Pregnancy when coupled with domestic violence is a form of intimate partner violence (IPV) where health risks may be amplified. Abuse during pregnancy, whether physical, verbal or emotional, produces many adverse physical and psychological effects for both the mother and fetus. Domestic violence during pregnancy is categorized as abusive behavior towards a pregnant woman, where the pattern of abuse can often change in terms of severity and frequency of violence. Abuse may be a long-standing problem in a relationship that continues after a woman becomes pregnant or it may commence in pregnancy.Johnson, J.K., F. Haider, K. Ellis, D.M. Hay, S.W. Lindow. "The prevalence of domestic violence in pregnant women." BJOG: An International Journal of Obstetrics & Gynecology 110.3 (2003): 272-75. Web. 22 Mar 2011. Although female-to-male partner violence occurs in these settings, the overwhelming form of domestic violence is perpetrated by men against women.Stephenson, Rob, Michael A. Koenig, Rajib Acharya and Tarun K. Roy. "Domestic Violence, Contraceptive Use, and Unwanted Pregnancy in Rural India." Studies in Family Planning. 39.3 (2008): 177-86. Print. Pregnancy provides a unique opportunity for healthcare workers to screen women for domestic violence though a recent review found that the best way in which to do this is unclear. Reducing domestic violence in pregnancy should improve outcomes for mothers and babies though more good quality studies are needed to work out effective ways of screening pregnant women.

Causes and triggers

Domestic abuse can be triggered by pregnancy for a number of reasons. Pregnancy itself can be used a form of coercion and the phenomenon of preventing an intimate partner's reproductive choice is referred to as reproductive coercion. Studies on birth control sabotage performed by males against female partners have indicated a strong correlation between domestic violence and birth control sabotage.Domestic Violence and Birth Control Sabotage: A Report from the Teen Parent Project , Center for Impact Research, 1999. Pregnancy can also lead to a hiatus of domestic violence when the abuser does not want to harm the unborn child. The risk of domestic violence for pregnant women is greatest immediately after childbirth.Mezey, Gillian C., and Bewley Susan. "Domestic Violence and Pregnancy: Risk Is Greatest after Delivery." BMJ: British Medical Journal. 314.7090 (1997): 1295. Print.

Domestic violence can increase a woman's chances of becoming pregnant and the number of children she has, both because the woman may be coerced into sex and because she may be prevented from using birth control. A correlation has been shown between large families and domestic violence. Whereas previously it was thought that having many children and the resultant stress of large families increased likelihood domestic violence, it has been shown that the violence commonly predates the births.

Birth control sabotage

Birth control sabotage, or reproductive coercion, is a form of coercion where someone manipulates another person's use of birth control - weakening efforts to prevent an unwanted pregnancy. Replacing birth control pills with fakes, puncturing condoms, and threats and violence are examples of prevention of an individual's attempt to avoid pregnancy. Pregnancy-promoting behavior of abusive male partners is one method of domestic violence and is associated with unwanted pregnancy, particularly in adolescents.Miller, Elizabeth, Decker, Michelle, Reed, Elizabeth, Male Partner Pregnancy-Promoting Behaviors and Adolescent Partner Violence: Findings from a Qualitative Study with Adolescent Females. Reproductive coercion itself is a form of domestic violence because it results from unwanted sexual activity and hinders a woman's ability to control her body. Forced pregnancy can also be a form of financial abuse when a woman becomes trapped in a relationship because the pregnancy has led to economic dependence for new mothers.Pregnancy offers no protection from abuse

Unintended pregnancies are two to three times more likely to be associated with abuse than intended pregnancies.J.E. Hathaway, L.A. Mucci and J.G. Silverman et al., Health status and health care use of Massachusetts women reporting partner abuse, Am J Prev Med 19 (2000), pp. 302–307. Research among adolescent populations shows females who experience IPV use condoms at low rates and are fearful of negotiating the use of condoms.A. Raj, M.C. Santana and A. La Marche et al., Perpetration of intimate partner violence associated with sexual risk behaviors among young adult men, Am J Public Health 96 (2006), pp. 1873–1878. In a study of sexually experienced women 15–19 in Uganda, surveys found that 14% of women's first sexual intercourse had been coerced. Of those 14%, the women were far more likely to be having unprotected sex without the use of modern contraceptives and to have had unintended pregnancies within the last six months compared to women who had not been sexually coerced.Michael A. Koenig, Iryna Zablotska, Tom Lutalo, Fred Nalugoda, Jennifer Wagman and Ron Gray. "Coerced First Intercourse and Reproductive Health among Adolescent Women in Rakai, Uganda." In Egypt, over 80% of rural women believe that beatings are sometimes justifiedEl-Zanaty F et al. Egypt demographic and health survey 1995. Calverton, MD, Macro International, 1996 and one of the most common reasons given as a just cause for beatings is refusing a man sex.El-Zanaty F et al. Egypt demographic and health survey 1995. Calverton, MD, Macro International, 1996.David F, Chin F. Economic and psychosocial influences of family planning on the lives of women in Western Visayas. Iloilo City, Central Philippines University and Family Health International, 1998. This affects the ability of women to protect themselves from unwanted sexual contact and the consequences of sexual intercourse, such as pregnancy and sexually transmitted infections.Violence by Intimate Partners WHO: World Health Organization.

A study conducted by the Center for Impact Research on young mothers classified birth control sabotage into two categories: verbal and behavioral. Verbal sabotage is verbal or emotional pressure not to use birth control, or pressure to become pregnant. Behavioral sabotage is the use of force to prevent the use of birth control, or to have unprotected sexual intercourse.

Mechanisms In most cases, domestic violence can be prompted by or intensified by pregnancy, but in some cases domestic violence ends during pregnancy because the abuser makes a conscious effort to not harm the fetus.Campbell, JC, Oliver C, Bullock L. "Why battering during pregnancy?" AWHONN's clinical issues in perinatal and women's health nursing. 4.3 (1993.) 343. Print.

Decreased violence Domestic violence does not always increase during pregnancy and can even lead to a hiatus in violence. This phenomenon can provide protection for both the woman and child. Because this can lead to decreased violence, some women use pregnancy as a means of protection against domestic abuse. Since abuse generally restarts after the pregnancy ends, women may get pregnant intentionally to prevent violence. However, since women who have been abused before getting pregnant are more likely to experience violence during pregnancy, this is not a reliable means of protection.Bacchus, Loraine,, Gill Mezey, Susan Bewley, and Alison Haworth. "Prevalence of domestic violence when midwives routinely enquire in pregnancy." BJOG: An International Journal of Obstetrics & Gynaecology 111.5 (2004): 441-45. Web. 22 Mar 2011

Increased violence Although pregnancy can be a protective period for some women, either in terms of a hiatus of pre-existing violence, for others it is a risk period during which abuse may begin or escalate. Women with violent partners have a hard time protecting themselves from unintended pregnancy and sexual violence can directly lead to pregnancy.Heise LL, Ellsberg M, Gottemoeller M. Ending violence against women. Baltimore, MD, Johns Hopkins University School of Public Health, Center for Communications Programs, 1999 (Population Reports, Series L, No. 11). Studies consistently indicate that domestic violence is more common in large families.Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey. Washington, DC, National Institute of Justice, Office of Justice Programs, United States of Justice and Centers for Disease Control and Prevention, 2000 (NCJ 183781). However, international studies show that 25% of women are abused for the first time during pregnancy.

In one study conduct by Campbell et al., women were asked to speculate on why they thought they were abused during their pregnancies. The answers were categorized into four categories: Jealousy towards the unborn child Anger towards the unborn child Pregnancy specific violence not directed toward the child "Business as usual."

Effects There are many dangerous effects that violence during pregnancy can cause for both the mother and child. A violent pregnancy is considered high risk because verbal, emotional, and physical abuse all lead to adverse health consequences for both the mother and fetus.Johnson, J.K., F. Haider, K. Ellis, D.M. Hay, S.W. Lindow. "The prevalence of domestic violence in pregnant women." BJOG: An International Journal of Obstetrics & Gynaecology 110.3 (2003): 272-75. Web. 22 Mar 2011. Violence during pregnancy has been associated with miscarriage, late prenatal care, stillbirth, preterm birth, fetal injury (including bruising, broken and fractured bones, stab woundsMezey, Gillian C., and Bewley Susan. "Domestic violence and pregnancy." BJOG: An International Journal of Obstetrics and Gynecology. 104.5 (1997): 528-531. Print. and low birth weight. Violence during pregnancy also leads to additional risks for the mother such as increased mental health problems, suicide attempts, worsening of chronic illness, injury, substance abuse, anxiety, stress, chronic pain, and gynecological problems.0014/71240/MPS_GEM_ MDA_ new.pdf WHO Europe. "Making Pregnancy Safer & Gender Maisntreaming: Response to domestic violence in pregnancy" Women battered during pregnancy were more frequently and severely beaten throughout the course of their relationship compared to women who were not abused during pregnancy. IPV also accounts for a large portion of maternal mortality. Homicide is the second leading cause of injury related deaths in pregnant and post-partum women in the United StatesAmerican Journal of Public Health, March 2005 and a study conducted in hospital in India found that 16% of all deaths during pregnancy were a result of partner violence.Too far, too little, too late: a community-based case–control study of maternal mortality in rural west Maharashtra, India. Bulletin of the World Health Organization, 1998 Studies have also found a correlation between domestic violence and increased use of abortion.Amaro et al. "Violence during pregnancy and substance abuse." Am J Public Health. May 1990. 575-9 Pregnant abused women are less likely to report abuse or leave their abuser because of added financial and housing security concerns. Houston Area Women's Center. "Dangers of Domestic Violence during Pregnancy.

Risk factors