This study documented high rates of lifetime and current exposure to violence among a population of substance-dependent pregnant women entering substance abuse treatment, as assessed by the VEQ. Physical, emotional, and sexual abuse histories were frequently reported with high rates of co-occurrence. Usually, the perpetrator was the partner or someone closely related to the victim (i.e., a family member) and, unfortunately, children frequently witnessed such violence.
The prevalence rate of physical violence during pregnancy in this sample (20.3%) was two to five times higher than prevalence rates previously reported in survey studies on pregnant women in the general population (3%–14%; GAO, 2000; Gazmararian, 2000
). High rates of physical abuse during pregnancy similar to those found in this study have been reported infrequently elsewhere (O’Campo, Gielen, Faden, & Kass, 1994
; Parker, McFarlane, Soeken, Torres, & Campbell, 1993
) when researchers used a detailed in-person interview (i.e., the AAS and Conflict Tactic Scale) and screened subjects several times during all three trimesters of their pregnancy (Gazmararian et al., 1996
; Jasinski, 2004
Although the rates of violence that we found are high, we nonetheless believe that they represent underestimates of the true scope of the problem. We have clinically observed that women frequently deny exposure to violence upon program admission, only to disclose abuse subsequently during their treatment. It is also possible that substance-dependent women may accept some abusive aspects of their life as normal or may experience psychosocial pressure to deny a history of abuse. In addition, the high rates of physical and yelling/screaming fights reported suggest that violent episodes between partners are frequent; therefore, it is likely that violent behavior stems from both partners. Some of the women involved in these episodes may not perceive these situations as an abusive event perpetrated by their partner. Therefore, it may not be surprising to find higher rates of abuse later on in treatment when substance-abusing pregnant women become aware of their abusive relationships and feel more comfortable disclosing to therapists the reality of their everyday lives.
The finding that 7.1% of the women reported sexual abuse during pregnancy is of particular concern. Sexual abuse has been associated with multiple health risks for mothers and infants, including sexually transmitted diseases (e.g., AIDS), urinary tract infection, complications during labor and delivery, and depression (Gilbert, El-Bassel, Schilling, Wada, & Bennet, 2000
; King, Britt, McFarlane, & Hawkins, 2000
; Jasinski, 2004
). In addition, substance-abusing pregnant women who report both sexual and physical abuse during pregnancy present with high levels of psychological distress (Velez et al., 2003
Treatment programs for chemically dependent pregnant women often fail to recognize sexual or physical abuse, which may result in premature treatment dropout, relapse to substance use, and poor perinatal outcomes (Berenson, San Miguel, & Wilkinson, 1992
; Hien & Levin, 1994
). Routine screening for sexual abuse in substance-abusing pregnant women is imperative so that appropriate services and safety plans can be established for the victims, their existing children, and their newborns. The VEQ may serve as a screening tool given that it was very well accepted by this study population and facilitated development of individualized intervention plans.
Intervention strategies for pregnant drug-dependent women experiencing violence differ depending on the relationship of a perpetrator to a victim. The most frequent perpetrators found among this sample of women experiencing physical and emotional abuse were partners (current and/or ex), which is consistent with previously published reports (Martin et al., 1999
; Tjaden & Thoennes, 2000
). However, it is notable that, in this sample, many perpetrators of violence against women during their current pregnancy were reported to be persons other than their current or ex-partner (i.e., fathers, mothers, and/or others). In the case of sexual abuse during current pregnancy, more than half (56.1%) of those women sexually abused reported that it had been done by a person other than their current partner ().
This has negative implications for women in their ability to access shelters for women experiencing violence. Most of these types of shelters stipulate that the perpetrator of physical or sexual abuse must be a victim’s current and cohabiting partner. Also, even serious emotional abuse by a partner or another person is rarely a criterion for acceptance into a shelter or other domestic violence services. Many of the women in this sample stated that their emotional abuse was more disturbing than their physical abuse.
Interestingly, a relatively low percentage of women in this sample reported feeling unsafe at home (10.4%). Only 6% of the women reported fearing their current partner, and 7. 9% were afraid of their ex-partner despite most reporting violence in the hands of their intimate partner. This may be caused by the frequently unstable domiciliary arrangements of this population. Feeling unsafe at home may imply a literal interpretation that may not apply to a woman who either is homeless or has transient housing accommodations. Substance abuse providers must be prepared to assess each woman’s ongoing degree of risk in her near past, current, and potential future living environments, even if these arrangements are temporary and when needed to offer assistance in developing and facilitating a safety plan.
A total of 26% of the women reported having a weapon available at home, 39% of whom reported having guns. Studies have found that instead of conferring protection, keeping a gun in the home can be used against family members, especially by male intimates against women (Sorenson & Wiebe, 2004
), and has been associated with increased risk for both suicide and homicide in women (Paulozzi, Saltzman, Thompson, & Holmgreen, 2001
). Bailey et al. (1997)
found that use of illicit drugs, domestic violence, and readily available firearms place women at a particularly high risk for homicide in the hands of a spouse, an intimate acquaintance, or a close relative. The high number (74%) of women who reported having a knife as a weapon is consonant with the report that men are more likely than women to be killed by knives in IPV situations (Paulozzi et al., 2001
Children are frequently collateral victims of their mother’s violence exposure. The women in this sample reported that their children were frequently exposed to and/or witnessed different types of violence at home. Research have found that children who experience or witness violence are at risk of developing emotional, behavioral, social, academic, and developmental problems (Mahony & Campbell, 1998
; McFarlane, Groff, O’Brien, & Watson, 2003
; Osofsky, 1995
). They are also at increased risk of developing alcohol and drug problems in later life as well as becoming either batterers or victims in adulthood (Anda et al., 2002
; Dube, Anda, Felitti, Edwards, & Williamson, 2002
In addition to the violence experienced at home, women and their children from this sample reported experiencing significant rates of community violence. Exposure to violence may have a significant negative impact on developmental and adaptive functioning in children. Several studies suggest that long-term exposure to community violence may have a profound negative impact on children’s cognitive, social, psychological, and moral development (Fry-Bowers, 1997
; Perry & Azad, 1999
). In addition, community violence exposure has been associated with aggressive behaviors in adolescents (Song, Singer, & Anglin, 1998
). Although this study was designed to characterize violence exposure among pregnant drug-dependent women, the potential effects of exposure to violence among their children should not be underestimated. Indeed, several of the study women ascribed multiple difficulties in their children’s lives to violence exposure. Clearly, such children require further investigation.
Studies indicate that the most important resource protecting children from the negative effects of exposure to violence is a strong relationship with a competent, caring, stable adult, most often a parent. However, when parents are themselves victims of violence, they may have difficulty fulfilling this role (Graham-Berman & Levendosky, 1998
; Levendosky & Graham-Berman, 2000
). It is noteworthy here that only 15% of all the women experiencing violence perceived a need for assistance for their children whereas more than 30% of these women reported a need for self-assistance.
The present study data should be interpreted with caution because methodological limitations must be considered. First, this is a cross-sectional study and may only reflect the current situation of the patients and what they can recall, which may in turn be affected by memories of a traumatic event. Second, the data are based on self-report, which may or may not reflect the true situation of victimization. Third, the results are from a sample of substance-abusing pregnant women seeking drug treatment, which may be different from those from the general population. In addition, this study reports findings based on a single screening for violence exposure during the first week of treatment as opposed to screening at a predetermined gestational age or repeated screening over time. There may be a cohort effect given that women of more advanced gestational age have had more chances of being exposed to violence than those who are just beginning their pregnancy or vice versa.
Some of the strengths of the study include the relatively large sample size, the fact that data were collected in a relatively short period, and the application of an instrument developed to assess the prevalence and characteristics of violence exposure among pregnant substance-abusing women, for which there is no precedent. Administering the questionnaire after a structured group session that defined abuse and terms used to describe different types of abuse seems both a potential limitation and a strength. Although the group session helped define the terms used in discussing abuse and helped build trust that allowed the women to respond affirmatively to some of the items, it may also have produced higher rates of item endorsement than would be seen without it.
In summary, substance-abusing pregnant women and their children reported high rates of exposure to all types of violence. This exposure has significant health consequences for the women, children, and fetuses involved. The data reported here support the importance of routine screening for lifetime and current exposure to violence among substance-abusing pregnant women. Providers must understand and teach the complex relationships among substance abuse, exposure to violence, and mental health. The process of recovery for each pregnant substance-abusing woman experiencing violence must incorporate treatment for IPV issues both for herself and for her children. Treatment facilities for substance-abusing pregnant women should be prepared to address exposure to violence among their clients. Further research should be conducted to design and evaluate treatment models for violence exposure as a component of substance abuse treatment and to understand the effects of physical, sexual, and emotional abuse during pregnancy on both substance-dependent mothers and their unborn children.