Matern Child Health J
DOI 10.1007/s10995-011-0784-y
Physical Abuse Around the Time of Pregnancy Among Women
With Disabilities
Monika Mitra • Susan E. Manning
Emily Lu
•
Ó Springer Science+Business Media, LLC 2011
Abstract Women with disabilities are at greater risk for
physical abuse than women without disabilities. However,
no previous population-based studies have examined physical abuse against women with disabilities around the time of
pregnancy, a critical period for mother and child. The
objective of this study was to describe the prevalence of
physical abuse before and during pregnancy among a representative sample of Massachusetts women with and without disabilities. Data from the 2007–2008 Massachusetts
Pregnancy Risk Assessment Monitoring System (PRAMS)
were analyzed in 2010. Disability prevalence was 4.9%
(95% CI = 3.9–6.2) among Massachusetts women giving
birth during 2007–2008. The prevalence of physical abuse
during the 12-months before pregnancy among women with
disabilities was 13.6% (95% CI = 7.2–24.0) compared to
2.8% for women without disabilities (95% CI = 2.1–3.7).
Similarly, 8.1% (95% CI = 4.0–15.7) of women with disabilities compared to 2.3% (95% CI = 1.7–3.1) of women
without disabilities experienced physical abuse during
pregnancy. Multivariate analyses indicated that women with
disabilities were more likely to report physical abuse before
pregnancy (OR = 4.3, 95% CI = 1.9–9.7), during pregnancy (OR = 2.8, 95% CI = 1.1–7.1), or during either time
period (OR = 3.2, 95% CI = 1.4–7.1) than women without
M. Mitra (&)
Department of Family Medicine and Community Health/Center
for Health Policy and Research, University of Massachusetts
Medical School, 333 South Street, Shrewsbury, MA 01545, USA
e-mail: [email protected]
S. E. Manning E. Lu
Massachusetts Department of Public Health, Boston, MA, USA
e-mail: [email protected]
E. Lu
e-mail: [email protected]
disabilities while controlling for maternal age, education,
race/Hispanic ethnicity, marital status and household poverty status. No difference was observed by disability status in
the likelihood of prenatal-care providers talking to women
about physical abuse. These analyses reveal disproportionate
prevalence of physical abuse before and during pregnancy
among women with disabilities. Screening for physical
abuse and timely referral of women in need of assistance are
critical to optimize health outcomes for both mother and
child.
Keywords Physical abuse Violence Disabilities Women Pregnancy
Introduction
Over the last decade, there has been emerging research
examining the prevalence and consequences of violence
against women with disabilities. Women with disabilities
are at increased risk for violence and may experience
unique forms of abuse [1–12]. Barrett and colleagues found
that 33.2% of women with disabilities experienced intimate
partner violence compared to 21.2% of women without
disabilities [10]. Casteel et al. found that after controlling
for selected characteristics, women with severe disabilities
were four times more likely to be sexually assaulted than
women without disabilities [11].
This study seeks to build on prior research on violence
against women with disabilities by focusing on the prevalence of physical abuse among women with disabilities
around the time of pregnancy. We document the prevalence
of physical abuse 12-months before and during pregnancy
among a population-based sample of Massachusetts women
with disabilities and compare the prevalence of abuse
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Matern Child Health J
between women with and without disabilities. We also
examine the association between prenatal counseling of
physical abuse and disability status.
Methods
Participants
Data were derived from the Massachusetts Pregnancy Risk
Assessment Monitoring System (MA-PRAMS). MAPRAMS collects state-specific data on maternal attitudes and
experiences before, during, and shortly after pregnancy.
Survey participants were sampled from a frame of eligible
birth certificates which included all live-born infants born in
Massachusetts to Massachusetts-resident women. During
2007–2008, 4,697 Massachusetts women were sampled and
the overall weighted response rate was 71%. Details about
the purpose, sampling methods, and data collection of the
MA-PRAMS are available elsewhere [13].
Measures
The survey assessed physical abuse by asking women if
they were pushed, hit, slapped, kicked, choked or physically hurt in any way by an ex-husband/partner and whether they were ‘‘physically hurt in any way’’ by their
husband/partner during the 12-months before and during
their most recent pregnancy. We grouped physical abuse
into three categories [1] before pregnancy; [2] during
pregnancy; and [3] before or during pregnancy. Disability
status was ascertained by participants’ responses to the
question: ‘‘Are you limited in any way in any activities
because of physical, mental, or emotional problems?’’
Additional maternal characteristics examined were age,
education, race/Hispanic ethnicity, marital status, and
household poverty status. Household poverty status was
measured as a ratio of family income to the number of
dependent members in the household as compared to the
Department of Health and Human Services Federal Poverty
guidelines [14]. Maternal age, education, marital status,
and race/ethnicity data were from birth certificates and
physical abuse, disability, and prenatal counseling data
were from the MA-PRAMS.
with non-overlapping confidence intervals were considered
statistically significant. We used multiple logistic regression
to examine the association of disability with abuse while
controlling for potential covariates. Significant predictors at
alpha = 0.1 in the univariate analysis or potential confounders of the association between abuse and disability
were included in the adjusted model. SAS 9.1 and SUDAAN
10 were used to account for PRAMS complex survey design.
The MA-PRAMS study has been approved by the Massachusetts Department of Public Health’s Research and Data
Access Review Institutional Review Board.
Results
Among the 2,876 respondents in the 2007–2008 MAPRAMS, 138 (4.9%, 95% CI = 3.9–6.2) reported having a
disability (Table 1). Approximately 1 in 8 (13.6%, 95%
CI = 7.2–24.0) women with disabilities reported physical
abuse by either a former or current husband/partner during
the 12-months before pregnancy compared to 2.8% (95%
CI = 2.1–3.7) of women without disabilities. During
pregnancy, 8.1% (95% CI = 4.0–15.7) of women with
disabilities and 2.3% (95% CI, 1.7–3.1) of women without
disabilities reported physical abuse. Prenatal care providers
were equally likely to discuss abuse by husbands and
partners to women with (54.3%, 95% CI = 42.7–65.5%)
and without disabilities (59.4%, 95% CI = 56.8–61.9%).
In crude analyses, women with disabilities were more
than 5 times as likely before pregnancy (5.5, 95% CI =
2.6–11.8) and almost 4 times as likely during pregnancy
(3.7, 95% CI = 1.7–8.5) to report abuse compared to
women without disabilities. Women with disabilities were
4.3 times more likely to report physical abuse before or
during pregnancy (4.3, 95% CI = 2.1–8.7) compared to
women without disabilities.
In analyses adjusted for age, education, marital status,
race/Hispanic ethnicity, and household poverty status,
women with disabilities were significantly more likely to
experience physical abuse before (OR = 4.3, 95% CI =
1.9–9.7), during (OR = 2.8, 95% CI = 1.1–7.1), and
before/during pregnancy (OR = 3.2, 95% CI = 1.4–7.1)
compared to women without disabilities (Table 2).
Discussion
Analytic Methods
We used chi-square statistics to compare the distributions of
selected characteristics by disability status. Confidence
intervals around population estimates were calculated by
using point estimates and their standard errors, and estimates
123
This study demonstrates that women with disabilities are at a
greater risk of physical abuse before and during pregnancy
compared to women without disabilities. After adjusting for
selected characteristics, women with disabilities were three
to four times more likely to experience abuse before/during
pregnancy. No difference was observed by disability status
Matern Child Health J
Table 1 Selected characteristics of women with live births by disability status in Massachusetts, 2007–2008 MA-PRAMS
Overall
All women
n = 2,876
% (95% CI)
Women with disabilities
n = 138
% (95% CI)
Women without disabilities
n = 2,738
% (95% CI)
100
4.9 (3.9–6.2)
95.1 (93.9–96.1)
P value
Demographics
Race/ethnicity
White, Non-Hispanic
68.7 (68.2–69.1)
71.2 (63.1–78.1)
Black, Non-Hispanic
8.1 (7.9–8.3)
10.8 (7.5–15.4)
8.0 (7.7–8.3)
13.9 (13.7–14.2)
11.0 (7.4–16.0)
14.1 (13.7–14.4)
9.3 (9.0–9.6)
7.0 (4.6–10.5)
9.4 (9.1–9.8)
Married
66.1 (63.8–68.3)
55.8 (44.3–66.7)
66.6 (64.3–68.9)
Unmarried
33.9 (31.7–36.2)
44.3 (33.3–55.7)
33.4 (31.1–35.7)
No previous live births
48.9 (46.4–51.4)
44.1 (33.1–55.8)
49.1 (46.6–51.7)
Previous live births
51.1 (48.7–53.6)
55.9 (44.3–66.9)
50.9 (48.3–53.4)
Hispanic
Other, Non-Hispanic
0.088
68.5 (2 (67.9–69.1)
Marital status
0.070
Parity
0.700
Education
0.074
\High school
10.9 (9.6–12.4)
11.5 (5.8–21.5)
10.9 (9.5–12.4)
High school diploma
25.3 (23.1–27.5)
40.1 (29.3–51.8)
24.5 (22.3–26.8)
Some college
18.0 (16.3–19.9)
13.5 (7.6–22.8)
18.2 (16.4–20.2)
45.8 (43.4–48.3)
35.0 (25.1–46.4)
46.4 (43.9–48.9)
College graduate
Age (years)
\20
0.146
6.6 (5.4–7.9)
6.5 (3.1–13.3)
6.6 (5.4–8.0)
20–29
40.7 (38.3–43.1)
49.2 (37.9–60.6)
40.2 (37.8–42.7)
30–39
49.1 (46.7–51.6)
36.8 (26.6–48.4)
49.8 (47.2–52.3)
3.7 (2.9–4.7)
7.5 (3.3–16.0)
3.5 (2.7–4.5)
B 100% FPL
21.0 (19.2–22.9)
46.5 (34.9–58.4)
19.7 (17.9–21.6)
[100% FPL
79.0 (77.1–80.8)
53.6 (41.6–65.1)
80.3 (78.4–82.1)
40?
Household poverty status (approximate)a
\0.001
Physical abuse
Physical Abuse 12 months before pregnancy
3.3 (2.5–4.3)
13.6 (7.2–24.0)
2.8 (2.1–3.7)
0.015
Husband or partner
2.3 (1.7–3.2)
12.8 (6.6–23.3)
1.8 (1.2–2.6)
0.013
Ex-husband or ex-partner
2.7 (2.0–3.5)
10.6 (5.4–20.1)
2.2 (1.7–3.0)
0.025
Physical abuse during pregnancy
2.6 (2.0–3.4)
8.1 (4.0–15.7)
2.3 (1.7–3.1)
0.044
Husband or partner
2.0 (1.4–2.8)
5.4 (2.3–12.3)
1.8 (1.3–2.6)
0.133
Ex-husband or ex-partner
1.8 (1.3–2.5)
7.6 (3.6–15.3)
1.5 (1.0–2.1)
0.032
4.3 (3.5–5.4)
14.4 (7.9–24.7)
3.8 (3.0–4.8)
0.017
59.2 (56.7–61.6)
54.3 (42.7–65.5)
59.4 (56.8–61.9)
0.403
Physical abuse before or during pregnancy
Preventive counseling
Prenatal care provider talked about physical abuse
a
To examine differences in household income level, household Federal Poverty Level (FPL) was approximated using self-reported income (as a
range) and the number of dependent household members, and comparing these to the 2007 Department of Health and Human Services Federal
Poverty guidelines [14]. Because exact dollar amounts were not reported, the mid-point of each income range was used to approximate household
income. Thus, the estimated household poverty level should be viewed as approximate, and may misclassify some households
in the likelihood of prenatal-care providers talking to women
about physical abuse. Although there is considerable literature on violence against women with disabilities, this is the
first study, to our knowledge, to examine physical abuse
among women with disabilities around the time of
pregnancy.
Research on the impact of violence on maternal and
child health indicates that women experiencing violence
before and during pregnancy are at risk for multiple poor
maternal and infant health outcomes [15]. These adverse
health consequences observed in the general population
could potentially be even stronger for women with
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Matern Child Health J
Table 2 Association between selected maternal characteristics and physical abuse around the time of pregnancy, 2007–2008 MA-PRAMS
Physical abuse
Before pregnancy
Crude OR
(95% CI)
During pregnancy
Adj. OR
(95% CI)
Crude OR
(95% CI)
Before/during pregnancy
Adj. OR
(95% CI)
Crude OR
(95% CI)
Adj. OR
(95% CI)
Disability status
Yes
5.5 (2.6–11.8)
4.3 (1.9–9.7)
3.7 (1.7–8.5)
2.8 (1.1–7.1)
4.3 (2.1–8.7)
3.2 (1.4–7.1)
No
1.0
1.0
1.0
1.0
1.0
1.0
Black, Non-Hispanic
2.1 (1.1–3.8)
1.1 (0.5–2.2)
2.3(1.2–4.4)
1.3 (0.5–2.9)
2.0 (1.2–3.4)
1.0 (0.5–1.9)
White, Non-Hispanic
1.0
1.0
1.0
1.0
1.0
1.0
Hispanic
2.8 (1.6–4.9)
1.2 (0.6–2.5)
3.0 (1.6–5.5)
1.5 (0.6–3.5)
3.1 (1.9–4.9)
1.4 (0.8–2.6)
Other
0.7 (0.4–1.5)
0.7 (0.3–1.6)
0.9 (0.4–1.9)
0.9 (0.4–2.2)
0.7 (0.4–1.4)
0.7 (0.3–1.4)
Yes
1.0
1.0
1.0
1.0
1.0
1.0
No
4.5 (2.6–8.0)
2.3 (1.1–4.5)
3.3 (1.8–6.3)
1.5 (0.7–3.4)
4.3 (2.6–7.0)
2.0 (1.1–3.8)
Race/ethnicity
Marital status
Education
Less than high school
1.7 (0.8–3.5)
1.5 (0.7–3.4)
1.7 (0.7–3.7)
1.3 (0.5–3.3)
1.5 (0.8–2.9)
1.2 (0.6–2.4)
High school
Some college
1.0
1.2 (0.6–2.4)
1.0
1.8 (0.8–4.1)
1.0
1.3 (0.6–2.8)
1.0
2.0 (0.8–4.7)
1.0
1.4 (0.8–2.5)
1.0
2.2 (1.1–4.3)
College
0.2 (0.1–0.5)
0.5 (0.2–1.2)
0.3 (0.1–0.8)
0.8 (0.3–2.2)
0.3 (0.1–0.5)
0.6 (0.3–1.4)
Age (years)
\20
0.7 (0.4–1.4)
0.3 (0.1–0.7)
1.1 (0.5–2.1)
0.6 (0.3–1.4)
0.9 (0.5–1.6)
0.5 (0.2–0.9)
20–29
1.0
1.0
1.0
1.0
1.0
1.0
30–39
0.4 (0.2–0.7)
0.89 (0.4–1.7)
0.4 (0.2–0.9)
1.0 (0.5–2.0)
0.4 (0.2–0.6)
0.8 (0.5–1.5)
40?
0.4 (0.1–2.8)
1.2 (0.1–9.4)
0.1 (0.02–0.9)
0.3 (0.0–2.3)
0.4 (0.1–2.0)
1.0 (0.2–5.9)
Household poverty status
B100% Federal poverty level
6.4 (3.6–11.4)
3.0 (1.4–6.2)
6.7 (3.6–12.4)
4.1 (1.6–10.7)
6.5 (3.9–10.7)
3.6 (1.8–7.0)
[100% Federal poverty level
1.0
1.0
1.0
1.0
1.0
1.0
disabilities and their infants given the already fragile
relationship between disability and health. Women with
disabilities have a narrower margin of health compared to
women without disabilities [16] and are more likely to
report poor health, chronic conditions, and unmet health
care needs [1, 17, 18]. Therefore, it is reasonable to assume
that violence potentially has a greater impact on the health
of pregnant women with disabilities and their infants.
Our results indicate that women with and without disabilities were equally likely to receive prenatal counseling.
We were not able to assess whether women with disabilities were more or less likely to disclose partner abuse or
receive appropriate referrals from providers compared to
women without disabilities. Given the opportunity that
prenatal-care provides for preventive health counseling,
this finding has important implications. First, because
women with disabilities are at a greater need, counseling
for partner abuse should be conducted among all women
with disabilities. Second, effective methods to assess a
woman with disabilities’ risk of partner abuse should be
123
developed. Massachusetts is one of only two states to
include a disability screener in PRAMS, enabling us to
examine maternal experiences and attitudes among women
with disabilities at a population level. Other PRAMS states
should consider including disability screeners to enable
exploration of maternal experiences and health outcomes
by disability status.
There are some limitations to this study. First, a relatively small number of women self-reported disability,
which may have limited the precision and generalizability
of our findings. Further the MA-PRAMS does not allow for
determination of type or severity of disability which may
have an impact on experience of abuse. The MA-PRAMS
data are based on self-report and therefore subject to selfreport bias. The MA-PRAMS questions on abuse are
restricted to physical abuse and do not ascertain other
forms of abuse that might differentially impact women
with disabilities. Finally we cannot determine abuse during
pregnancies that resulted in stillbirths or in live births of
multiples of four or more [13]. Despite these limitations,
Matern Child Health J
these findings suggest that women with disabilities are at a
greater risk for physical abuse. Screening for physical
abuse and timely referral of women in need of assistance
are critical to optimize health outcomes for both mother
and child.
Acknowledgments Monika Mitra is supported by the Massachusetts
Medicaid Infrastructure and Comprehensive Employment Opportunities Grant which is funded by Centers for Medicare and Medicaid
Services (CFDA No. 93.768). Emily Lu is supported by the Massachusetts PRAMS project which is supported in part by grant No. 1 UR6
DP000513-01 from the Centers for Disease Control and Prevention.
The authors thank the Maternal and Child Health Epidemiology Program, Applied Sciences Branch, Division of Reproductive Health,
National Center for Chronic Disease Prevention and Public Health
Promotion, Centers for Disease Control and Prevention and the Health
Services and Resources Administration for scientific guidance on this
analysis and manuscript.
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