The murder of Laci Peterson, and her unborn son Conner, shattered our image of pregnancy as a safe, protected haven.

We now know that pregnancy can be a dangerous time for women. Experts on intimate partner violence say pregnant women who are already in abusive relationships are the most vulnerable to violence. For other women, violence may begin when they become pregnant.

But as the Peterson case demonstrated, victims of intimate partner violence might be the women we least expect - even the girl next door.

"There is nothing about the color of your skin or the neighborhood that you live in that protects you from violence," says Dr. Judith McFarlane, professor at Texas Woman's University, College of Nursing and a graduate of the University of Texas School of Public Health at Houston.

Who's at risk?

The Peterson case, and other high profile cases of violence against pregnant women, focused public awareness on a problem long shrouded in secrecy. Each year, more than 300,000 women experience intimate partner violence sometime during their pregnancies, according to the Centers for Disease Control and Prevention. And a landmark 2001 study published by Maryland state health researchers in the Journal of the American Medical Association, found that murder was the number one cause of death among pregnant women in that state that year.

"A woman who is abused in pregnancy is four times more likely to be murdered by that intimate partner, than a woman who is not being abused during pregnancy," McFarlane says.

It's about control

Pregnancy is a life-changing event for fathers as well as mothers, changing relationships and demanding new responsibilities. Fathers-to-be may feel jealous that the pregnancy is diverting attention away from them. They may also feel anxious at the thought of providing financial support to the child, and the prospect of being tied to the mother and child for life. Feeling trapped, some lash out at their partners.

"Some men perceive pregnancy as a threat," says Ann Coker, an associate professor at the UT School of Public Health studying intimate violence. "Pregnancy can be a very stressful time for an abusive partner who is jealous, because she (the mother) needs to think about herself and the child, and that can be infuriating for him."

"Pregnancy is a time of increased family pressure-economic stress, changes in family patterns and impending additional duties," says Dr. Joan Engebretson, professor at the UT School of Nursing. "In families that display poor coping skills during stressful times, or where the male partner has not developed good frustration control, violence can erupt."

Cultural behavior also plays a role in both domestic violence and the resultant secrecy about it. "Some cultural models condone men's abuse of women in myriad forms-economically, psychologically, verbally or physically," Engebretson says. "This contributes to a woman's hesitancy to report it and to the roadblocks for public health and safety systems to respond appropriately."

While some partners stop abusing women when they become pregnant, many continue to be abusive - physically or psychologically - throughout the pregnancy. And once the violence starts, it usually continues.

“No woman ever has to leave that hospital and go home to her abuser. We can get her to safety, quickly and discreetly. But first, she has to drop the secret and tell us. To do that, we must keep asking the right questions until she can trust us.”

"The violence never gets better, but it can get worse," says McFarlane, who has studied intimate partner violence against women for more than 20 years.

The consequences of abuse

Intimate partner violence can have tragic health consequences for both mother and baby, and can increase the risk of miscarriage and preterm labor. Abuse during pregnancy is also associated with preterm low birth weight deliveries and neonatal death, according to a paper Coker published in the Journal of Paediatric & Perinatal Epidemiology in July 2004.

Psychological abuse, such as constant verbal putdowns or controlling behavior , can also affect the baby because it stresses the mother. Once the baby is born, the violence may likely continue.

"Violence against the mother many times translates into child abuse," Coker says. "If a woman is battered it is likely her child would be battered as well."

Stopping the violence
"Are you safe?"

Adding these three simple words to a woman's prenatal visits or routine check-up could be a lifeline for abused women who are pregnant, say Coker and McFarlane. Many women keep quiet out of shame, or a feeling of helplessness.

"During the victimization process, women are told, either by society or by their partners, that they are worthless," Coker says. "And when healthcare workers don't ask, they [feel like they are being] told that they are not important, and that they should remain quiet."

Coker leads a research project that screens for intimate partner violence in women seeking care in rural primary clinics in South Carolina . The project is funded by a $2 million grant from the CDC. If patients give their consent, health care providers ask them about their safety during their routine check-ups. A staff member from a local shelter is also on site at the clinic to help connect patients with resources they may need - from a safe place to live, to legal aid. Coker hopes that such an assessment tool will help reach women at risk for intimate violence, many of which wouldn't ordinarily ask for help.

"Secrecy is really key in maintaining the partner's behavior," she says. "That is why it is very important that health care providers ask about partner violence. It sends a very important message to that woman."

Some health care providers are reluctant to ask women about their safety because they are disheartened by attempts to help her, only to find that she has put herself in the line of fire again, says Diane Wardell, Ph.D., professor at the UT School of Nursing. "At times, the lack of patient questioning may be due to a sense of futility on the part of the practitioner, as the woman often returns to the abusive relationship repeated times."

Another reason health professionals are reluctant to ask probing questions about domestic safety is because they don't have experience with intimate partner violence. Last year, the Houston Area Women's Center, the largest domestic and sexual violence shelter for women and children in the United States, trained 430 medical professionals on how to recognize intimate partner abuse. Medical students from UT Medical School and Baylor College of Medicine participate in the training.

"We teach them what signs to look for and how to ask the right questions to women who may be abused," says Kelly Boros, education and service coordinator for the Houston Area Women's Center. "The most important part for medical students is that they feel comfortable to ask questions and to offer help."

UPDATED: 1-08-2005

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