Intimate Partner Violence During Pregnancy

Diana Filipa da Cos a Ma ques In ima e Pa ne Violence Du ing P egnancy 2011/2012 ma ço, 2012 Diana Filipa da Cos a Ma ques In ima e Pa ne Violence Du ing P egnancy Mes ado In eg ado em Medicina Á ea: Medicina Legal T abalho e e uado sob a O ien ação de: P o esso a Dou o a Te esa Magalhães E sob a Coo ien ação de: P o esso a D a. Ana Cla a G ams T abalho o ganizado de aco do com as no mas da e is a: Jou nal o Fo ensic and Legal Medicine ma ço, 2012 P oje o de Opção do 6º ano - DECLARAÇÃO DE INTEGRIDADE Eu, Diana Filipa da Cos a Ma ques, abaixo assinado, nº mecanog á ico 060801220, es udan e do 6º ano do Mes ado In eg ado em Medicina, na Faculdade de Medicina da Uni e sidade do Po o, decla o e a uado com absolu a in eg idade na elabo ação des e p oje o de opção. Nes e sen ido, con i mo que NÃO inco i em plágio (a o pelo qual um indi íduo, mesmo po omissão, assume a au o ia de um de e minado abalho in elec ual, ou pa es dele). Mais decla o que odas as ases que e i ei de abalhos an e io es pe encen es a ou os au o es, o am e e enciadas, ou edigidas com no as pala as, endo colocado, nes e caso, a ci ação da on e bibliog á ica. Faculdade de Medicina da Uni e sidade do Po o, 21/03/2012 Assina u a: _________________________________________________________ P oje o de Opção do 6º ano – DECLARAÇÃO DE REPRODUÇÃO Nome: Diana Filipa da Cos a Ma ques Ende eço ele ónico: med062[email p o ec ed].p Tele one ou Telemó el: 937481679 Núme o do Bilhe e de Iden idade: 13006596 Tí ulo da Disse ação: In ima e Pa ne Violence Du ing P egnancy O ien ado : P o esso a Dou o a Te esa Magalhães Ano de conclusão: 2012 Designação da á ea do p oje o: Medicina Legal É au o izada a ep odução in eg al des a Disse ação pa a e ei os de in es igação e de di ulgação pedagógica, em p og amas e p oje os coo denados pela FMUP. Faculdade de Medicina da Uni e sidade do Po o, 21/03/2012 Assina u a: _________________________________________________________ INTIMATE PARTNER VIOLENCE DURING PREGNANCY AUTHORS Diana Filipa da Cos a Ma ques (co esponding Au ho ) Facul y o Medicine o Po o Uni e si y, Al. P o . He nâni Mon ei o 4200 - 319 Po o, Po ugal e-mail add ess: [email protected] ; Tel: +(351) 937481679 ABSTRACT In oduc ion: In ima e pa ne iolence is an impo an wo ldwide p oblem. Du ing p egnancy his phenomenon can s a o exace ba e wi h se ious implica ions o he p egnancy ou come. This ype o iolence can also ha e se ious consequences in he physical and men al heal h o bo h, mo he and child. The aim o his s udy is o cha ac e ize women who a e ic ims o in ima e pa ne iolence du ing p egnancy o con ibu e o p omo e he de elopmen o ea ly in e en ion s a egies as soon as he isk ac o s a e ecognized. Ma e ial and me hods: This s udy is a e ospec i e analysis o selec ed medico-legal epo s o ic ims o in ima e pa ne iolence, submi ed o o ensic assessmen a he no h se ices o he Na ional Ins i u e o Legal Medicine o Po ugal, du ing he pe iod be ween 2005 and 2010. I includes wo g oups wi h 49 cases each: one g oup wi h women who we e p egnan a he momen o he abuse and ano he g oup wi h non p egnan women (con ol). Resul s: O e his pe iod, 11263 suspec ed emale ic ims o in ima e pa ne iolence we e examined; 0.44% (n=49) o hem we e p egnan . In he p egnan g oup mos women we e single (67.3%), while in he non p egnan g oup mos we e ma ied (51%) a he ime o he abuse; s a is ical signi ican di e ences ha e been ound (p=0.025). Rega ding he p o essional s a us, he majo i y o ic ims o he p egnan g oup we e unemployed (38.8%). Wi h espec o he numbe o child en, signi ican s a is ical di e ences we e ound be ween he wo g oups (p=0.003). In he p egnan g oup i was ound ha a la ge numbe o women had no p e ious child en. The p egnan g oup also showed a highe numbe o women wi h only one p e ious p egnancy (p=0.022). The non p egnan g oup showed signi ican di e ences o he du a ion o abuse: “less han one yea ” when compa ed wi h “mo e han one yea ” (p=0.02). The majo i y o he ic ims epo ed mul iple mechanisms o abuse. They we e mainly punching, pushing, slapping and kicking (49%, 40.8%, 36.7% and 34.7%, espec i ely) in he p egnan g oup case. Fo he non p egnan g oup, he same mechanisms we e he mos equen s (53.1%, 32.7%, 26.5% and 28.6%, espec i ely). Bo h in he p egnan g oup and in non p egnan g oup ace and limbs a e he ana omical a eas mo e equen ly inju ed, wi h no signi ican ly s a is ical di e ences, bu in p egnan g oup he e is desc ip ion o inju ies a he o so in 14.3% o he cases, while in non p egnan g oup only he ho ax has been in ol ed. No signi ican s a is ical di e ences we e ound be ween bo h g oups wi h ega d o demands o medical ca e a e abuse (p=0.539). Conclusions: In ima e pa ne iolence in p egnancy is p obably unde epo ed. Women ic ims o in ima e pa ne iolence du ing p egnancy a e mos ly unma ied compa ed wi h non p egnan and he e seems o be a p edominance o abuse in women who a e p egnan o he i s ime. Fu he s udies a e necessa y o be e cha ac e ize he medico-legal aspec s in his kind o si ua ions. KEYWORDS: In ima e pa ne iolence; emale ic ims; p egnancy; Po ugal INTRODUCTION Violence, which includes abuse, is a e y se ious and complex social issue, wi h ha m ul physical and psychological consequences o ic ims. Besides, i also has impo an implica ions o hei amilies and socie y in gene al.1 Acco ding o he Wo ld Heal h O ganiza ion (WHO), he mos common o m o abuse su e ed by women is pe pe a ed by an in ima e pa ne .2, 3 This in ima e pa ne iolence (IPV) is de ined as ac ual o h ea ened physical, sexual, psychological, and emo ional abuse by a cu en o o me in ima e pa ne , ega dless o he in ol ed gende s and cohabi a ion.4 Consequences a e always e y se e e in e ms o psychological and physical heal h and in socioeconomic aspec s; u he mo e, each yea , a leas 1400 women die in he Uni ed S a es o Ame ica as a esul o IPV.3 P egnancy is a high- isk pe iod du ing which iolence can s a o exace ba e,3, 4, 5, 6, 7, 8, 9 usually esul ing on ad e se ou comes o he newbo n.3, 4, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17 Acco ding o a s udy de eloped a he Obs e ics Depa men o São João Hospi al, in Po o, p e e m deli e y was signi ican ly mo e equen among physically abused han non-abused p egnan women (21.4% s 6.8%; p<0.0001).10 S udies show ha he p e alence o iolence om a man o a woman in an in ima e ela ionship a any ime anges om 9.7% o 29.7%,5 and he o e all p e alence o IPV du ing p egnancy a ies be ween 0.9% and 20.1%.5, 9, 11, 12, 18, 19, 20, 21 In Po ugal he es ima ed alue is a ound 10%.10 Violence du ing p egnancy dese es special a en ion because i a ec s women a a momen o g ea ulne abili y. Mo eo e , i may po en ia e an inc ease in mo bidi y and mo ali y o he mo he as well as he newbo n. This iolence may in luence he e olu ion o he pe ina al pe iod by he in e e ence o wo mechanisms: (a) he i s is he auma i sel , capable o p omo ing lesions ha a ec women du ing p egnancy; (b) he second is based on he heo y o con inuous s ess.2, 10, 18 This kind o abuse may ha e se ious consequences o he women’s physical and men al heal h.11 Di ec heal h e ec s include he inc ease likelihood o misca iage, p ema u e labou o deli e y, low bi h weigh as well as highe le els o dep ession. An indi ec heal h e ec desc ibed in se e al s udies is subs ance abuse by women who su e iolence in o de o diminish eelings o shame and humilia ion.3, 5, 13 Hedin e al. ound ha physical abuse du ing p egnancy occu ed mos ly in cases we e i was al eady happening du ing he pe iod o ime p eceding he p egnancy, sugges ing ha i is impo an o conside p e ious his o y o abuse.5 Some isk ac o s ha e been associa ed wi h IPV du ing p egnancy.4, 6, 8, 9, 11, 12, 13, 18, 17, 22, 23, 24, 25, 26, 27, 28, 29, 30 Risk ac o s e e o aspec s ha inc ease he p obabili y o occu ence o main enance o abuse. They may be ela ed o he indi idual cha ac e is ics o he ic im o he abuse , hei amily backg ound and socio-cul u al en i onmen . The p esence o a isk ac o does no mean, by i sel , he p esence o abuse. I is known, howe e , ha he combina ion o se e al isk ac o s could signi ican ly inc ease he likelihood o abuse.1 Risk ac o s o iolence du ing p egnancy include: socioeconomic s a us,11, 22, 25 a young age,5, 6, 8, 9, 11, 12, 15, 18, 22, 23, 25, 27, 29, 30 e hnici y,11, 12, 18, 22 ma i al s a us (single),5, 12, 17, 18, 22, 25, 28 low le el o educa ion,4, 6, 12, 18, 22, 25 unemploymen ,18 pa i y,6,18 absence o p ena al ca e,18, 25 low le el o social suppo ,11, 25, 26 unin ended p egnancy,9, 30 smoking, alcohol and d ug abuse by women pa ne s.3, 4, 5, 11, 12, 13, 15, 17, 31 Ano he ac o o en associa ed wi h inc eased isk o IPV is wi nessing o being a ic im o iolence du ing childhood.11, 12, 17 OBJECTIVES The gene al objec i e o his s udy was o cha ac e ize women who a e ic ims o IPV du ing p egnancy o con ibu e o p omo e he de elopmen o ea ly in e en ion s a egies as soon as he isk ac o s a e ecognized. The speci ics objec i es we e o cha ac e ize household’s si ua ion, including ic ims, alleged pe pe a o s and couple’s si ua ion, as well as physical abuse and legal ou comes o he cases. MATERIALS AND METHODS The p esen s udy is a e ospec i e e iew o selec ed medico-legal epo s o ic ims o IPV, submi ed o o ensic assessmen a he no h se ices o he Na ional Ins i u e o Legal Medicine o Po ugal (INML), du ing he pe iod be ween 2005 and 2010. I includes wo g oups. Fo he g oup o p egnan women (n=49), he inclusion c i e ia we e: a) Women in ep oduc i e age (15-49 yea s old); b) P esen ing a claim o IPV; c) Pe pe a ed du ing he p egnancy; d) Obse ed a he no h se ices o he INML; e) Be ween 2005 and 2010. Fo con ol, a g oup o non p egnan women was andomly selec ed (n=49); he inclusion c i e ia we e: a) Women in ep oduc i e age (15-49 yea s old); b) P esen ing a claim o IPV; c) No p egnan a he ime o he alleged abuse; d) Obse ed a he no h se ices o he INML; e) Be ween 2005 and 2010. Fo da a collec ion, a o m, p e iously de eloped o collec ing da a om abused women, was adap ed and applied o medico-legal epo s o selec ed women. Va iables s udied included he cha ac e iza ion o he: (a) household a he momen o he o ensic assessmen ( ic im, alleged abuse , couple ela ionship and p e ious p egnancies); (b) cu en episode o iolence; (c) physical abuse ha led o medico-legal obse a ion; (d) legal ou comes. In o de o e alua e he judicial ou come o he p egnan g oup, judicial decisions we e eques ed by mail o he espec i e he Public P osecu o O ices and Cou s; only in 19 cases he in o ma ion was sen o us. S a is ical analysis was pe o med using SPSS (S a is ical Package o Social Sciences), e sion 17.0; including desc ip i e s a is ics and co ela ion es s using Pea son’s Chi-squa e, due o sample sizes. The signi icance le el conside ed was p<0.05. he esul ing small size o he sample migh impai he esul s. We acknowledge ha p e alence ob ained by us is hus p obably much lowe han eal, since many women ic ims o abuse we e no ques ioned abou he p esence o absence o episodes o agg ession du ing p egnancy and some, e en ha ing been asked abou his had denied by shame o emba assmen abou he subjec . Ano he limi a ion has o do wi h he ac ha his is a e ospec i e s udy based on he analysis o medico-legal epo s ha ha e no been pe o med in o de o pa icipa e in his kind o s udy, he e o e do no include all i ems ha we ied o analyze. In Po ugal, i was al eady conduc ed a s udy wi h he aim o unde s anding he ela ionship be ween IPV du ing p egnancy and p e e m bi h. They ha e concluded ha women abused du ing p egnancy had an inc eased isk o p e e m bi h ega dless o p esence o ano he ac o s ela ed o he highe incidence o p e e m deli e y.10 Howe e he e is s ill a gap wi h espec o he o ensic cha ac e iza ion o his phenomenon. The e o e, i would be in e es ing o conduc a longi udinal s udy in o de o be e cha ac e ize he medico-legal aspec s o cases o IPV du ing p egnancy. The heal h sec o has an impo an ole in comba ing his ype o iolence by means o esea ch, case no i ica ions, o ganiza ion o e e ence se ices o ic ims as well as o he p oposals in ol ing in e en ion.11 In ac , s udies show ha women abused du ing p egnancy equen ly con inue o su e abuse a e child bi h, so bo h he sa e y o he mo he and child a e a isk.36 The emo ional consequences o child en who wi ness iolence be ween hei pa en s can be e en wo se han when hey become a ge s hemsel es.25, 35 The e o e i would be impo an o implemen s anda dized sc eening measu es o be applied a he p ima y heal h ca e cen e in o de o imely de ec cases o iolence du ing p egnancy, making i sa e o he women and hei baby. The Ame ican Medical Associa ion ecommends ha heal h ca e p o ide s ou inely ask pa ien s abou IPV37 and in ac , mos women ag ee o IPV sc eening.26 CONCLUSIONS This s udy allows us o conclude ha : a) IPV in p egnancy is p obably unde epo ed by he ic ims and he heal h ca e p o essionals, aking in o accoun he low p e alence o women who we e unde going o ensic e alua ion du ing he s udy pe iod when compa ed o he alues ound in in e na ional s udies; b) Women ic ims o IPV du ing p egnancy a e mos ly unma ied compa ed wi h non p egnan ; c) The e seems o be a p edominance o abuse in women who a e p egnan o he i s ime when compa ed wi h hose who al eady ha e child en; d) The majo i y o women, p egnan and non p egnan , seek o medical help a e abuse; e) Mos o he ic ims is achie ed by mul iple mechanisms o agg ession whe eas punching, pushing, slapping and kicking a e e ealed he mos commons ega dless he women a e p egnan o no ; ) The a ec ed body a eas a e mos ly he ace and uppe limbs in bo h p egnan and non p egnan women. Fu he s udies a e necessa y o be e cha ac e ize he medico-legal aspec s in his kind o si ua ions. I is impo an o e alua e hese cases in e ms o sequelae ( empo a y and pe manen ) as well as in e ms o li e- h ea ening. Ano he impo an o ensic aspec ha needs o be be e known is i he e is a p e e ence o abdominal a aining which in his s udy could no be s a is ically analyzed due o missing da a. ETHICAL APPROVAL Despi e we do no equi e he app o al om he E hics Commi ee, since i is a e ospec i e s udy in which he iden i y o women in ol ed was p ese ed, he de elopmen o he s udy was conduc ed acco ding o high e hical s anda ds. REFERENCES 1. L. Magalhães T. Violência e Abuso Respos as Simples pa a Ques ões Complexas. Imp ensa da Uni e sidade de Coimb a; 2010. 2. Lou enço MA, Deslandes SF. Expe iência do cuidado ma e no e amamen ação sob a ó ica de mulhe es í imas de iolência conjugal. Re Saúde Pública 2008; 42(4): 615-21. 3. Linda R. In ima e Pa ne Violence and i s Implica ion o P egnancy. 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TABLES Table 1: Cha ac e iza ion o he ic ims PG (n=49) NPG (n=49) p n % n % Residen ype Na ional 46 93.9 46 93.9 Immig an 3 6.1 3 6.1 Ma i al s a us Single 33 67.3 22 44.9 0.025 O he condi ion 16 32.6 27 55.1 Ma ied 8 16.3 25 51.0 Di o ced 7 14.3 2 4.1 Widow 1 2.0 0 0 Educa ion le el 1s o 4 h g ade 0 0 1 2.0 5 h o 6 h g ade 1 2.0 0 0 7 h o 9 h g ade 3 6.1 2 4.1 10 h o 12 h g ade 2 4.1 2 4.1 Uni e si y 2 4.1 0 0 No in o ma ion 41 83.7 44 89.8 P o ession Unemployed 19 38.8 15 30.6 0.355 O he condi ion 29 58.9 34 69.4 Scien i ic occupa ion, echnical, a is ic o simila 3 6.1 1 2.0 Di ec o o senio 0 0 1 2.0 Admnis a i e o simila 1 2.0 0 0 Indus y wo ke 1 2.0 2 4.1 P o ec ion se ices, secu i y, pe sonal, domes ic se ices o simila 11 22.4 18 36.7 T ade and selle s 6 12.2 4 8.2 “Housewi e” 3 6.1 3 6.1 S uden 3 6.1 2 4.1 O he 1 2.0 3 6.1 No in o ma ion 1 2.0 0 0 Psychia ic his o y Yes 2 4.1 1 2.0 No 4 8.2 0 0 No in o ma ion 43 87.8 48 98.0 His o y o childhood abuse Yes 1 2.0 1 2.0 No 4 8.2 2 4.1 No in o ma ion 44 89.8 46 93.9 Table 2: Mechanisms o he cu en physical abuse Mechanism PG (n=49) NPG (n=49) n % n % Pushing 20 40.8 16 32.7 P essing 8 16.3 12 24.5 Pinching 1 2.0 0 0 Sc a ching 1 2.0 1 2.0 Pulling hai 7 14.3 10 20.4 Slapping 18 36.7 13 26.5 Punching 24 49.0 26 53.1 Kicking 17 34.7 14 28.6 Bi ing 1 2.0 3 6.1 S angling 5 10.2 5 10.2 Blun ins umen 3 6.1 4 8.2 Sha p ins umen 1 2.0 1 2.0 Mixed ins umen 0 0 1 2.0 O he s 9 18.4 7 14.3 Table 3: Ana omical dis ibu ion o he inju ies Ana omical dis ibu ion PG (n=49) NPG (n=49) n % n % C anium 4 8.2 8 16.3 Face 12 24.5 15 30.6 Neck 2 4.1 1 2.0 Rachis 1 2.0 0 0 Tho ax 5 10.2 5 10.2 Abdomen 2 4.1 0 0 Pe ineum 0 0 0 0 Righ Uppe Limb 11 22.4 14 28.6 Le Uppe Limb 12 24.5 17 34.7 Righ Lowe Limb 8 16.3 9 18.4 Le Lowe Limb 8 16.3 9 18.4 ANEXOS Anexo 1: Reg as de publicação (Re is a de e e ência: Jou nal o Fo ensic and Legal Medicine) INTRODUCTION Types o pape The ollowing ypes o a icles will be conside ed o publica ion: O iginal Communica ion: new esea ch, p e iously unpublished. 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