30 | International Journal of Childbirth Education | Volume 28 Number 3 July 2013

Domestic Violence and

Pregnancy: A Literature Review
by Tanya Menezes Cooper, MA MFT-I
Abstract: The World Health Organization
(WHO), along with other health organi-
zations, has declared the prevalence of
domestic violence to be a serious global
health concern needing more attention to
promote healthier outcomes for mothers
and children following birth. Even with
the encouragement of the WHO, and
with the convenience of private health
treatment rooms, few health providers
have conducted assessments for domestic
violence. Finally, this article addresses the
important role childbirth educators can
play in assessing and educating expectant
parents about the implications of domes-
tic violence and pregnancy, and provides
information for the process.
Keywords: domestic violence, pregnancy, abuse, childbirth educators
Introduction
Pregnancy is a time of new life and of new beginnings
for two people in a relationship. When domestic violence is
an added factor, then pregnancy can be a further complica-
tion for the woman carrying a child. Health care providers,
including childbirth educators in contact with the prospec-
tive mother, have the opportunity to assess mothers for the
possibility of domestic violence occurring in their relation-
ship. These may be the only opportunities a mother has of
safely voicing the dilemma she and her unborn child are
in. It may also lead to her only chance of escaping her or
her unborn childs death sentence. Pregnant women and
their unborn infants are vulnerable populations who should
be treated as such, yet some reports show that death rates
among pregnant women have escalated in recent years (Cle-
ments, Holt, Hasson, & Fay-Hillier, 2011).
Background Information on Domestic Violence
Domestic violence, also termed intimate partner
violence (IPV), has existed since the dawn of man. Its oc-
currence is more acceptable in some countries than it is in
others. Domestic violence is commonly described as the
occurrence or threat of physical, verbal, or sexual abuse, as
well as emotional and psychological abuse by a spouse or
intimate partner (McMahon & Armstrong, 2012). Domestic
violence occurs before, during and after pregnancy but has
been observed to occur more often during the vulnerable
time of pregnancy (Adesina, Oyugbo, & Olubukola, 2011;
OReilly, 2007). During pregnancy, domestic violence can
become particularly dangerous and devastating, causing
premature birth, serious injury or death to the baby, while
also causing detriment to the mothers mental and physical
health (Keeling, 2012; Manzolli et al., 2009; OReilly, 2007;
Oweis, Gharaibeh, & Alhourani, 2009).
According to Sarkar (2008), the World Health Orga-
nization (WHO) claimed that 15 countries reported the
prevalence of domestic violence within their countries was
15% to 71%. Additionally, in North Africa and the Middle
East domestic violence is widely accepted, and in Egypt and
Jordan, 90% of ever-married women consider wife-beating
as acceptable (Sarkar, 2008). More than 40% of Nigerian
women have experienced domestic violence (Sarkar, 2008).
In the United States, 24% of heterosexual couples reported
domestic violence (Sarkar, 2008). Taiwan and the UK report-
ed prevalence rates of 6.9% and 29%, respectively (Sarkar,
2008; Keeling, 2012). These statistics are in consideration
of overall physical abuse within a relationship, regardless of
whether or not the couple is experiencing a pregnancy at the
time.
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Volume 28 Number 3 July 2013 | International Journal of Childbirth Education | 31
Domestic violence has been observed to
occur more often during the vulnerable
time of pregnancy
Prevalence of Domestic Violence and Pregnancy
Domestic violence during pregnancy happens to women
of varying ages, cultures, and socio-economic status; how-
ever, it has been determined through various studies, that
women of lower socio-economic status tend to experience
domestic violence during pregnancy more often (Bravemann
et al., 2010; Keeling, 2012; OReilly, 2007).
There are two different associations commonly recog-
nized when discussing domestic violence and pregnancy.
One association is that of the occurrence of domestic
violence during pregnancy, while the other is the occurrence
of sexual assault by a spouse or intimate partner that results
in pregnancy (Sarkar, 2008). Both circumstances can be
devastating for a woman who nds herself in either situation.
Commonly, the abuse continues throughout the pregnancy
and the woman remains in danger (Sarkar, 2008).
In Pakistan, 44% of women report regular physical
abuse during marriage, with 23% reporting physical abuse
during pregnancy (Sarkar, 2008). In a study conducted in
Brazil by Manzolli et al. (2009), 43.4% of women receiving
primary prenatal care reported having experienced domestic
violence, with 18.9% claiming abuse during their current
pregnancy. In the same study, a postpartum survey indicated
that 33.8% of women experienced domestic violence during
their previous pregnancy (Manzolli et al., 2009). Developing
countries report that 4% to 29% of women experience do-
mestic violence during pregnancy, while developed countries
report that 1% to 20% of women experience domestic vio-
lence in pregnancy (Oweis, Gharaibeh, & Alhourani, 2009).
The WHO, the CDC, and Healthy People 2020 have
all declared domestic violence as a leading health concern
and cause for traumatic death to mothers and their unborn
infants (Clements et al., 2011). In a recent study, Clements
et al. (2011) stated that 77% of pregnant mothers who were
murdered died in the rst trimester of their pregnancy. The
number one cause of death to a mother during pregnancy is
homicide (Clements et al., 2011). There were further reports
of battering to pregnant women, kicking and striking of
their abdomen, breasts, and genitals, choking, slapping and
sexual assault (Clements et al., 2011). The injuries are often
detrimental even when death is not imminent.
It is important to acknowledge that spousal and partner
inicted violence is not the only violence that occurs during
a womans pregnancy. Some women also must contend with
assault from other members of their family, such as older
children in the home, parents living in the home, and in-laws
(Raj et al., 2011). Abuse by in-laws, particularly mothers-
in-law is common in some Asian countries and in Muslim
cultures such as India (Raj et al., 2011). In Mumbai, 26.3% of
the sample population reported experiencing abuse from in-
laws. The abuse usually consists of economic abuse, such as
withholding money, verbal and physical abuse, and neglect,
such as withholding food (Raj et al., 2011). It is accepted
within these particular cultures and is usually indicative of
partner inicted violence as well (Raj et al., 2011).
Women often feel there is little or nothing they can do
when domestic violence occurs during pregnancy, except to
tolerate it (Libuku, Small, & Wilkinson, 2008). Some women
stay in abusive relationships because they have no source of
income, have no place to go, or they feel it is best for their
child (Libuku et al., 2008). They also may choose to stay
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Domestic Violence and Pregnancy: A Literature Review
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32 | International Journal of Childbirth Education | Volume 28 Number 3 July 2013
because they have low self-esteem, or have a fear for their
safety if they try to leave (Libuku et al., 2008). For some
women, during pregnancy is their rst experience with being
assaulted by their spouse or partner (McMahon & Arm-
strong, 2012). Still other women will actually have a reprieve
from the usual domestic violence in their relationship during
pregnancy (McMahon & Armstrong, 2012).
Implications of Domestic Violence during
Pregnancy
Women abused during pregnancy may experience many
complications. Some of the reported complications are high
blood pressure, premature rupture of the membranes, pre-
mature birth, preeclampsia, edema, urinary tract and bladder
infections, vaginal bleeding, placenta previa, excessive
vomiting, dehydration, or homicide (Cook & Bewley, 2008;
Lazzenbatt & Greer, 2009).
There are also implications related to the child being
carried in the womb, besides the dangers associated with the
mother. An unborn child subjected to domestic violence is at
risk of being miscarried, born preterm, born under-weight or
smaller than normal, or born under-developed (Lazzenbatt
& Greer, 2009). A child is also at risk of dying soon after
birth due to complications of the birthing processes incurred
because of domestic violence, such as placenta previa (Laz-
zenbatt & Greer, 2009).
Risk Factors for Domestic Violence
Some known risk factors for domestic violence are low
socio-economic status, cultural beliefs, and substance abuse
by the mother, the partner or both (McMahon & Armstrong,
2012). Additional risk factors include the pregnant mother
having sex with multiple partners, negative or volatile family
dynamics, nancial difculties within the family, and low
social support (McMahon & Armstrong, 2012). These dif-
culties are seen as risk factors only, not as excuses.
Signs and Symptoms of Domestic Violence
Signs and symptoms of domestic violence are sometimes
obvious and at other times not so obvious. In cases when
it is not as obvious, it may take screening and assessment
procedures to bring the signs and symptoms or the actual oc-
currences of domestic violence to the surface. The most com-
monly recognized signs and symptoms of domestic violence
can be excessive bruising, especially a combination of new
and old bruises, low weight gain by the mother, noticeable
anxiety, depression, low self-esteem, and negative self-image
(McMahon & Armstrong, 2012). During assessment, a
woman may express a lack of safety, or a fear of upsetting her
spouse or partner (McMahon & Armstrong, 2012).
How Assessment Can Play a Role
Though during pregnancy and immediately postpartum
are especially vulnerable times for mothers and their infants
to experience domestic violence (OReilly, 2007), this is also
a particularly advantageous time for health care profession-
als, including childbirth educators, to assess and address the
problem with the mother, because this is a time in which
they will likely come in contact the most often. Assessments
must be culturally sensitive, yet address the problem of
domestic violence by spouses or partners, as well as other
family members (McMahon & Armstrong, 2012). It is equally
important to remember that a person may need to be as-
sessed regularly for their own safety, as some women are not
ready to seek help at rst but may be prepared as violence
escalates or the pregnancy advances (Clements et al., 2011;
McMahon & Armstrong, 2012).
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Domestic Violence and Pregnancy: A Literature Review
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Volume 28 Number 3 July 2013 | International Journal of Childbirth Education | 33
There are barriers to assessment. Some social workers
and healthcare providers, including doctors, do not feel they
have time to conduct the assessment and make appropriate
referrals, or wish to make either the mother or her part-
ner uncomfortable by bringing up the subject of domestic
violence (Clements et al., 2011; McMahon & Armstrong,
2012). Providers, such as childbirth educators, may also fear
they will alienate the mother or partner if they bring up the
subject or make a violent situation worse for the mother
(Clements et al., 2011). With these concerns in mind, it is
more important than ever for childbirth educators to take an
active role in assessing and educating new parents about the
dangers of domestic violence for both the mother and the
unborn child.
The Role of Childbirth Educators
Women enduring domestic violence are often in denial,
believing the violence will not get worse or that it will end
once the child is born (Libuku et al., 2008). Through as-
sessment, group education, and private conversations with
participants, educators have an opportunity to present the
facts about what pregnant victims of domestic violence are at
risk of experiencing. Discussing the dangers and the resourc-
es associated with domestic violence may help to empower
a woman in a domestic violence situation to take steps to
make a change.
It is vitally important for childbirth educators to be in
a position of giving the complete truth to mothers regard-
ing the possible implications of being in a domestic violence
situation during pregnancy. Homicide is the number one
cause of death to pregnant mothers and their unborn chil-
dren; more than auto collisions or suicide (Clements et al.,
2011). Childbirth educators are in a position to discuss the
prevalence of domestic violence during pregnancy with new
parents, without placing judgment on those parents, giving
them the opportunity to reach out for assistance. Childbirth
educators can also offer resources to the mother regardless
of the fathers knowledge or willingness to participate in a
solution. The childbirth educator may be the only person a
pregnant victim of domestic violence comes in contact with
that can assess for the abuse and take actions to resolve it.
References
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Bravemann, P., Marchi, K., Egerter, S., Kim, S., Metzler, M., Stancil, T., &
Libert, M. (2010). Poverty, near-poverty, and hardship around the timeof
pregnancy. Maternal & Child Health Journal, 14, 20-35. doi: 10.1007/s10995-
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Clements, P. T., Holt, K. E., Hasson, C. M., & Fay-Hillier, T. (2011). Enhanc-
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Tanya has a masters degree in counseling psychology and is a
registered marriage and family therapist intern in the state of
California. She is currently earning a PhD in Health Psychology
at Walden University with an emphasis on child and adolescent
health. Tanya enjoys working with children of all ages in improv-
ing their physical and psychological health while employed as
a clinician/quality improvement coordinator in her county of
residence.
Domestic Violence and Pregnancy: A Literature Review
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