Reference: Am J Obstet Gynecol. 2020 Feb;222(2):123-133.e5. (level 2 [mid-level] evidence)
Intimate partner violence (IPV) is any behavior that brings harm to an individual by someone of a past or current relationship (World Health Organization, 2012). IPV can manifest as physical violence, sexual abuse, psychological/emotional trauma, or coercion (World Health Organization, 2012). The United States Preventive Service Task Force (USPSTF) recommends routine screening for IPV of all women of child-bearing age (JAMA. 2018). The World Health Organization (WHO) estimates about 1 in 3 women have experienced IPV at some point in their lifetime (World Health Organization, 2013). Limited evidence suggests that the prevalence of IPV in pregnant women can range anywhere from 1% to 28% (World Health Organization, 2011). Complications of IPV during pregnancy can include uterine rupture, fetal and/or maternal death, low birth weight, and preterm deliveries (Clinical obstetrics and gynecology, 2007). Infant perinatal mortality remains a public health concern in the United States and throughout the world. Despite efforts, rates of infant perinatal mortality have remained unchanged. The study to be reviewed assesses the relationship between IPV and infant perinatal mortality.
A recent systemic review of 17 observational studies evaluated IPV in 32,397,499 pregnant women (Am J Obstet Gynecol. 2020 Feb). Study participants were women from 10 different countries. Inclusion criteria were observational (cross-sectional, case-control, cohort) studies that included associations between IPV during pregnancy and perinatal infant death. The types of IPV included were physical violence in 7 studies, psychological violence in 1 study, sexual violence in 2 studies, and unspecified type of violence in 10 studies.
Compared to no IPV, there was an increased risk of infant perinatal death associated with any type of IPV (odds ratio [OR] 2.89, 95% CI 2.04-4.08) in analysis of 16 studies with 32,365,641 women, physical IPV (OR 2.46, 95% CI 1.76-3.44) in analysis of 7 studies with 19,634 women, sexual IPV (OR 3.19, 95% CI 1.54-6.62) in analysis of 2 studies with 14,624 women, and unspecified IPV (OR 3.18, 95% CI 1.88-5.38) in analysis of 10 studies with 32,367,264 women. Results for any type of IPV and unspecified IPV were each limited by significant heterogeneity. Psychological IPV was not found to be associated with a significant increase in risk of infant perinatal death in 1 study with 358 women.
When looking at the socioeconomic variables, the association between IPV and infant perinatal death was stronger in higher GDP countries (OR 1.03, 95% CI 1.02-1.04) and in countries with higher percentages of health expenditure (OR 1.27, 95% CI 1.09-1.46) each in analysis of 16 studies with 32,365,641 women.
Prior to this study being conducted, no comprehensive analysis of the relationship between IPV and infant perinatal death had been performed. This meta-analysis found that infants of women who experience IPV during pregnancy are almost 3 times as likely to experience perinatal death compared to infants of women who have not been exposed to IPV during pregnancy. The stronger association of IPV and perinatal death in higher GDP countries and countries with higher health expenditure may be due to improved screening and detection methods. However, additional studies would be necessary to confirm this. Although IPV as a significant risk factor for infant perinatal mortality is a novel finding, these results are not surprising as previous studies have shown associations between maternal risk factors, such as violence, and poor obstetric outcomes (Women Birth. 2019 Dec) (BMC Pregnancy Childbirth. 2019 Mar 13) (BMC Public Health. 2018 May 3). This study is not without limitations, much of which can be attributed to the small number of studies identified, particularly for psychological and sexual subtypes of IPV, limiting the ability to make strong conclusions about the individual effects of each. Another limitation of this review was evidence of publication bias for physical IPV, with potential for an overestimation of effect. Despite limitations, this study suggests that IPV may be a risk factor for infant perinatal death and supports current recommendations and the importance of screening for IPV in women of child-bearing age.
For more information, see Intimate Partner Violence in DynaMed.
This Resident Focus was written by Zachary McGalliard, MD, MPH originally from Warner Robins, Ga. He obtained an undergraduate chemistry degree at Georgia Southern University in Statesboro, GA and shortly after a Master in Public Health degree. He went to Mercer University School of Medicine’s Savannah Campus for medical school and has continued to serve in southeast Ga as a family medicine resident at Memorial Health in Savannah. Dr. McGalliard has a passion for health inequity and social justice, with a strong focus on the psychological, social, and spiritual aspects of health. Dr. McGalliard plans to practice family medicine in rural underserved areas of southeast Ga. He cherishes time with his family and loving others continually. His favorite past time is running.