JOURNAL OF ADOLESCENT HEALTH 1992;13:466-469
Prevalence of Physical a Pregnant Adolescents ABBEY B. BERIXNSON, GREGG S, WILKINSON,
M.D.,
VIRGINIA
V. SAN
MIGUEL,
J.D.,
M.D.,
AND
Ph.D.
Few studies have addressed the prevalence of violence among pregnant adolescents. We interviewed 342 pregnant teenagers 17 years of age or younger for a history of assault; 9% reported physical assault, 8% sexual assault, and 8% both physical and sexual assault. Of those physically abused, 40% had been hit during pregnancy. The most common perpetrator of physical assault was a member of their family of origin as compared to a mate (46% versus 33%), although a boyfriend or spouse was the attacker in 88% of cases in which abuse had increased during pregnancy. The face or neck was the most common site of contact. A total of 14% reported being hit in the abdomen, one-third of them while pregnant. We conclude that a significant proportion of pregnant teenagers have experienced violence and therefore should be screened routinely for a history of abuse. KEYWORDS: Physical abuse Sexual abuse Child abuse Battering Adolescent pregnancy Teen pregnancy
the mother and fetus; it may result in maternal inand has been associated with fetal injuries (5) and a lower infant birth weight (6). A total of 13% of all births in the United States are to women less than 20 years of age (7). Studies on violence in pregnancy, however, have primarily included adults. Preliminary data suggest that adolescents who become pregnant may be at increased risk of abuse as compared to their nonpregnant peers. For example, the prevalence of childhood sexual assault was reported to be 8% in a survey of high school students (8) and 16% in a study of 301 college women (9). In contrast, a study on 41 young rural mothers who had been pregnant as teenagers revealed that 54% had been sexually abused as children (10). Hillard (4) observed that pregnant teenagers living at home are at risk of being physically assaulted by both their parents and their boyfriend or spouse. The aims of this investigation were to determine the prevalence of physical and sexual abuse in a pregnant adolescent population, the relationship of the perpetrator to the victim, whether pregnancy modified the pattern of assault, and demographic characteristics associated with abuse. juries,
Recent investigations on violence during pregnancy have found that between 4% and 8% of women are victims of physical or sexual assault (l-4). Assault during pregnancy has medical significance for both
Materials and Methods
Fmm the Deprtmemt of Obstetrics and Gynecology (A.B.B., V.V.S.M.), and the Department of Prwentutiue Medicine and Community Health (G.S.W.1, The University of Texas Medical Branch, G&e&n. Texas. Address reprint requests to: Abbey Berenson, M.D., Department of Obstrtricsand Gynecology, E-87, The University of Texas Medical Bran& Gatwston, Texas 77550. Manuxriptacceptwl March 4,1992.
Participants in this study were part of an ongoing project at our institution to identify pregnant patients at risk for violence. All new patients 17 years of age or younger who attended the teen pregnancy clinic at the University of Texas hiedicdl Branch between May 8, 1989, and December 8, 1990, were interviewed at their first visit about physical and sexual abuse. This clinic serves indigent patients
466 m4-l39x/92/$5.00
8 Societyfor AdolescentMedicine, 1992 Published by Ekwier science Publishing Co., Inc., 655Avenue of the meritis, New York, Ny 101~10
September 1992
from Galveston and surrounding counties. S&uctured interviews, based on a modified version of a questionnaire developed by Helton and Snodgrass (11) were conducted. A Spanish translation was used to interview patients who could not converse in English. A total of 18 patients (5%) were not surveyed because of an oversight by their clinician. No patient refused to answer the survey. A total of 342 teenagers were asked whether they had ever been physically or sexually assaulted. Physical assault was defined as being hit, slapped, kicked, or otherwise physically hurt. Data were obtained about their relationship to the attacker, the date of the most recent abuse, and the body site injured. Patients were asked whether medical care had ever been sought for a physical assault injury and whether physical abuse had occurred or increased in severity or frequency during the current pregnancy. Questions on sexual assault included whether the adolescent had ever been sexually abused or raped. Sociodemographic data were obtained by reviewing, with approval of the Institutional Review Board, each patient’s hospital record. The computerized data for a subset of 15% of interviewed patients were compared with the original records and interview forms to assure accuracy of data entry; 98% accuracy was observed. Information on legal rights and community resources for assault victims was disseminated to all patients. An on-site social worker counseled those with a positive history of abuse. For purposes of analysis, participants were grouped into those physically assaulted (with no history of sexual assault), those sexually (but not physically) assaulted, and those with a history of both physical and sexual assault. The t test was used to assess mean differences between victims and nonvictims of assault for patient’s age, gestational age of the fetus, gravidity, parity, number of abortions, and number of living children. After measuring the prevalence of physical and sexual assault, we calculated odds ratios for victims of violence compared with nonvictims for race, employment, and student status. Perpetrators were identified as either members of the family of ori@ (parents, step-parents, and siblings) or not of the family of origin (spouses or boyfriends, hereinafter referred to as mates). The 95% confidence limits around the odds ratios based on a procedure developed by Cornfield (12) and later modified by Gart (13) were calculated to estimate the precision of our relative risk estimates (14). Calculations were performed using Number
VIOLENCE IN ADOLESCENT PREGNANCY
467
Table 1. Prevalence of Physical Assault During Pregnancy by Perpetrator Family
Nonfamily of
Total II
of origin 70 n
origin % n
%
battering Battered while
58
43
(25)
31
(18)
19
(11)
pregnant Battering increased in pceqancy
23
22
(5)
52
(12)
22
(5)
-
(0)
80
(4)
20
(0)
Both n
-
History of
5
Cruncher Statistical System Software (15), the BMDP Statistical package (16) or a standard set of algorithms for hand calculators (17).
Results White non-Hispanics made up 45% of this population, 34% were blacks, and 21% were Hispanics. The mean age was 16.0 * 1.0 years at the time of interview. Most patients were single (83%) and not employed (94%). Four patients spoke Spanish only. Twenty-five percent reported a history of some type of personal violence; 9% reported that they had experienced physical but not sexual assault (CL = 6%, 12%), 8% had encountered sexual but not physical assault (CL = 5%, ll%), and 8% had been both physically and sexually abused (CL = 5%, 10%). Among 58 patients who reported physical abuse, 23 had been assaulted during pregnancy, most commonly by a mate (Table 1). Five adolescents reported an increase in the frequency or severity of violence during pregnancy. Only 14% of all victims of phvr.ical abuse had sought medical treatment; 59% of adolescents who reported being hit in a single site during the last attack were struck in the face or neck and 24% on the extremities; 24% of the adolescents reported being hit in multiple sites, and 14% of the physically abused teenagers were hit in the abdomen-onethird of them while pregnant. When compared with blacks or Hispanics, white non-Hispanic adolescents were more likely to report sexual abuse (RR = 2.6, CL = 1.1, 5.7) or both physical and sexual assault combined (RR 4.1, CL = 1.7, 9.9). Hispanics were less likely to report a history of combined abuse (RR = 0.2, CL = 0.0, 0.7) than were white non-Hispanic teenagers. All adolescents who admitted a history of abuse were fluent in English.
468
BERENSON ET AL.
Adolescents who had a history of sexual assault obtained prenatal care earlier than did those with a negative history (18.5 & 7.9 versus 22.0 + 8.9 weeks, p c 0.05). No other demographic differences (patient’s age, gravidity, parity, number of abortions, and number of living children) were found between victims of abuse and those who had not been assaulted. Adolescents who had experienced sexual assault (RR = 2.3, CL = 1.0, 5.1), as well as those with a history of combined physical and sexual assault (RR = 2.4, CL = 1.0, 5.5), were twice as likely to have dropped out of school compared with teenagers without a history of abuse. Adolescents who had been physically, but not sexually, abused were not at higher risk of discontinuing school than those without a history of assault (RR = 1.1, CL = 0.5, 2.3).
Discussion previous investigations on childhood violence among adolescents have primarily been conducted in substance abuse centers or psychiatric settings and have frequently lacked control groups. Schoolbased surveys have been plagued by high refusal rates (18). Our survey of pregnant adolescents included 95% of all new clinic patients seen during the study period, without a single patient refusal. The 25% prevalence of physical or sexual abuse detected in this study is lower than that reported for adolescents in other specialized settings (19-22), which may,/be due to differences in methodology or population$. Our survey was administered as part of the routine intake process at the first prenatal visit, therefore, the number of questions concerning assault was limited. Inquiries regarding sexual abuse tended to select adolescents who had experienced severe abuse or rape. Although all interviews were conducted in private, teenagers who had been accompanied to the clinic by an abusive boyfriend, spouse, or parent may have been intimidated by their presence and afraid to discuss their assault experiences. We detected a higher prevalence, however, than that reported in the school-based selfadministered written surveys by Hibbard et al. (18%) (18) and Riggs et al. (13%) (8). A higher prevalence would be expected in a pregnant adolescent population if abused teenagers are at higher risk than nonabused girls to become pregnant, as suggested by Butler and Burton (10). We also observed that adolescents not in school were almost twice as likely (RR = 1.8, CL = 1.1,2.9) to have experienced mal-
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 6
treatment as adolescents who attended school; thus a lower prevalence in previous surveys may be partially explained by the exclusion of drop-outs. We observed that white non-Hispanic adolescents reported a history of assault more often than Hispanic adolescents, a finding similar to other reports on pregnant women (1,2). This difference between ethnic groups in the prevalence of assault may be due to an actual difference or to response bias, particularly if Hispanics are less likely than nonHispanic whites to confide in their clinicians. Matching the ethnic@ of the subject and interviewer as suggested by Wyatt and peters (23) might assist in obtaining a higher prevalence rate of child abuse among minorities. Of adolescents with a history of physical assault, 40% reported violence during pregnancy, which is higher than reports on pregnant adults by Helton et ai. (35%) (3) and Berenson et al. (29%) (2) This higher prevalence may be due to a difference in reporting if adolescents are more likely than adults to disclose ongoing abuse. It also may be due to an actual increased incidence in pregnancy as adolescents, who often live at home, are at risk of being hit both by their parents and their mate. A total of 23% of the adolescents reported that a member of their family of origin was the sole perpetrator during pregnancy. Although adolescents may experience assault from both parents and a boyfriend or spouse, we observed that the mate was most often the sole attacker in those cases of increased abuse during pregnancy. In contrast, most adolescents who had previously been hit by a parent reported either a decrease or no change in violence during pregnancy. An emotional attachment between grandparents and their unborn grandchild may protect the adolescent from further or more severe physical assault by their parents during pregnancy. The abusive boyfriend or spouse, who may or may not be the baby’s father, however, does not appear to share these protective feelings. Previous studies have shown that children who have been physically assaulted are at a higher risk of developing aggressive behavior, thus establishing what has been termed the “cycle of violence” (24). Individuals with a history of maltreatment are six times more likely than the general population to abuse their own children (30% f 5% versus 5%) (25). Egeland et al. (26) demonstrated that mothers who participated in therapy during any point in their lives were more likely to break this abusive cycle and provide adequate care for their children than
September 1992
abused mothers who did not undergo therapy. The frequent visits during pregnancy provide an ideal time to educate victims that physical abuse is not acceptableor permissibleand to provide both counseling and instruction in parenting skills. Removal of the mother from the abusive environment may prevent further injuries. We conclude that a significantproportion of pregnant teenagers have experiencedboth physicaland sexual abuse. Pregnant adolescents may be victims of ongoing child abuse by parents as well as victims of assault by a mate. Pletsch (27) observed that among inner-city high school students, pregnant subjectsdemonstrated more positive health behaviors than nonpregnant subjects. Their heightened awareness of the need for proper health care can serve as a basis for positiveinterventionwith pregnant abuse victims. It is imperativeto identifythose at risk so that support, counseling, education, and referral, when appropriate, can be offered to the victim.
References 1. Amaro H, Fried LE, Cabral H, et al. Violence during pregnancy and substance use. Am J Pub Health 1990;80:575-9. 2. Berenson AB, Stiglich NJ, Wilkinson GS, et al. Drug abuse and other risk factors for physical abuse in pregnancy among White non-Hispanic, Black and Hispanic women. Am J Obstet Gynecol 1991;164:1491-9. 3. Helton AS, McFarlane J, Anderson ET. Battered and pregnant: A prevalence study. Am ] Public Health 1987;77:13379. 4. Hillard PJA. Physical abuse in pregnancy.
Obstet Gynecol 1985;66:185-90. 5. Morey MA, Begleiter ML, Harris DJ. Profile of a battered fetus. Lancet 1981;2:1294. 6. Schei B, Samuelsen SO, Bakketeig LS. Does spousal physical abuse affect the outcome of pregnancy? Stand J Sot Med lYY1;19:26-31. 7. National Center for Health Statistics. Advance report of final natality statistics, 1986. Monthly Vital Stat Rep 1988;37:1-48. 8. Riggs S, Alario AJ, McHorney C. Health risk behaviors and attempted suicide in adolescents who report prior maltreatment. J Pediatr 1990;116:815-21.
VIOLENCE IN ADOLESCENT PREGNANCY
469
9. Sedney M, Brooks S. Factors associated with a history of childhood sexual experience in a nonclinical female poputation. J Am Acad Child Psychiatry 1984;23:215_8.
10. Butler JR, Burton LM. Rethinking teenage childbearing: Is sexual abuse a missing link. Fam Relat 190;39:73-80. 11. Helton AS, Snodgrass FG. Battering during pregnancy: intervention strategies. Birth 1987;14:142-7. 12. Coenfield J. A statistical problem arising from retrospective studies. In: Proceedings of the 3rd Symposium on Mathematical Statistics. Berkeley, University of California Press, 1956135-48.
13. Gart J. The comparison of proportions: A review of significance tests, confidence intervals and adjustments for stratification. Rev Inst Stat Inst 1971;39:148-69. 14. Rothman KJ. Modern epidemiology. Boston, Little, Brown and Company, 1986. 15. Hintze JL. Number Cruncher Statistical System Version 5.031 5/YO.Kaysville, Utah: Jerry L. Hintze, 1990. 16. Dixon WJ. (Chief Editor) BMDP Statistical Software Manual. Berkeley, University of California Press, 1988.
17. Rothman KJ, Boice JD, Jr. Epidemiologic Analysis with a Programmable Calculator. Chestnut Hill, Epidemiology Kesources Inc., 1982. 18. Hibbard RA, Brack CJ, Rauch S, et al. Abuse, feelings, and health behaviors in a student population. Am J Dis Child 1988;142:326-30. 19. Dembo R, Dertke M, LaVoie L, et al. Physical abuse, sexual victimization and illicit drug use; a structural analysis among high risk adolescents. J Adolesc 1987;10:13-34. 20. Harrison PA, Hoftinann NG, Edwall GE. Differential drug use patterns among sexually abused adolescent girls in treatment for chemical dependency. Int J Addict 1989;24:499-514. 21. Dembo R, Dertke M, Borders S, et al. The relationship between physical and. sexual abuse and tobacco, alcohol, and illicit drug use among youth in a juvenile detention center. Int J Addict 1988;23:351-378. 22. Cavaiola AA, Schiff M. Behavioral sequelae of physical and/ or sexual abuse in adolescents. Child Abuse Negi 1988;12:181-8. 23. Wyatt GE, Peters SD. Methodological considerations in research on the prevalence of child sexual abuse. Child Abuse Negl1986;10:241-51. 24, Dodge KA, Bates JE, Pettit GS. Mechanisms in the cycle of violence. Science lYYO;250:1680-3. 25. Kaufman J, Sigler E. Do abused children became abusive parents. Am J Orthopsychia 1987;57:186-92. 26. Egeland 8, Jacob&z D, Stroufe LA. Breaking the cycle of abuse. Child Dev 1988;59:1080-8. 27. Pletsch PK. Substance use and health activities of pregnant adolescents. J Adolesc Health Care 1988;9:38-45.
Prevalence of Physical a Pregnant Adolescents ABBEY B. BERIXNSON, GREGG S, WILKINSON,
M.D.,
VIRGINIA
V. SAN
MIGUEL,
J.D.,
M.D.,
AND
Ph.D.
Few studies have addressed the prevalence of violence among pregnant adolescents. We interviewed 342 pregnant teenagers 17 years of age or younger for a history of assault; 9% reported physical assault, 8% sexual assault, and 8% both physical and sexual assault. Of those physically abused, 40% had been hit during pregnancy. The most common perpetrator of physical assault was a member of their family of origin as compared to a mate (46% versus 33%), although a boyfriend or spouse was the attacker in 88% of cases in which abuse had increased during pregnancy. The face or neck was the most common site of contact. A total of 14% reported being hit in the abdomen, one-third of them while pregnant. We conclude that a significant proportion of pregnant teenagers have experienced violence and therefore should be screened routinely for a history of abuse. KEYWORDS: Physical abuse Sexual abuse Child abuse Battering Adolescent pregnancy Teen pregnancy
the mother and fetus; it may result in maternal inand has been associated with fetal injuries (5) and a lower infant birth weight (6). A total of 13% of all births in the United States are to women less than 20 years of age (7). Studies on violence in pregnancy, however, have primarily included adults. Preliminary data suggest that adolescents who become pregnant may be at increased risk of abuse as compared to their nonpregnant peers. For example, the prevalence of childhood sexual assault was reported to be 8% in a survey of high school students (8) and 16% in a study of 301 college women (9). In contrast, a study on 41 young rural mothers who had been pregnant as teenagers revealed that 54% had been sexually abused as children (10). Hillard (4) observed that pregnant teenagers living at home are at risk of being physically assaulted by both their parents and their boyfriend or spouse. The aims of this investigation were to determine the prevalence of physical and sexual abuse in a pregnant adolescent population, the relationship of the perpetrator to the victim, whether pregnancy modified the pattern of assault, and demographic characteristics associated with abuse. juries,
Recent investigations on violence during pregnancy have found that between 4% and 8% of women are victims of physical or sexual assault (l-4). Assault during pregnancy has medical significance for both
Materials and Methods
Fmm the Deprtmemt of Obstetrics and Gynecology (A.B.B., V.V.S.M.), and the Department of Prwentutiue Medicine and Community Health (G.S.W.1, The University of Texas Medical Branch, G&e&n. Texas. Address reprint requests to: Abbey Berenson, M.D., Department of Obstrtricsand Gynecology, E-87, The University of Texas Medical Bran& Gatwston, Texas 77550. Manuxriptacceptwl March 4,1992.
Participants in this study were part of an ongoing project at our institution to identify pregnant patients at risk for violence. All new patients 17 years of age or younger who attended the teen pregnancy clinic at the University of Texas hiedicdl Branch between May 8, 1989, and December 8, 1990, were interviewed at their first visit about physical and sexual abuse. This clinic serves indigent patients
466 m4-l39x/92/$5.00
8 Societyfor AdolescentMedicine, 1992 Published by Ekwier science Publishing Co., Inc., 655Avenue of the meritis, New York, Ny 101~10
September 1992
from Galveston and surrounding counties. S&uctured interviews, based on a modified version of a questionnaire developed by Helton and Snodgrass (11) were conducted. A Spanish translation was used to interview patients who could not converse in English. A total of 18 patients (5%) were not surveyed because of an oversight by their clinician. No patient refused to answer the survey. A total of 342 teenagers were asked whether they had ever been physically or sexually assaulted. Physical assault was defined as being hit, slapped, kicked, or otherwise physically hurt. Data were obtained about their relationship to the attacker, the date of the most recent abuse, and the body site injured. Patients were asked whether medical care had ever been sought for a physical assault injury and whether physical abuse had occurred or increased in severity or frequency during the current pregnancy. Questions on sexual assault included whether the adolescent had ever been sexually abused or raped. Sociodemographic data were obtained by reviewing, with approval of the Institutional Review Board, each patient’s hospital record. The computerized data for a subset of 15% of interviewed patients were compared with the original records and interview forms to assure accuracy of data entry; 98% accuracy was observed. Information on legal rights and community resources for assault victims was disseminated to all patients. An on-site social worker counseled those with a positive history of abuse. For purposes of analysis, participants were grouped into those physically assaulted (with no history of sexual assault), those sexually (but not physically) assaulted, and those with a history of both physical and sexual assault. The t test was used to assess mean differences between victims and nonvictims of assault for patient’s age, gestational age of the fetus, gravidity, parity, number of abortions, and number of living children. After measuring the prevalence of physical and sexual assault, we calculated odds ratios for victims of violence compared with nonvictims for race, employment, and student status. Perpetrators were identified as either members of the family of ori@ (parents, step-parents, and siblings) or not of the family of origin (spouses or boyfriends, hereinafter referred to as mates). The 95% confidence limits around the odds ratios based on a procedure developed by Cornfield (12) and later modified by Gart (13) were calculated to estimate the precision of our relative risk estimates (14). Calculations were performed using Number
VIOLENCE IN ADOLESCENT PREGNANCY
467
Table 1. Prevalence of Physical Assault During Pregnancy by Perpetrator Family
Nonfamily of
Total II
of origin 70 n
origin % n
%
battering Battered while
58
43
(25)
31
(18)
19
(11)
pregnant Battering increased in pceqancy
23
22
(5)
52
(12)
22
(5)
-
(0)
80
(4)
20
(0)
Both n
-
History of
5
Cruncher Statistical System Software (15), the BMDP Statistical package (16) or a standard set of algorithms for hand calculators (17).
Results White non-Hispanics made up 45% of this population, 34% were blacks, and 21% were Hispanics. The mean age was 16.0 * 1.0 years at the time of interview. Most patients were single (83%) and not employed (94%). Four patients spoke Spanish only. Twenty-five percent reported a history of some type of personal violence; 9% reported that they had experienced physical but not sexual assault (CL = 6%, 12%), 8% had encountered sexual but not physical assault (CL = 5%, ll%), and 8% had been both physically and sexually abused (CL = 5%, 10%). Among 58 patients who reported physical abuse, 23 had been assaulted during pregnancy, most commonly by a mate (Table 1). Five adolescents reported an increase in the frequency or severity of violence during pregnancy. Only 14% of all victims of phvr.ical abuse had sought medical treatment; 59% of adolescents who reported being hit in a single site during the last attack were struck in the face or neck and 24% on the extremities; 24% of the adolescents reported being hit in multiple sites, and 14% of the physically abused teenagers were hit in the abdomen-onethird of them while pregnant. When compared with blacks or Hispanics, white non-Hispanic adolescents were more likely to report sexual abuse (RR = 2.6, CL = 1.1, 5.7) or both physical and sexual assault combined (RR 4.1, CL = 1.7, 9.9). Hispanics were less likely to report a history of combined abuse (RR = 0.2, CL = 0.0, 0.7) than were white non-Hispanic teenagers. All adolescents who admitted a history of abuse were fluent in English.
468
BERENSON ET AL.
Adolescents who had a history of sexual assault obtained prenatal care earlier than did those with a negative history (18.5 & 7.9 versus 22.0 + 8.9 weeks, p c 0.05). No other demographic differences (patient’s age, gravidity, parity, number of abortions, and number of living children) were found between victims of abuse and those who had not been assaulted. Adolescents who had experienced sexual assault (RR = 2.3, CL = 1.0, 5.1), as well as those with a history of combined physical and sexual assault (RR = 2.4, CL = 1.0, 5.5), were twice as likely to have dropped out of school compared with teenagers without a history of abuse. Adolescents who had been physically, but not sexually, abused were not at higher risk of discontinuing school than those without a history of assault (RR = 1.1, CL = 0.5, 2.3).
Discussion previous investigations on childhood violence among adolescents have primarily been conducted in substance abuse centers or psychiatric settings and have frequently lacked control groups. Schoolbased surveys have been plagued by high refusal rates (18). Our survey of pregnant adolescents included 95% of all new clinic patients seen during the study period, without a single patient refusal. The 25% prevalence of physical or sexual abuse detected in this study is lower than that reported for adolescents in other specialized settings (19-22), which may,/be due to differences in methodology or population$. Our survey was administered as part of the routine intake process at the first prenatal visit, therefore, the number of questions concerning assault was limited. Inquiries regarding sexual abuse tended to select adolescents who had experienced severe abuse or rape. Although all interviews were conducted in private, teenagers who had been accompanied to the clinic by an abusive boyfriend, spouse, or parent may have been intimidated by their presence and afraid to discuss their assault experiences. We detected a higher prevalence, however, than that reported in the school-based selfadministered written surveys by Hibbard et al. (18%) (18) and Riggs et al. (13%) (8). A higher prevalence would be expected in a pregnant adolescent population if abused teenagers are at higher risk than nonabused girls to become pregnant, as suggested by Butler and Burton (10). We also observed that adolescents not in school were almost twice as likely (RR = 1.8, CL = 1.1,2.9) to have experienced mal-
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 6
treatment as adolescents who attended school; thus a lower prevalence in previous surveys may be partially explained by the exclusion of drop-outs. We observed that white non-Hispanic adolescents reported a history of assault more often than Hispanic adolescents, a finding similar to other reports on pregnant women (1,2). This difference between ethnic groups in the prevalence of assault may be due to an actual difference or to response bias, particularly if Hispanics are less likely than nonHispanic whites to confide in their clinicians. Matching the ethnic@ of the subject and interviewer as suggested by Wyatt and peters (23) might assist in obtaining a higher prevalence rate of child abuse among minorities. Of adolescents with a history of physical assault, 40% reported violence during pregnancy, which is higher than reports on pregnant adults by Helton et ai. (35%) (3) and Berenson et al. (29%) (2) This higher prevalence may be due to a difference in reporting if adolescents are more likely than adults to disclose ongoing abuse. It also may be due to an actual increased incidence in pregnancy as adolescents, who often live at home, are at risk of being hit both by their parents and their mate. A total of 23% of the adolescents reported that a member of their family of origin was the sole perpetrator during pregnancy. Although adolescents may experience assault from both parents and a boyfriend or spouse, we observed that the mate was most often the sole attacker in those cases of increased abuse during pregnancy. In contrast, most adolescents who had previously been hit by a parent reported either a decrease or no change in violence during pregnancy. An emotional attachment between grandparents and their unborn grandchild may protect the adolescent from further or more severe physical assault by their parents during pregnancy. The abusive boyfriend or spouse, who may or may not be the baby’s father, however, does not appear to share these protective feelings. Previous studies have shown that children who have been physically assaulted are at a higher risk of developing aggressive behavior, thus establishing what has been termed the “cycle of violence” (24). Individuals with a history of maltreatment are six times more likely than the general population to abuse their own children (30% f 5% versus 5%) (25). Egeland et al. (26) demonstrated that mothers who participated in therapy during any point in their lives were more likely to break this abusive cycle and provide adequate care for their children than
September 1992
abused mothers who did not undergo therapy. The frequent visits during pregnancy provide an ideal time to educate victims that physical abuse is not acceptableor permissibleand to provide both counseling and instruction in parenting skills. Removal of the mother from the abusive environment may prevent further injuries. We conclude that a significantproportion of pregnant teenagers have experiencedboth physicaland sexual abuse. Pregnant adolescents may be victims of ongoing child abuse by parents as well as victims of assault by a mate. Pletsch (27) observed that among inner-city high school students, pregnant subjectsdemonstrated more positive health behaviors than nonpregnant subjects. Their heightened awareness of the need for proper health care can serve as a basis for positiveinterventionwith pregnant abuse victims. It is imperativeto identifythose at risk so that support, counseling, education, and referral, when appropriate, can be offered to the victim.
References 1. Amaro H, Fried LE, Cabral H, et al. Violence during pregnancy and substance use. Am J Pub Health 1990;80:575-9. 2. Berenson AB, Stiglich NJ, Wilkinson GS, et al. Drug abuse and other risk factors for physical abuse in pregnancy among White non-Hispanic, Black and Hispanic women. Am J Obstet Gynecol 1991;164:1491-9. 3. Helton AS, McFarlane J, Anderson ET. Battered and pregnant: A prevalence study. Am ] Public Health 1987;77:13379. 4. Hillard PJA. Physical abuse in pregnancy.
Obstet Gynecol 1985;66:185-90. 5. Morey MA, Begleiter ML, Harris DJ. Profile of a battered fetus. Lancet 1981;2:1294. 6. Schei B, Samuelsen SO, Bakketeig LS. Does spousal physical abuse affect the outcome of pregnancy? Stand J Sot Med lYY1;19:26-31. 7. National Center for Health Statistics. Advance report of final natality statistics, 1986. Monthly Vital Stat Rep 1988;37:1-48. 8. Riggs S, Alario AJ, McHorney C. Health risk behaviors and attempted suicide in adolescents who report prior maltreatment. J Pediatr 1990;116:815-21.
VIOLENCE IN ADOLESCENT PREGNANCY
469
9. Sedney M, Brooks S. Factors associated with a history of childhood sexual experience in a nonclinical female poputation. J Am Acad Child Psychiatry 1984;23:215_8.
10. Butler JR, Burton LM. Rethinking teenage childbearing: Is sexual abuse a missing link. Fam Relat 190;39:73-80. 11. Helton AS, Snodgrass FG. Battering during pregnancy: intervention strategies. Birth 1987;14:142-7. 12. Coenfield J. A statistical problem arising from retrospective studies. In: Proceedings of the 3rd Symposium on Mathematical Statistics. Berkeley, University of California Press, 1956135-48.
13. Gart J. The comparison of proportions: A review of significance tests, confidence intervals and adjustments for stratification. Rev Inst Stat Inst 1971;39:148-69. 14. Rothman KJ. Modern epidemiology. Boston, Little, Brown and Company, 1986. 15. Hintze JL. Number Cruncher Statistical System Version 5.031 5/YO.Kaysville, Utah: Jerry L. Hintze, 1990. 16. Dixon WJ. (Chief Editor) BMDP Statistical Software Manual. Berkeley, University of California Press, 1988.
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