Factors associated with domestic violence prior to and during pregnancy in HIV infected and HIV at risk women
Rodney Wright, MD
Mentor: Mayris Webber, DrPH
Background
Verbal and physical abuse of women is a significant public health problem
Approximately 1.5 million women are raped and/or physically assaulted by an intimate partner each year in the US
Over 1200 women were killed by an intimate partner in the year 2000
Domestic violence has been estimated to occur in 4-8% of pregnancies
CDC Intimate Partner Violence Fact Sheet, 2006Tjaden, et al Department of Justice Report No.: NCJ 181867
Background
Domestic violence during pregnancy associated with: Low birth weight Neonatal death Increased NICU admissions
Domestic violence in the home has been associated with increased aggressive behavior in childhood
Yost et al, Obstetrics and Gynecology 2005 Jul;106(1):61-5Silverman et al, Am J Obset Gyn, 2006;195(1):140-8Whitaker, et al. Archives of general psychiatry 2006 May;63(5):551-60
Background
HIV infection is likewise a major health concern for women AIDS is the leading cause of death in
African American women aged 25 – 34 Second leading cause of death in
Hispanic women of the same age group
CDC, HIV/AIDS Among US Women, July 2003
Regional HIV statistics and features for women 2003 and 2005
Number or women (15-49) living with HIV
Percent of adults (15-49) with HIV who are women (%)
Sub-Saharan Africa 2003
2005
13.1 million
13.5 million
57
57
South and SE Asia 2003
2005
1.6 million
1.9 million
25
26
Caribbean 2003
2005
140 000
140 000
50
50
Western and Central Europe
2003
2005
180 000
190 000
27
27
North America 2003
2005
270 000
300 000
25
25
Total (worldwide) 2003
2005
16.5 million
17.5 million
47
46
Source: UNAIDS / WHO AIDS Epidemic Update: December 2005
Background
Many risk factors associated with domestic violence also associated with increase risk of contracting HIV Annual income < $10,000 Trading sex for drugs or money Having sex with men who use drugs Drug abuse Alcohol abuse
Koenig et al, Mat Child Health J, 2000 Jun;4(2):103-9
Objectives
Primary: To determine the factors associated with domestic violence during and prior to pregnancy in HIV positive and HIV at risk women participating in the MIRIAD study
Secondary: To determine if domestic violence is associated with adverse birth outcomes in this cohort
MIRIAD
Mother Infant Rapid Intervention at Delivery
Evaluated the feasibility of performing rapid HIV testing on the labor floor
Cohort consisted of poor, inner city, primarily minority women, some with limited access to medical care
Hypothesis
HIV positive status is associated with domestic violence in the MIRIAD cohort of women
Methods
MIRIAD conducted at 16 sites in six US cities Women offered enrollment into MIRIAD if they presented
to the labor floor without documentation of HIV status Data collected from November 2001 - January 2005 Data analyzed from post partum interviews conducted as
part of this study Initially when a patient tested HIV positive, an interview was
offered to her and the next three HIV negative MIRIAD enrollees at her site
Procedure changed in December 2002 when 500 HIV negative women were interviewed
Additional peri-partum data were extracted from patient charts
Methods
Bivariate analyses were performed using χ² derived by logistic regression
Odds ratios and 95% confidence intervals were derived
Student’s t tests were performed to analyze demographic data
Both linear and logistic regression were used to evaluate birth outcomes
Methods
Separate multivariate logistic regression models were created to describe factors associated with ever experiencing domestic violence and for experiencing domestic violence during pregnancy Age, race and variables with p<0.25 were
initially included in the violence during pregnancy model
Age, race and variables with p<0.10 were initially included in the ever experiencing domestic violence model
Methods
Multiple gestations were excluded from birth outcome analyses
Women who were very ill or whose children did not survive were not interviewed
Data analysis was conducted using Stata 9.1
Characteristics of population studied
HIV-Negative
(n= 653)
HIV-Positive
(n= 35)
Characteristic Percent n Percent n p value
Age (years) 25.9† ± 6.6* 29.0† ± 6.7* 0.01
African American race 64% 421 89% 31 0.003
Single 51% 326 77% 27 0.002
History of Drug Use‡ 33% 216 29% 10 0.58
History of STD 18% 115 17% 6 0.94
Received psychiatric services in past year
5% 326 14% 5 0.01
Total monthly household income less than $250
13% 87 23% 8 0.11
* standard deviation
† mean
‡ includes marijuana and “street drugs” (cocaine, heroin, crack)
Results
Ever experienced domestic violence: 22%
HIV positives: 24.2% HIV negatives: 21.8%
p=0.75
Experienced domestic violence during pregnancy: 5.8% HIV positives: 3.0% HIV negatives: 5.9%
p=0.37
Correlates of domestic violence during pregnancy
n = 688 Odds Ratio
95% Confidence
Interval p
HIV status 0.37 0.45 – 3.19 0.37
Age <24 years 2.71 1.27 – 5.80 0.01
Less than high school education 1.72 0.81 – 3.66 0.16
Total monthly household income less than $250 2.52 1.00 – 6.34 0.05
Mexican / Central American born 4.73 1.26 – 17.78 0.02
Used drugs during pregnancy 3.22 1.39 – 7.48 0.01
Ever used drugs 2.13 0.87 – 5.27 0.10
Father of baby uses drugs 4.71 1.69 – 13.14 0.003
Depression score 1.07 0.99 – 1.16 0.10
STD during pregnancy 1.22 0.43 – 3.44 0.71
Single 1.92 0.85 – 4.34 0.12
Homeless in past year 1.62 0.73 – 3.63 0.23
Currently lives in shelter 8.92 0.90 – 88.44 0.06
Moved in past year 1.97 0.93 – 4.16 0.08
Number of years lived in US 0.95 0.91 – 0.99 0.01
Correlates of ever experiencing domestic violence
n = 688 Odds Ratio
95% Confidence
Interval p
HIV status 1.14 0.51 – 2.59 0.75
Age < 24 years 0.67 0.46 – 0.96 0.03
US born 2.26 1.47 – 3.47 <0.001
Caribbean born 0.52 0.28 – 0.99 0.05
Less than high school education 1.51 1.05 – 2.19 0.03
Used drugs during pregnancy 3.36 1.99 – 5.66 <0.001
Ever used drugs 3.45 2.34 – 5.11 <0.001
Father of baby uses drugs 3.13 1.64 – 5.99 0.001
Depression score 1.16 1.11 – 1.22 <0.001
History of STD 3.96 2.59 – 6.05 <0.001
Single 1.89 1.30 – 2.76 0.001
Homeless in past year 3.35 2.11 – 5.31 <0.001
In prison in past year 3.23 1.76 – 5.93 <0.001
History of trichomonas 5.28 2.37 – 11.76 <0.001
In drug rehab program in past year 7.28 1.32 – 40.13 0.02
New male partner during this pregnancy 3.55 1.67 – 7.54 0.001
Has children in foster care 4.13 2.07 – 8.03 <0.001
Birth Outcomes
Data available for 301 subjects (269 HIV negative and 32 HIV positive)
No association between domestic violence during pregnancy and low birth weight, low Apgar score, preterm labor, cesarean delivery, or post partum complications
HIV status was associated with low birth weight (OR 2.26, 95%CI 1.00-5.10)
This association was not present after adjusting for maternal age, race, and drug use (OR 1.64, 95%CI 0.67-4.03)
Birth outcomesN = 301
VARIABLE ODDS RATIO
95% CONFIDENCE
INTERVAL p
Violence During Pregnancy
Cesarean delivery 0.26 0.05 – 1.28 0.10
Preterm labor 1.63 0.46 – 5.76 0.45
Positive urine toxicology screen 5.38 1.59 – 18.12 0.01
Low birth weight 2.40 0.69 – 8.29 0.17
Apgar score 0.13* -0.26 – 0.52* 0.50
Post partum complications 0.98 0.17 – 5.51 0.98
Ever Experienced Violence
Cesarean delivery 1.01 0.53 – 1.92 0.97
Preterm labor 1.15 0.48 – 2.62 0.80
Positive urine toxicology screen 2.11 1.04 – 4.27 0.04
Low birth weight 1.03 0.51 – 2.05 0.94
Apgar score 0.03* -0.20 – 0.26* 0.78
Post partum complications 2.37 0.86 – 6.47 0.09
* Linear regression performed. Values reported are β coefficients
Multivariate logistic regression models
VARIABLE ODDS RATIO 95% CI p
Ever Experienced Domestic Violence*
Age 1.04 1.01 – 1.07 0.02
Ever used drugs 2.33 1.46 – 3.71 <0.001
Ever had STD 3.08 1.86 – 5.09 <0.001
Number of children in the home 1.15 1.03 – 1.28 0.01
Depression score 1.10 1.04 – 1.16 <0.001
Homeless in past year 2.67 1.51 – 4.72 0.001
Domestic Violence During Pregnancy†
Age 0.94 0.88 – 1.01 0.07
Father of baby uses drugs 3.45 1.12 – 10.59 0.03
Lives in shelter 9.38 0.78 – 112.84 0.08
Used drugs during pregnancy 4.02 1.57 – 10.24 0.004* Variables considered in the prediction model:
HIV status, ever used drugs, new partner during pregnancy, partner support score, depression (CESD) score, ever had STD, homeless in past year, race, marital status, in prison in past year, number of children in the home, insurance status, place of birth and age
†Variables considered in the prediction model:
HIV status, educational level, lives in shelter, used drugs during pregnancy, depression (CESD) score, marital status, age, total monthly household income, place of birth, and father of baby currently uses drugs
Conclusions
Many factors were found to be associated with domestic violence
HIV infection was not associated with domestic violence Possibly due to small number of women testing positive Risk profiles of HIV positives and HIV negatives were
similar in this population Similar number of sexual partners, prevalence of
homelessness, history of STD, substance abuse
Place of birth can be a significant predictor of risk of domestic violence
Limitations
Data collected for reasons other than the evaluation of domestic violence Some questions related to domestic violence were not
asked History of childhood sexual abuse How recently did the domestic violence that was reported to
occur actually occur No scale of partner aggression or relationship power
included
Possible social desirability bias Direct questioning done on the labor floor may have
limited responses to questions Possibly underestimates rates of domestic violence and
risk factors
Limitations
Birth outcome data limited by the exclusion of women who were very ill themselves or whose infants died Part of the original design of the MIRIAD study
Data only available for 301 women Due to IRB issues Some records incomplete
Conclusions
Even though domestic violence was not associated with HIV status, many important social and demographic factors are.
Additional targeted interventions are needed to identify and protect at risk women and to lessen the potentially devastating long term effects of domestic violence.
Acknowledgments
Mayris Webber DrPH Peter Bernstein MD MPH Irwin Merkatz MD MIRIAD staff and team
Especially Kelly Monaghan
MIRIAD study participants
MIRIAD funded by CDC
This analysis funded through Bronx CREED