February 27,2014 — Summary of "Associations Between Intimate Partner Violence and Termination of Pregnancy: A Systematic Review and Meta-Analysis," Hall et al., PLOS Medicine, January 2014.
In this study, Megan Hall and colleagues at King's College's Women's Health Academic Centre in London conducted a research review and meta-analysis to examine whether there is a relationship between intimate partner violence (IPV) and termination of pregnancy (TOP). "An evidence-based understanding of the association between IPV and TOP would directly inform the development of strategies for effective interventions for IPV," the researchers wrote.
Hall and colleagues conducted a review of literature related to TOP and IPV published through September 2013. They included any studies that "(1) included women who were seeking or had undergone a TOP and studied at least one aspect of IPV in this group; (2) were a randomised control trial, case-control study, cohort study, cross-sectional analysis, experimental study, or secondary study with data of interest; and (3) were peer reviewed."
The researchers excluded studies that "focus[ed] on violence by individuals other than current or former intimate partners."
The researcher identified 74 research articles that met their criteria for inclusion. Most of the studies had been published since 2000, with the locations for research spanning Africa, Asia, Australasia, Europe, North America and South America, with one study analyzing intercontinental data. According to the researchers, the exposures in the studies included physical violence (53 studies), sexual violence (47), emotional violence (19) and a combination of one or more types of violence (42).
The researchers found that reported rates of IPV in the previous year among women who had undergone TOP ranged from 2.5% to 30%, while lifetime rates of IPV varied from 14% to 40%. According to a meta-analysis of the information, the "lifetime prevalence of IPV among TOP-seeking populations was found to be 24.9%."
Hall and colleagues found no significant association between "being single and IPV among a TOP-seeking population," between "partner support for the TOP and IPV" or between "IPV and previous TOP." However, the researchers did find an association between "partner not knowing about the TOP and IPV."
The researchers also examined the studies to assess associations between IPV with other reproductive and pregnancy factors, such as past obstetric history and contraceptive use. For example, nine studies found that "women who reported IPV were more likely than the comparator group to have a history of multiple TOPs." They also highlighted multiple studies that found an association between IPV and reproductive coercion.
In examining other factors related to TOP, the researchers found that women "reporting IPV were more likely to report an unwanted pregnancy" and that "women in violent relationships were more likely not to tell their partner about their decision to terminate." There was no association between "IPV and gestation at TOP," they noted.
Hall and colleagues also found a "significant association between reported IPV and psychosocial problems including" depression, suicidal ideation, stress and disturbing thoughts. Further, they noted that "many women wished to talk about IPV with regard to further management or intervention," with some citing their doctor as the main source of information.
In examining demographic factors, the researchers found that age, drug and alcohol use, education, employment, ethnicity, income and marital status did not have a "strong or consistent mediating effect" on IPV.
"High rates of physical, sexual, and emotional IPV were found across six continents among women seeking a TOP," the researchers wrote, adding that a "partner not knowing about the TOP was associated with IPV among women seeking TOP."
They noted also that women in violent relationships "were more likely to report inability to make autonomous contraceptive choices, partner contraceptive sabotage, and sexual violence, and they were less likely to have informed their partner about the pregnancy or involved him in decision-making about it." They added, "IPV was cited as a reason for wanting TOP, and rape-related pregnancy had a particularly high chance of leading to TOP."
Hall and colleagues wrote that while there was a "lack of data regarding long-term outcomes for women in violent relationships who underwent TOP ... associations with repeat TOP (and possibly miscarriage) lend support to the notion of a repetitive cycle of abuse and pregnancy."
Implications and Conclusion
"Health care professionals should be aware of the high rates of physical, sexual, and emotional violence among women seeking TOP, and particularly the clinical factors associated with greatest risk: previous TOP, lack of contraception, initially planned pregnancy, ultrasound redating, and the partner not funding or not being told about the TOP," the researcher wrote, adding that IPV can potentially be associated with "young age, marital status, ethnicity and low household income."
They wrote that "[g]ood practice obligates that termination services should have robust policies for ensuring women's safety and confidentiality, providing information and referral pathways for those who disclose IPV, and exemplar guidance exists."
In conclusion, they called for "novel public health approaches ... to address IPV against women and repeat TOP," adding that pregnancy termination services "provide an opportune health-based setting in which to design and test interventions at the individual level."