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, 2006
Tjaden, 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):61-5
Silverman et al, Am J Obset Gyn, 2006;195(1):140-8
Whitaker, 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)
Characteristic
HIV-Positive
(n= 35)
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
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
n = 688
Correlates of ever experiencing
domestic violence
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
n = 688
Birth Outcomes


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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 outcomes
ODDS RATIO
95%
CONFIDENCE
INTERVAL
p
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
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
N = 301
VARIABLE
Violence During Pregnancy
Ever Experienced Violence
* Linear regression performed. Values reported are β coefficients
Multivariate logistic regression
models
VARIABLE
ODDS RATIO
95% CI
p
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
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
Ever Experienced Domestic Violence*
Domestic Violence During Pregnancy†
* 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