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