Spousal abuse increases the risk of miscarriage by 50%

Domestic violence against women, more specifically violence perpetrated by a partner or spouse, is an important problem worldwide.  A 2005 study by the World Health Organization that assessed 24,000 women in 10 countries found that between 15% and 71% of women had experienced physical or sexual violence, or both, at the hands of their partner.  Women in rural areas in Bangladesh, Ethiopia, Peru, and the United Republic of Tanzania were most likely to suffer abuse; alarmingly, as many as 71% of women in Ethiopia reported having experienced sexual and/or physical violence by an intimate partner.

Physical violence can also occur during pregnancy, with such abuse often involving blows or kicks to the abdomen. Of all women in the WHO study who who reported spousal abuse, between 11% and 44% also experienced violence during pregnancy.  Not surprisingly, abuse during pregnancy is associated with adverse birth outcomes.

A new study published this week in British journal The Lancet has found that spousal violence during pregnancy can also affect unborn babies, increasing the risk of miscarriage or stillbirth by 50% in women in sub-Saharan Africa.  Given that such a large proportion of risk for fetal mortality can be pinned onto spousal violence, such fetal deaths are potentially preventable; indeed, this study showed that interventions that reduce domestic violence could prevent more than a third of fetal deaths.

The authors of this study interviewed 2,562 women of childbearing age who lived in Cameroon, a large and relatively stable country on the west coast of Africa.  Participants were asked about their experiences of emotional, physical, and sexual violence from their spouse and whether they had ever had a spontaneous abortion (miscarriage) or a stillbirth.

In total, more than half of the women interviewed reported having experienced at least one type of violence from their husband, most typically physical violence (39%), followed by emotional (31%) and sexual (15%) abuse.

Compared with women who had not experienced any form of domestic violence, women who had experienced abuse were 50% more likely to have had a miscarriage or stillbirth. Women who were exposed to at least two types of violence (for example both physical and emotional abuse) had a higher frequency of fetal death than did victims of only one type of violence.

Strikingly, emotional violence was almost as strongly associated with fetal death as were physical abuse and sexual violence; however, the strongest link between spousal violence and fetal death was seen in women who suffered sexual abuse. On the other hand, women who experienced emotional abuse were most likely to have repeated instances of miscarriage or stillbirth.

This study also threw up some rather surprising results.  Women married to men with some education were more likely to have experienced domestic violence than were women married to uneducated men, and women in the richer categories were also more likely to experience abuse than their poorer counterparts.  These results are at odds with findings elsewhere: as the authors point out, “in the USA, abused women tend to be younger, less educated, and more economically disadvantaged”.

Estimates in this study suggest that interventions to prevent spousal abuse could also prevent a considerable proportion of miscarriages and stillbirths.  An intervention that is 100% effective at reducing domestic violence, or even one that is only 75% effective, could prevent up to a third of fetal deaths.

Writing in a comment article that accompanies this research, Claudia Garcia-Moreno, a member of the WHO Department of Reproductive Health and Research in Geneva, discusses the significance of these findings.

This study is an important contribution to the field, because it is one of the first to document this association [between spousal abuse and fetal death] and one of the first in Africa, where the rate of fetal loss is high. [The authors] highlight the important contribution that addressing intimate-partner violence can make in prevention, particularly recurrent fetal loss, and in the improvement of maternal and neonatal health.

It is important that public-health initiatives to prevent spousal abuse are implemented, not only in sub-Saharan Africa but worldwide, in order to prevent unnecessary fetal deaths and to protect the health and wellbeing of pregnant women.  Given that during pregnancy is one of the only times that healthy women have frequent scheduled contact with the health system, it is important, both for mother and baby, that antenatal care is improved so that women suffering at the hands of their partners can be identified and offered support.

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Alio A et al. (2009) Spousal violence and potentially preventable single and recurrent spontaneous fetal loss in an African setting: cross-sectional study The Lancet 373 (9660): 318-324 DOI: 10.1016/S0140-6736(09)60096-9

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Consumption of caffeine during pregnancy increases the risk of having an underweight baby

Caffeine has been proposed to have all sorts of effects on health, both good and bad. Just in the last few months, it has been reported that caffeine can help repair damaged blood vessels, protect against cataract formation, and even shrink women’s breasts.

Now new research published in the British Medical Journal has found that consuming caffeine during pregnancy can increase the risk of giving birth to low-birth-weight baby. Underweight babies are more likely to be delivered early or by cesarean section, and are at a higher risk of having neurological disabilities.

The authors of this study devised a questionnaire on habitual caffeine intake that was administered before conception and twice during pregnancy in 2,635 women. They then looked at information on pregnancy complications and delivery details in the electronic databases of the two large UK maternity hospitals in which the study was conducted.

The mean caffeine intake during pregnancy in these women was 159mg a day – equivalent to approximately a cup and a half of filter coffee, three cups of tea, or about three cans of cola drink. Approximately 62% of the total caffeine ingested was in the form of tea, 14% was in coffee, 12% in cola drinks and 8% in chocolate.

Compared with women who consumed less than 100mg of caffeine a day, the risk of having a low-birth-weight baby was 20% higher in those who consumed 100-199mg per day and 50% higher in those who consumed 200-299mg per day. The size of the reduction in birth weight increased as caffeine intake increased.

Importantly, the magnitude of the association between caffeine consumption and baby size was similar to that seen between alcohol consumption and birth weight, i.e. caffeine consumption increased the risk of having a low-birth weight baby as much as alcohol consumption did.

The Food Standards Agency in the UK has now changed it’s recommendations on caffeine intake during pregnancy on the basis of this research, lowing the limit from 300mg a day to 200mg a day.
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CARE Study Group (2008). Maternal caffeine intake during pregnancy and risk of fetal growth restriction: a large prospective observational study BMJ, 337 DOI: 10.1136/bmj.a2332

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IVF does not increase the risk of complications at birth

I recently read an interesting paper in The Lancet about birth complications in women who conceive using assisted fertilization, i.e. IVF, compared with complications in women who give birth having conceived normally.

Studies generally report a higher risk of complications at birth for babies conceived by IVF than for those conceived naturally. Women who undergo fertility treatment are far more likely to have twins or triplets than are women who conceive naturally thanks to the high number of embryos implanted, so a considerable proportion of the risks associated with IVF are in fact complications relating to multiple births.

However, the risks of complications before, during and after birth are still higher in women who conceive only a single child when undergoing assisted reproduction. For example, a meta-analysis published in the BMJ in 2007 found that singleton babies conceived with assisted reproduction were at least twice as likely to be born prematurely as babies conceived naturally, and one and a half times more likely to be born by cesarean section.

A group in Norway lead by Dr Liv Bente Romundstad has now found that the risk of perinatal complications in singleton births conceived using assisted reproduction is no worse than that of singleton births conceived naturally, suggesting that IVF techniques are more safe than previously thought.

The authors came to this conclusion by assessing 2,500 women who had given birth to at least one child who had been conceived naturally and one who had been conceived using assisted fertilization. Among these siblings, the risk of premature delivery and of small size for gestational age were not significantly higher in those conceived by assisted reproduction than in those conceived naturally. The authors suggest that the poor perinatal outcomes reported in women who conceive using IVF might not be the fault of the assisted reproduction techniques and instead might be attributable to maternal factors, such as underlying infertility.

This study is particularly interesting because researchers investigating outcomes after assisted reproduction find it hard to untangle the possible negative effects of IVF technology from other factors that might adversely affect birth outcomes. The women who use IVF tend to do so because they’re having fertility problems, making them – and their birth outcomes – inherently different to women who conceive naturally.

Romundstad et al. controlled for such maternal factors by comparing IVF and natural conceived births in the same women, rather than births in two completely separate populations,. The births in either group had the same maternal baseline characteristics, so the authors were able discern the effect of IVF.

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