk for death than were those born to women who had not been abused (2% vs. 0.2%); however, infants born to women in the physical-abuse group did not show an increased incidence of low birth weight.

The women who declined to be interviewed had higher rates of placental abruption and premature births (32 or fewer weeks' gestation) when compared with the no-abuse group (2% vs. 0.2% and 5% vs. 1%, respectively). Infants born to women in the declined-interview group required admission to the neonatal intensive care unit at a higher rate than all other groups--7% versus 2%. These infants also had an increased rate of low birth weight (13%, compared with 5% in the no-abuse group). Infants born to women who declined to be interviewed weighed less than those born to women who reported no abuse (mean weight, 3,192 g vs. 3,366 g).

Noting that the women most unwilling to discuss the issue of domestic violence are at the highest risk for adverse pregnancy outcomes, the investigators speculate that these women are being abused and do not speak up for fear of retribution. They suggest that "future efforts to study and prevent domestic violence during pregnancy should consider that the women who remain silent when questioned about the subject may, in fact, be speaking the loudest." Although they provided women who declined to be interviewed with the same intervention offered to the women who reported abuse (the telephone number of a crisis center), the researchers suggest that subsequent studies focus on new interventions to help "those who do not (cannot) respond to questions about their circumstances."

REFERENCE

(1.) Yost NP et al., A prospective observational study of domestic violence during pregnancy, Obstetrics & Gynecology, 2005, 106(1):61-65.