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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

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Rodney wright md mentor mayris webber drph

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
Background during pregnancy in HIV infected and HIV at risk women

  • 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


Background1
Background during pregnancy in HIV infected and HIV at risk women

  • 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


Background2
Background during pregnancy in HIV infected and HIV at risk women

  • 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
Regional HIV statistics and features for women 2003 and 2005 during pregnancy in HIV infected and HIV at risk women

Source: UNAIDS / WHO AIDS Epidemic Update: December 2005


Background3
Background during pregnancy in HIV infected and HIV at risk women

  • 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
Objectives during pregnancy in HIV infected and HIV at risk women

  • 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
MIRIAD during pregnancy in HIV infected and HIV at risk women

  • 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
Hypothesis during pregnancy in HIV infected and HIV at risk women

  • HIV positive status is associated with domestic violence in the MIRIAD cohort of women


Methods
Methods during pregnancy in HIV infected and HIV at risk women

  • 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


Methods1
Methods during pregnancy in HIV infected and HIV at risk women

  • 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


Methods2
Methods during pregnancy in HIV infected and HIV at risk women

  • 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


Methods3
Methods during pregnancy in HIV infected and HIV at risk women

  • 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
Characteristics of population studied during pregnancy in HIV infected and HIV at risk women


Results
Results during pregnancy in HIV infected and HIV at risk women

  • 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
    Correlates of domestic violence during pregnancy during pregnancy in HIV infected and HIV at risk women


    Correlates of ever experiencing domestic violence
    Correlates of ever experiencing domestic violence during pregnancy in HIV infected and HIV at risk women


    Birth outcomes
    Birth Outcomes during pregnancy in HIV infected and HIV at risk women

    • 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 outcomes1
    Birth outcomes during pregnancy in HIV infected and HIV at risk women


    Multivariate logistic regression models
    Multivariate logistic regression models during pregnancy in HIV infected and HIV at risk women


    Conclusions
    Conclusions during pregnancy in HIV infected and HIV at risk women

    • 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
    Limitations during pregnancy in HIV infected and HIV at risk women

    • 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


    Limitations1
    Limitations during pregnancy in HIV infected and HIV at risk women

    • 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


    Conclusions1
    Conclusions during pregnancy in HIV infected and HIV at risk women

    • 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 during pregnancy in HIV infected and HIV at risk women

    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

    Acknowledgments