Intimate partner violence during the perinatal period by disability status: Findings from a United States population-based analysis

Reproductive Health Care Inequities by Disability Status: Experiences With Providers and Barriers to Care

The literature has documented that many women with disability (WWD) report barriers to obtaining reproductive health care as well as poor experiences with providers when care is received. This project sought to compare barriers and experiences in reproductive health care for WWD to those of women without disability in the United States. Using representative data from the National Survey of Family Growth (2017-2019), we present weighted estimates of poor or fair experiences with providers by disability status, as well as weighted estimates of the proportion of women reporting types of barriers to services by disability status, among individuals identifying as women between the ages of 15 and 49. We then used weighted logistic regressions to compare barriers and experiences with providers by disability status. After controlling for potential confounders, women with any disability had 2.6 times higher odds as women without disability to rate their providers' respect for them as "poor" or "fair" (95% CI: 1.1-6.2). WWD did not significantly differ from women without disability in whether they reported more than one type of barrier (AOR = 1.3, 95% CI: 0.8-2.1), yet WWD had higher odds of reporting financial barriers compared to women without disability (AOR = 1.5, 95% CI: 1.02-2.2). While access to reproductive health care and experience with providers needs to be improved for all, these findings suggest that targeted efforts are needed to eliminate inequities for WWD in the reproductive health care system.

Physical Assault During the Perinatal Period by Disability Status and Racial/Ethnic Background

Physical assault of women at the intersection of race/ethnicity and physical disability is not well studied. This study seeks to assess the prevalence of physical assault-related emergency department or hospital visits among women with physical disabilities during different stages of the perinatal period, stratified by racial/ethnic background. This study used 1998-2020 data from the Massachusetts Pregnancy to Early Life Longitudinal Data System. Unique singleton deliveries were classified into 10 cohorts by combining maternal physical disability status (yes/no) and racial/ethnic background (White, Black, Latinx, Asian/Pacific Islander [API], and American Indian/Alaska Native [AIAN]); nondisabled White mothers served as referent. Outcomes assessed were the presence of assaults up to 1 year before conception, during pregnancy, and up to 1 year postpartum. Compared to nondisabled White mothers, Black, Latinx, and AIAN mothers with physical disabilities were at the highest risk and experienced 16.0, 12.0, and 12.0 times the risk, respectively, of preconception assault; 15.3, 12.7, and 11.6 times the risk of prenatal assault; and 9.0, 8.2, and 9.3 times the risk of postpartum assault (p < .001 for all risk ratios). Adjusting for sociodemographic differences between groups reduced the magnitude of disparities, but Black, Latinx, and AIAN mothers with physical disabilities remained at greatest risk among all cohorts. Women with physical disabilities from minoritized racial/ethnic backgrounds experienced compounded risk of perinatal violence, with risks exceeding those of nondisabled women in the same racial/ethnic groups as well as White women with physical disabilities. Violence against women with physical disabilities, especially during pregnancy, is a major and ongoing public health crisis. Urgent needs include screening and outreach efforts to Black, Latinx, and AIAN mothers with physical disabilities.

Examining perinatal health inequities: The role of disability and risk of adverse outcomes through the U.S. Pregnancy Risk Assessment Monitoring System

OBJECTIVE

To examine pre-pregnancy characteristics, pregnancy complications, and birth outcomes among respondents with self-reported disability compared to those without disability.

METHODS

A cross-sectional weighted sample of 2,006,700 respondents with singleton live births who participated in the United States Pregnancy Risk Assessment Monitoring System (PRAMS) between 2018 and 2021 provided data on disability, including difficulty in vision, hearing, ambulation, cognition, communication, and self-care. We estimated covariate-adjusted odds of differences in pre-pregnancy chronic health conditions, pregnancy intention, intimate partner violence (IPV), depression, adequacy of prenatal care, pregnancy-related health conditions, and birth outcomes by disability status.

RESULTS

Of the 2,006,700 respondents included, 59.5% reported no disability, 33.9% had moderate disability, and 6.6% had severe disability. Across most outcomes, there was a graded pattern with those with severe disability having the worst outcomes compared to the other two groups. Respondents with severe disability were more likely to report diabetes and hypertension before becoming pregnant than respondents without disabilities. Those respondents with severe disability or moderate disability had an increased odds of reporting IPV and depression than those with no disability. During pregnancy, respondents with severe disability had an increased odds of gestational diabetes (aOR 1.46, 95% CI 1.18, 1.80) and hypertensive disorders of pregnancy (aOR 1.70, 95% CI 1.43, 2.02) as compared to respondents with no disability. Respondents with moderate disability also had an increased odds of both gestational diabetes (aOR 1.19, 95% CI 1.06, 1.34) and hypertensive disorders of pregnancy (aOR 1.29, 95% CI 1.17, 1.42) as compared to those with no disability. The odds of reporting an unintended pregnancy were highest in respondents with a severe disability (aOR 1.66, 95% CI 1.43, 1.94) and were also increased in respondents with moderate disability (aOR 1.48, 95% CI 1.36, 1.62) as compared to those reporting no disability. Across most birth outcomes, respondents with severe disabilities had worse outcomes with an increased odds of low birth weight infants (aOR 1.28, 95% CI 1.08, 1.52), preterm birth (aOR 1.32, 95% CI 1.11, 1.57), and neonatal intensive care unit admission (aOR 1.45, 95% CI 1.02, 2.06) as compared to respondents with no disability. There were not differences in being classified as small for gestational age or infants' length of hospital stay by disability status.

CONCLUSIONS

Across the perinatal period, respondents with moderate or severe disability experienced worse outcomes than those without disability. There is a critical need to improve pre-conception health in an effort to reduce inequities in pregnancy outcomes. Additionally, health care providers and systems must provide equitable access to care to persons with disabilities to reduce inequities in outcomes.

Disability-Related Disparities in Screening for Intimate Partner Violence During the Perinatal Period: A Population-Based Study

BACKGROUND

Persons with disabilities are at higher risk of experiencing intimate partner violence (IPV) during the perinatal period than persons without disabilities. Although screening for IPV during the perinatal period is recommended by many organizations, little is known about screening rates for IPV by disability status.

METHODS

Our objective was to compare rates of IPV screening during the perinatal period among persons with and without disabilities in the United States. A cross-sectional sample of 43,837 respondents provided data on disability, including difficulty in vision, hearing, ambulation, cognition, communication, and self-care. We conducted a secondary analysis of nationally representative data from the 2018-2020 Pregnancy Risk Assessment Monitoring System.

RESULTS

During pregnancy, respondents with disabilities had a lower odds of IPV screening as compared with respondents without disabilities (adjusted odds ratio .83, 95% confidence interval [.70, .99]). Despite similar screening rates in the 12 months before conception and postpartum among respondents with and without disabilities who attended health care visits, those with disabilities were less likely to receive pregnancy-related care during pregnancy (p < .0001) and in the postpartum period (p < .0001) and thus missed opportunities to be screened.

CONCLUSION

Our findings demonstrate a need for health care providers to collaborate with policy makers, disability advocates, and researchers to reduce the disparities people with disabilities face in accessing health care, including screening for IPV during the perinatal period. Such efforts are essential for maximizing the health and safety of pregnant persons and new parents with disabilities and their children during the perinatal period.

Prevalence of unintended pregnancy and associated factors among pregnant women with disabilities in Ethiopia: from the social model of disability perspective

Background

In low-income countries, women with disabilities face numerous challenges in accessing sexual and reproductive health services and experience high unintended pregnancy rates and adverse pregnancy outcomes, with 42% of cases ending in abortion. However, little is known about unintended pregnancy among women with disabilities in Ethiopia. Therefore, this study aimed to assess the prevalence of unintended pregnancy and associated factors among women with disabilities in the Central Regional State of Ethiopia.

Methods

A community-based cross-sectional study was conducted from December 2023 to February 2024, and multistage random sampling was used to enroll 572 study participants. The sample size was proportionally allocated to each zone, district and kebele. The Kobo Toolbox was used for data collection and cleaning, and the Statistical Package for Social Science version 26 was used for analysis. The multivariable analysis was used to identify the factors significantly associated with unintended pregnancy using an adjusted odds ratio (AOR), a 95% confidence interval (CI), and a p-value less than 0.05.

Results

The prevalence of unintended pregnancy was 43.8% (95% CI: 39.5, 47.8) in the Central Ethiopia Regional State, Ethiopia. The significantly associated factors were household size (AOR = 4.6, 95% CI: 2.6, 7.9), awareness of pregnancy intention (AOR = 2.4, 95% CI:1.4, 4.1), domestic violence (AOR = 5.9, 95% CI: 3.4, 10.4), accessibility of service (AOR = 2.4, 95% CI: 1.2, 5.4), discrimination by care providers (AOR = 2.1, 95% CI: 1.5, 2.9), disability-unfriendly health facility structure (AOR = 1.5, 95% CI: 1.2, 2.40), and negative community attitudes (AOR = 2.7, 95% CI: 1.7, 4.3). The overall direction of the associated variables' effect was positive.

Conclusion

This study sheds light on the need for disability-inclusive and sensitive healthcare services. Therefore, to achieve universal access to sexual and reproductive healthcare targeted under the Sustainable Development Goals, the Minister of Women and Social Affairs, Ministry of Health, Regional Health Bureau, and health facilities authorities should pay attention to improving awareness on pregnancy intention and domestic violence and ensuring accessible, inclusive, and equitable maternal health care for women with disabilities.

Effects of Intimate Partner Violence-Related Strangulation on Women Who Report a Disability and Received Forensic Nursing Services

Data on effects of strangulation in victims with a disability are lacking despite this population experiencing intimate partner violence at higher rates than women without a disability. A retrospective review was conducted on medical records of patients seeking care at a community-based, forensic nurse examiner program following an intimate partner violence-related strangulation event. The presence of disability was not associated with differences in reporting other types of victimization, additional abusive events, perpetrator characteristics, strangulation actions, or injury findings. Patients with a disability were more likely to report experiencing anoxic, hypoxic, and other physical symptoms following strangulation compared to patients without a disability.

Mental health outcomes across the reproductive life course among women with disabilities: a systematic review

PURPOSE

This systematic review examined literature on mental health outcomes among women with disabilities living in high-income countries within the context of reproductive health, spanning menstruation through menopause.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched MEDLINE, CINAHL, and PsycINFO databases for studies published through June 2023. Eligible studies were observational, quantitative, and included a comparison group without disabilities.

RESULTS

A total of 2,520 studies were evaluated and 27 studies met inclusion criteria. These studies assessed mental health during prepregnancy, pregnancy, postpartum, and parenting among women with and without disabilities. None of the studies examined reproductive health time periods related to menstruation, fertility, or menopause. Women of reproductive age with disabilities were more likely to have poor mental health outcomes compared to women without disabilities. During pregnancy and the postpartum, women with disabilities were at greater risk of diagnosed perinatal mental disorders and psychiatric-related healthcare visits. Findings also suggested mental distress and inadequate emotional and social support related to parenting among women with disabilities. The greatest risks of poor mental health outcomes were often observed among women with intellectual and developmental disabilities and among women with multiple types of disabilities, compared to women without disabilities.

CONCLUSIONS

Routine reproductive healthcare visits provide significant prevention and treatment opportunities for poor mental health among women with disabilities. Further research examining mental health outcomes within the context of reproductive health, especially understudied areas of menstruation, fertility, parenting, and menopause, among women with disabilities is needed.

Intimate partner violence: A clinical update

ABSTRACT

Intimate partner violence (IPV) is a significant public health issue associated with substantial morbidity and mortality. NPs are ideally positioned to screen for and intervene in IPV, thereby mitigating the health risks IPV carries for women, infants, and young children. Safety planning and appropriate referrals to community-based resources are critical components of addressing IPV.

Reproductive Coercion Among Women With Disabilities: An Analysis of Pregnancy Risk Assessment Monitoring Systems Data

BACKGROUND/AIMS

Reproductive coercion (RC) is a widespread yet understudied type of intimate partner violence that is associated with numerous negative outcomes. Women with disabilities may be at an increased risk of RC; however, little research has been conducted among this population. Using population-based data, we sought to examine the prevalence of RC in postpartum women with disabilities.

METHODS

This is a secondary analysis of a cross-sectional survey, the Pregnancy Risk Assessment Monitoring System, a nationally representative survey conducted by the Centers for Disease Control and Prevention in partnership with participating states. These analyses include 3,117 respondents who had information on both disability status and experiences of RC.

RESULTS

Approximately 1.9% of respondents reported experiencing RC (95% CI [1.3, 2.4]). When stratified by disability status, approximately 1.7% of respondents without a disability reported RC whereas 6.2% of respondents with at least one disability reported RC ( p < 0.001). In univariable logistic models, disability, age, education, relationship status, income, and race were all significantly associated with RC.

CONCLUSIONS

Our findings highlight the need for healthcare providers working with women with disabilities to screen for RC and potentially uncover intimate partner violence and prevent its negative health consequences. All states participating in Pregnancy Risk Assessment Monitoring System data collection are urged to incorporate measures of RC and disability status to better address this significant issue.

Prenatal Care Experiences of Childbearing People With Disabilities in Ontario, Canada

OBJECTIVE

To explore the care experiences of childbearing people with physical, sensory, and/or intellectual/developmental disabilities during pregnancy.

DESIGN

Descriptive qualitative.

SETTING

Ontario, Canada, where physician and midwifery care during pregnancy are provided at no direct cost to residents.

PARTICIPANTS

Thirty-one people with physical, sensory, and/or intellectual/developmental disabilities (who self-identified as cisgender women [n = 29] and trans or nonbinary persons [n = 2]) who gave birth in the last 5 years.

METHODS

We recruited childbearing people with disabilities through disability and parenting organizations, social media, and our team's networks. Using a semistructured guide, we conducted in-person and virtual (e.g., telephone or Zoom) interviews with childbearing people with disabilities in 2019 to 2020. We asked participants about the services they accessed during pregnancy and if services met their needs. We used a reflexive thematic analysis approach to analyze interview data.

RESULTS

Across disability groups, we identified four common themes: Unmet Accommodation Needs, Lack of Coordinated Care, Ableism, and Advocacy as a Critical Resource. We found that these experiences manifested in unique ways based on disability type.

CONCLUSION

Our findings suggest the need for accessible, coordinated, and respectful prenatal care for people with disabilities, with the requirements of such care depending on the needs of the individual person with a disability. Nurses can play a key role in identifying the needs and supporting people with disabilities during pregnancy. Education and training for nurses, midwives, obstetricians, and other prenatal care providers should focus on disability-related knowledge and respectful prenatal care.

Maternal disability and prenatal oral health experiences: Findings from Pregnancy Risk Assessment Monitoring System

BACKGROUND

Although disability has associations with poor health and reduced access to health care services, limited research exists on the connection between disability, oral health, and oral health care use. Moreover, to the authors' knowledge, no study has examined the association between disability and oral health around the time of pregnancy. This is an important gap in research, considering that both disability and oral health play a critical role in maternal and infant well-being.

METHODS

The authors obtained cross-sectional data from 15 states from 2019 and 2020 from the Pregnancy Risk Assessment Monitoring System (N = 20,189). The authors used multivariable logistic regression analyses to assess the relationship between cumulative disabilities and specific forms of disability (seeing, hearing, walking, remembering, self-care, and communicating) for 6 indicators of oral health experiences during pregnancy.

RESULTS

Women reporting multiple forms of disabilities around the time of pregnancy (especially ≥ 3 disabilities) reported lower levels of knowledge of appropriate oral health care during pregnancy, were less likely to undergo dental prophylaxis during pregnancy, were more likely to report needing care for dental health problems, and had more unmet oral health care needs than those without disabilities.

CONCLUSIONS

Maternal disability is a risk factor for poorer oral health outcomes and oral health care use during pregnancy.

PRACTICAL IMPLICATIONS

Given the potential harms of poor oral health to maternal and infant well-being, the findings of this study suggest the need for increased health promotion efforts to foster improved oral health for pregnant women living with disabilities.

Physical intimate partner violence and oral health problems during pregnancy

BACKGROUND

The aim of this study was to assess the association between physical intimate partner violence (IPV) during pregnancy and reports of prenatal oral health problems among a sample of mothers in the United States.

METHODS

Data were obtained from the Pregnancy Risk Assessment Monitoring System from 7 sites (Kentucky, Mississippi, New Hampshire, New York, Puerto Rico, Utah, West Virginia) for 2016 through 2020. The authors used multivariable logistic regression to examine the relationship between physical IPV and respondent self-reports of whether they needed to see a dentist for several oral health problems during pregnancy: (1) needing to have a tooth restored; (2) painful, red, or swollen gingivae; (3) toothache; (4) needing to have a tooth extracted; (5) having an injury to the mouth, teeth, or gingivae; or (6) another problem with teeth or gingivae.

RESULTS

Women who experienced physical IPV during pregnancy had elevated rates of oral health problems during pregnancy compared with women who did not experience IPV. The findings detailed associations between physical IPV and oral health problems that may stem from physical violence, including painful, red, or swollen gingivae; toothache; and mouth, teeth, or gingivae injury.

CONCLUSIONS

The results of this study highlight a connection between physical IPV during pregnancy and oral health problems consistent with orofacial injuries.

PRACTICAL IMPLICATIONS

The association between physical IPV and elevated rates of oral health problems and orofacial injuries highlights the critical role of oral health care providers in screening for, detecting, and intervening in IPV among pregnant women.

Depressive symptoms during the perinatal period by disability status: Findings from the United States Pregnancy Risk Assessment Monitoring System

AIMS

The aim of the current study was to compare the prevalence of depressive symptoms during the perinatal period among respondents with a disability as compared to those without a disability.

DESIGN

We conducted a secondary analysis of nationally representative data from the Pregnancy Risk Assessment Monitoring System data from 24 participating United States between 2018 and 2020.

METHODS

A cross-sectional sample of 37,989 respondents provided data on disability, including difficulty in vision, hearing, ambulation, cognition, communication and self-care. The outcome of interest was perinatal depressive symptoms, defined as experiencing depressive symptoms during the antenatal period or postpartum period. Regression models were used to calculate odds of depressive symptoms during these two time periods by disability status while controlling for relevant sociodemographic characteristics and depressive symptoms prior to pregnancy.

RESULTS

Respondents with disabilities experienced a higher prevalence of depressive symptoms in both the antenatal period and postpartum period as compared to those without disabilities. In fully adjusted models, respondents with disabilities had 2.4 times the odds of experiencing depressive symptoms during pregnancy and 2.1 times the odds of experiencing postpartum depressive symptoms as compared to respondents without disabilities.

CONCLUSION

Respondents with disabilities experience a higher prevalence of depressive symptoms throughout the perinatal period thereby increasing the risk for adverse maternal, neonatal and infant health outcomes.

IMPACT

Perinatal depression is a significant public health issue globally, and our findings suggest that persons with disability are at an increased risk for depressive symptoms both during pregnancy and in the postpartum period. Our findings represent a call to action to improve clinical and supportive services for women with disabilities during the perinatal period to improve their mental health and the consequent health of their offspring.

PATIENT OR PUBLIC CONTRIBUTION

We thank our Community Advisory Board members who have been instrumental in the conception of this study.

Disability and Interpersonal Violence in the Perinatal Period

OBJECTIVE

To compare the risk of interpersonal violence experienced by pregnant and postpartum individuals with physical disabilities, sensory disabilities, or intellectual or developmental disabilities with those without disabilities, and to examine whether a prepregnancy history of interpersonal violence puts individuals with disabilities, at excess risk of interpersonal violence in the perinatal period.

METHOD

This population-based study included all individuals aged 15-49 years with births in Ontario, Canada, from 2004 to 2019. Individuals with physical (n=147,414), sensory (n=47,459), intellectual or developmental (n=2,557), or multiple disabilities (n=9,598) were compared with 1,594,441 individuals without disabilities. The outcome was any emergency department visit, hospital admission, or death related to physical, sexual, or psychological violence between fertilization and 365 days postpartum. Relative risks (RRs) were adjusted for baseline social and health characteristics. Relative excess risk due to interaction (RERI) was estimated from the joint effects of disability and prepregnancy violence history; RERI>0 indicated positive interaction.

RESULTS

Individuals with physical (0.8%), sensory (0.7%), intellectual or developmental (5.3%), or multiple disabilities (1.8%) were more likely than those without disabilities (0.5%) to experience perinatal interpersonal violence. The adjusted RR was 1.40 (95% CI 1.31-1.50) in those with physical disabilities, 2.39 (95% CI 1.98-2.88) in those with intellectual or developmental disabilities, and 1.96 (95% CI 1.66-2.30) in those with multiple disabilities. Having both a disability and any violence history produced a positive interaction for perinatal interpersonal violence (adjusted RERI 0.87; 95% CI 0.47-1.29).

CONCLUSION

The perinatal period is a time of relative high risk for interpersonal violence among individuals with pre-existing disabilities, especially those with a history of interpersonal violence.