Associations between Intimate Partner Violence and Termination of Pregnancy: A Systematic Review and Meta-Analysis

: Lucy Chappell and colleagues conduct a systematic review and meta analysis to investigate a possible association between intimate partner violence and termination of pregnancy. Background: Intimate partner violence (IPV) and termination of pregnancy (TOP) are global health concerns, but their interaction is undetermined. The aim of this study was to determine whether there is an association between IPV and TOP. Methods and Findings: A systematic review based on a search of Medline, Embase, PsycINFO, and Ovid Maternity and Infant Care from each database's inception to 21 September 2013 for peer-reviewed articles of any design and language found 74 studies regarding women who had undergone TOP and had experienced at least one domain (physical, sexual, or emotional) of IPV. Prevalence of IPV and association between IPV and TOP were meta-analysed. Sample sizes ranged from eight to 33,385 participants. Worldwide, rates of IPV in the preceding year in women undergoing TOP ranged from 2.5% to 30%. Lifetime prevalence by meta-analysis was shown to be 24.9% (95% CI 19.9% to 30.6%); heterogeneity was high (I2>90%), and variation was not explained by study design, quality, or size, or country gross national income per capita. IPV, including history of rape, sexual assault, contraceptive sabotage, and coerced decision-making, was associated with TOP, and with repeat TOPs. By meta-analysis, partner not knowing about the TOP was shown to be significantly associated with IPV (pooled odds ratio 2.97, 95% CI 2.39 to 3.69). Women in violent relationships were more likely to have concealed the TOP from their partner than those who were not. Demographic factors including age, ethnicity, education, marital status, income, employment, and drug and alcohol use showed no strong or consistent mediating effect. Few long-term outcomes were studied. Women welcomed the opportunity to disclose IPV and be offered help. Limitations include study heterogeneity, potential underreporting of both IPV and TOP in primary data sources, and inherent difficulties in validation. Conclusions: IPV is associated with TOP. Novel public health approaches are required to prevent IPV. TOP services provide an opportune health-based setting to design and test interventions. Background: Intimate partner violence (sometimes referred to as domestic violence) is one of the commonest forms of violence against women and is a global health problem. The World Health Organization defines intimate partner violence as any act of physical, psychological, or sexual aggression or any controlling behavior (for example, restriction of access to assistance) perpetrated by the woman's current or past intimate partner. Although men also experience it, intimate partner violence is overwhelmingly experienced by women, particularly when repeated or severe. Studies indicate that the prevalence (the percentage of a population affected by a condition) of intimate partner violence varies widely within and between countries: the prevalence of intimate partner violence among women ranges from 15% in Japan to 71% in Ethiopia, and the lifetime prevalence of rape (forced sex) within intimate relationships ranges from 5.9% to 42% across the world, for example. Overall, a third of women experience intimate partner violence at some time during their lifetimes. The health consequences of such violence include physical injury, depression, suicidal behavior, and gastrointestinal disorders. Why Was This Study Done?: Intimate partner violence can also lead to gynecological disorders (conditions affecting the female reproductive organs), unwanted pregnancy, premature labour and birth, and sexually transmitted infections. Because violence may begin or intensify during pregnancy, some countries recommend routine questioning about intimate partner violence during antenatal care. However, women seeking termination of pregnancy (induced abortion) are not routinely asked about intimate partner violence. Every year, many women worldwide terminate a pregnancy. Nearly half of these terminations are unsafe, and complications arising from unsafe abortions are responsible for more than 10% of maternal deaths (deaths from pregnancy or childbirth-related complications). It is important to know whether intimate partner violence and termination of pregnancy are associated in order to develop effective strategies to deal with both these global health concerns. Here, the researchers conducted a systematic review and meta-analysis to investigate the associations between intimate partner violence and termination or pregnancy. A systematic review identifies all the research on a given topic using predefined criteria; meta-analysis combines the results of several studies. What Did the Researchers Do and Find?: The researchers identified 74 studies that provided information about experiences of intimate partner violence among women who had had a termination of pregnancy. Data in these studies indicated that, worldwide, intimate partner violence rates among women undergoing termination ranged from 2.5% to 30% in the preceding year and from 14% to 40% over their lifetime. In the meta-analysis, the lifetime prevalence of intimate partner violence was 24.9% among termination-seeking populations. The identified studies provided evidence that intimate partner violence was associated with termination and with repeat termination. In one study, for example, women presenting for a third termination were more than two and a half times more likely to have a history of physical or sexual violence than women presenting for their first termination. Moreover, according to the meta-analysis, women in violent relationships were three times as likely to conceal a termination from their partner as women in non-violent relationships. Finally, the studies indicated that women undergoing terminations of pregnancy welcomed the opportunity to disclose their experiences of intimate partner violence and to be offered help. What Do These Findings Mean?: These findings indicate that intimate partner violence is associated with termination of pregnancy and that a woman's partner not knowing about the termination is a risk factor for intimate partner violence among women seeking termination. Overall, the researchers' findings support the concept that violence can lead to pregnancy and to subsequent termination of pregnancy, and that there may be a repetitive cycle of abuse and pregnancy. The accuracy of these findings is limited by heterogeneity (variability) among the included studies, by the likelihood of underreporting of both intimate partner violence and termination in the included studies, and by lack of validation of reports of violence through, for example, police reports. Nevertheless, health-care professionals should consider the possibility that women seeking termination of pregnancy may be experiencing intimate partner violence. In trying to prevent repeat terminations, health-care professionals should be aware that while focusing on preventing conception may reduce the chances of a woman becoming pregnant, she may still be vulnerable to abuse. Finally, given the clear associations between intimate partner violence and termination of pregnancy, the researchers suggest that termination services represent an appropriate setting in which to test interventions designed to reduce intimate partner violence. Additional Information: Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001581.