By Isra Arif and Susan Bewley
Pregnancy Termination and Intimate Partner Violence
In a recent paper in the International Journal of Gynaecology and Obstetrics, Khan et al. address the well-known association between intimate partner violence (IPV) and pregnancy terminations in Latin American countries and are clearly empathetic towards women affected by IPV. However, they seem to argue that termination, rather than violence itself, is the adverse outcome of interest.
In this blog we argue that IPV should be reduced because it is wrong, whether it leads women to seek terminations of pregnancy or not.
Is Termination of Pregnancy A Problem?
Khan et al. state that “women who reported IPV were over 40% more likely to experience pregnancy termination”, but it is not completely clear why the number of terminations would be a negative outcome. The authors indicate a possible health-based rationale: “Women who lack access to safe abortion are vulnerable to unsafe pregnancy termination practices” – and list the possible risks of unsafe terminations.
But IPV is associated with higher rates of pregnancy overall, not just termination. Pregnancy is also dangerous, but the authors do not highlight pregnancy itself as the potentially harmful outcome associated with IPV which should be reduced (whether ending in labour, miscarriage, or termination). Although terminations contribute to maternal morbidity and mortality, especially when unsafe, they should not be the sole outcome considered. Concerns about unsafe abortion should prompt improved abortion care, rather than attempts to prevent terminations.
Is Screening The Right Approach?
Khan et al. suggest that “routine prenatal screening for IPV and counselling could potentially avert a substantial number of pregnancy terminations”. Screening is unlikely to be effective for several reasons. Firstly, it relies entirely upon women reporting abuse and many don’t: around 25% of women experience IPV in their lifetimes but only between 2.5% and 15% report it. This discrepancy may arise because women are frightened about discussing abuse or fear possible consequences. Screening also overstates women’s agency when experiencing IPV. If anything, screening could pose further danger to women by destabilizing their situation. For these reasons, the UK National Institute of Clinical Excellence instead promotes an enabling environment for disclosure, with women’s safety prioritised as they are offered referral to sources of advocacy and help.
Better approaches to prevention, at both local and societal levels, would empower women and challenge attitudes which normalise IPV. We should be calling for improved abortion care and pathways to advocacy for the women who need it as a matter of urgency, rather than focusing on the perpetration of violence and portraying abortion itself as an inherently negative outcome.
Khan, S., Dongarwar, D., Aliyu, M. and Salihu, H. (2019). Multicountry analysis of pregnancy termination and intimate partner violence in Latin America using Demographic and Health Survey data. Available at: https://doi.org/10.1002/ijgo.12876
Disclosure of interests
IA declares no competing interests. NA declares no competing interests. SB was a co-opted member of NICE PH50 and earns small royalties from a textbook, The ABC of Domestic and Sexual Violence. Her full declarations of interest are at http://www.whopaysthisdoctor.org/doctor/58
IA acted as first author. SB made amendments.
This blog was first offered to IJGO as a letter.