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