Published: January 22, 2009
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco .
TAMPA, Jan. 22 -- Women victimized by spousal abuse are at a substantially increased risk of losing at least one pregnancy, researchers found.
Women who had ever experienced domestic abuse of any kind were 50% more likely to have had a single or repeated stillbirth or spontaneous abortion, Amina Alio, Ph.D., of the University of South Florida here, and colleagues reported in the Jan. 24 issue of The Lancet.
Notably, sexual abuse had the strongest effect on fetal loss overall (OR 1.7, 95% confidence interval 1.3 to 2.2) whereas emotional abuse had the strongest association with multiple stillbirths or miscarriages (OR 1.7, 95% CI 1.2 to 2.3).
The effect of these kinds of nonphysical abuse is often underestimated across cultures, Dr. Alio said.
These findings from a population-based study in Africa, which has the world's highest fetal loss rates, supported prenatal screening for spousal violence, Dr. Alio said.
"Unfortunately, even in the U.S. we don't always screen for domestic violence," she said, adding that the effect would likely be generalizable to the developed world despite lower occurrence.
Claudia Garcia-Moreno, M.D., of the World Health Organization in Geneva, agreed that antenatal screening is appropriate. However, she noted in an accompanying editorial, few interventions have had a demonstrable impact on health outcomes.
Prior studies have linked spousal abuse to fetal demise but rarely distinguished between induced abortion and miscarriage.
So, Dr. Alio's group analyzed findings from a demographic health survey of women in the sub-Saharan nation of Cameroon that differentiated between voluntary and involuntary fetal deaths.
Among the 2,562 women who responded to specific questions regarding abuse under private, anonymous conditions, 51% reported at least one type of abuse from their husband or spouse.
Physical violence was most common (39%), followed closely by emotional abuse, defined as verbal or physical public humiliation or verbal threatening of the woman or her family (31%). Another 15% reported being forced to have sex or perform sexual acts.
Overall, women exposed to any form of domestic violence were at significantly elevated risk of at least one episode of fetal loss compared with women not exposed to abuse (28.8% versus 20.7%, odds ratio 1.5, P<0.0001).
This risk further increased for women exposed to more than one type of abuse by their spouse (31.5% versus 26.0% for one type, P<0.0001).
Recurrent fetal mortality was also more common with any type of spousal abuse than among women not reporting (9.8% versus 6.5%, P=0.002) and rose with multiple types of abuse (11% versus 9%, P=0.002).
Many times women don't consider sexual or emotional abuse to be violence, which screening needs to take into account, she added. "We need to ask the right questions and be a little more specific."
The findings also suggest that screening women who've unintentionally lost a pregnancy is important to potentially prevent recurrence, Dr. Alio's group wrote.
An intervention that could entirely eliminate spousal abuse was estimated to prevent 33% of recurrent fetal losses while reducing the prevalence of spousal abuse by even half would prevent 17% of these losses.
The researchers cautioned, though, that the study was limited by lack of temporal data to indicate whether spousal violence preceded fetal loss.
Primary source: The Lancet
Source reference: Alio AP, et al "Spousal violence and potentially preventable single and recurrent spontaneous fetal loss in an African setting: cross-sectional study" Lancet 2009; 373: 318-24.
Additional source: The Lancet
Source reference: Garcia-Moreno C "Intimate-partner violence and fetal loss" Lancet 2009; 373: 278-79.