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Linda J. Koenig, PhD, Daniel J. Whitaker, PhD, Rachel A. Royce, PhD, MPH, Tracey E. Wilson, PhD, Michelle R. Callahan, PhD and M. Isabel Fernandez, PhD For The Perinatal Guidelines Evaluation Project Group

Linda J. Koenig and Daniel J. Whitaker are with the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Ga. At the time of the study, Rachel A. Royce was with the Department of Epidemiology, University of North Carolina at Chapel Hill. Tracey E. Wilson is with the Department of Preventive Medicine and Community Health, Health Science Center, State University of New York at Brooklyn. Michelle R. Callahan is with the Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Conn. At the time of this study, M. Isabel Fernandez was with the Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, Miami, Fla.

Correspondence: Requests for reprints should be sent to Office of Communications, National Center for HIV, STD, and TB Prevention, Mail Stop E-06, Atlanta, GA 30333

	ABSTRACT

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Objectives. This study estimated the prevalence of violence during pregnancy in relation to HIV infection.

Methods. Violence, current partnerships, and HIV risk behaviors were assessed among 336 HIV-seropositive and 298 HIV-seronegative at-risk pregnant women.

Results. Overall, 8.9% of women experienced recent violence; 21.5% currently had abusive partners. Violence was experienced by women in all partnership categories (range = 3.8% with nonabusive partners to 53.6% with physically abusive partners). Neither experiencing violence nor having an abusive partner differed by serostatus. Receiving an HIV diagnosis prenatally did not increase risk. Disclosure-related violence occurred, but was rare.

Conclusions. Many HIV-infected pregnant women experience violence, but it is not typically attributable to their serostatus. Prenatal services should incorporate screening and counseling for all women at risk for violence. (Am J Public Health. 2002;92:367–370)

	INTRODUCTION

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Conservative estimates suggest that 4% to 8% of women in the United States experience violence during pregnancy.^1,2 Several factors suggest that risk for violence may be even higher for pregnant women with HIV infection. Women with HIV are at increased risk for violence relative to the general population,^3,4 perhaps because demographic and behavioral factors associated with HIV (e.g., poverty, drug use, bartering sex) also increase a woman's exposure to violence.^5–9 In addition, some HIV-infected women may be at risk for violence when their positive serostatus is disclosed.^10–15 Because a large proportion of HIV infections in women are diagnosed through routine prenatal screening,^16–19 many disclosures may occur during pregnancy. Moreover, modifications of obstetric and postpartum care to prevent perinatal transmission (e.g., additional medications, formula feeding)^20,21 may make it more difficult for women who are pregnant or have recently given birth to keep their serostatus private.

Data collected as part of the Perinatal Guidelines Evaluation Project—HIV and Pregnancy Study were used to examine the prevalence of violence during pregnancy among women with HIV and to ascertain if, and in what way, violence might be related to HIV serostatus. Specifically, seronegative women were matched to seropositive women on a number of demographic and HIV risk characteristics also associated with risk for violence. Owing to concerns that widespread prenatal screening for HIV might inadvertently increase women's risk for negative social consequences such as violence, the impact of receiving an HIV diagnosis during pregnancy was assessed. Finally, the association between recent violence and current partnership category was assessed and, for HIV-infected women, violence associated specifically with partner serostatus disclosure was examined.

	METHODS

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Between October 1996 and October 1998, pregnant women receiving prenatal care (336 HIV-infected and 298 HIVuninfected women) were recruited from health departments and clinics in Brooklyn, NY (n = 224), Connecticut (n = 55), Miami, Fla (n = 220), and North Carolina (n = 135), either directly or through their providers. All HIV-infected women at participating clinics were eligible. Eligible uninfected women (those receiving services at the clinic and testing negative for HIV during the current pregnancy) were screened and matched (± 5%) to HIV-infected women within the same state according to the frequency of the following: sexual transmission risk behavior (ever used crack, had sex with a man known to use or suspected of using intravenous drugs, or traded sex for drugs or money), intravenous drug use, race/ethnicity, and timing of entry into prenatal care. (The cohort and design have been previously described.²²)

Demographic, behavioral, and HIV-related information was collected from women through interviews (in English, Spanish, or Haitian Creole) at 24 weeks or more into the pregnancy. Violence during pregnancy, referred to as recent violence, was assessed by asking women whether they had been "beaten, physically attacked, or physically abused" or "sexually attacked, raped, or sexually abused" by anybody during the past 6 months. Relationship with an abusive partner was categorized by asking women with a main male partner how frequently, when upset, does he "physically abuse or hurt you" or "verbally or emotionally abuse you." Women answering "always," "often," or "sometimes" were considered to have an abusive main male partner. Thus, we measured the proportion of women who experienced acts of violence during the specified period (regardless of perpetrator), or who currently had an abusive intimate partner (regardless of whether a violent act occurred during pregnancy). HIV-infected women were asked, "Does your partner know about your HIV infection?" and "Did anything bad happen when he found out about your HIV?"

	RESULTS

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Demographic and behavioral characteristics of the HIV-infected sample reflected those of the broader HIV epidemic among women and, with few exceptions, were similar to those of uninfected women (Table 1). Recent violence was reported by 8.9% of women. All but 1 woman who reported sexual violence also reported physical violence. Most women had a main male partner; 21.5% described their partner as physically or verbally/emotionally abusive. Violence was significantly associated with partnership category (highest for physically abusive, lowest for nonabusive, intermediate for verbally/emotionally abusive or no partner), but almost three fourths of the women who experienced violence were not currently in a relationship with a physically abusive partner (Table 2).

	DISCUSSION

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Overall, 8.9% of pregnant women in this study experienced recent violence. Although this is only slightly higher than average proportions previously reported,¹ it confirms that violence against pregnant women is a significant public health problem, endangering both the woman and her fetus.^23–32 Extrapolating from the 6000 to 7000 yearly births to women in the United States with HIV,³³ we calculate that violence likely affects somewhere between 528 and 616 HIV-infected pregnant women each year. Although risk for violence did not differ by serostatus, we do not yet know if violence has a different impact on HIV-infected women, who are already at increased risk for adverse birth outcomes,^22,34,35 and who must adhere to complex medication regimens during pregnancy.^21,36

Moreover, many more women may be at risk for violence and its health-related consequences, as 21.5% of the women in the study currently had an abusive primary partner. Not surprisingly, women with a physically abusive partner were most likely to experience recent violence. However, many women whose partner was not physically abusive, and even those without a partner, experienced violence. This reinforces the need for routine risk assessment in prenatal care settings and for increased awareness that women face risks from ex-partners^5,37,38 and nonpartners,³⁹ as well as from current partners.

Consistent with other cohort studies of nonpregnant HIV-infected women in which the uninfected comparison women were drawn from demographically and behaviorally similar populations,^3,4,40 neither violence nor having an abusive partner was associated with serostatus. Moreover, receiving a prenatal HIV diagnosis was not associated with elevated risk for violence. Taken together, these findings suggest that violence against HIV-infected women is more likely related to the socioeconomic or behavioral contexts that characterize their lives than to serostatus itself. This is not to say that violence is never related to HIV. One woman was physically assaulted when her partner learned her serostatus. Moreover, many HIV-infected women had not disclosed their serostatus to their partners, and we do not know to what extent this may have been due to fear of violence. Providers must be aware of these risks and concerns when addressing issues of disclosure.⁶ However, HIV-infected women's risk for violence may be best addressed by providing access to economic and social services (e.g., financial assistance, substance abuse treatment) that target conditions known to be associated with risk of violence. The prenatal care setting, with its multiple scheduled provider contacts, may provide an important opportunity for identifying and referring women at risk.

These data represent a large and unique sample of HIV-infected and at-risk pregnant women. Nevertheless, certain limitations apply. Women in prenatal care may be at less risk for violence than those not in care. Moreover, by assessing only a 6-month period of time, some incidents of violence during pregnancy may have been missed. At the same time, because we enrolled women as early as 24 weeks into pregnancy, some incidents of violence may have occurred in the weeks just before conception. Future research will want to identify and address risk associated with specific pregnancy periods⁴¹ (e.g., preconception, postpartum) as well as the impact of partnership status on violence during those times.

	Acknowledgments

 
The Perinatal Guidelines Evaluation Project was funded by the Centers for Disease Control and Prevention (CDC) through cooperative agreements U64CCU412273 (Duke), U64CCU112274 (Yale), U64CCU412294 (Miami), and U64CCU212267 (SUNY). All procedures and consent forms were approved by the Institutional Review Boards at the Centers for Disease Control and Prevention and each participating university and hospital. We are grateful to the members of the study staff who assisted with data collection and project management and to the women who participated in the study.

Members of the Perinatal Guidelines Evaluation Project Group include Howard Minkoff, MD, Jack DeHovitz, MD, and Tracey Wilson, PhD (New York); Rachel Royce, PhD, and Emmanuel Walter, MD (North Carolina); Mary Jo O'Sullivan, MD, and M. Isabel Fernandez, PhD (Florida); Jeannette Ickovics, PhD, and Kathleen Ethier, PhD (Connecticut); and Linda Koenig, PhD, R. J. Simonds, MD, Jan Moore, PhD, Margaret Lampe, RN, Daniel Whitaker, PhD, Daphne Cobb, MS, and Ken Dominguez, MD (CDC).

	Footnotes

 
L. J. Koenig conceived of the study, with collaboration from all authors, and drafted and finalized the manuscript. D. J. Whitaker analyzed the data with assistance from L. J. Koenig and R. A. Royce. D. J. Whitaker, R. A. Royce, T. E. Wilson, M. R. Callahan, and M. I. Fernandez contributed to the interpretation of the results and to revisions of the paper. R. A. Royce, T. E. Wilson, and M. I. Fernandez directed study activities in their respective cities.

Peer Reviewed

Accepted for publication April 4, 2001.

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This Article Abstract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Koenig, L. J. Articles by Fernandez, M. I. Search for Related Content PubMed PubMed Citation Articles by Koenig, L. J. Articles by Fernandez, M. I. Related Collections HIV/AIDS Injury/Emergency Care/Violence Pregnancy Women's Health