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Drug Abuse During Pregnancy

INTRODUCTION

Many women, including those who are pregnant, have been victims of intimate partner violence (1-6). Each year, approximately 1.5 million US women are physically or sexually assaulted by their intimate partners (3,6), with such victimization being most likely when women are of reproductive age (1,6). Prenatal care based studies report that from 4% to 26% of patients are violence victims before pregnancy, whereas 1% to 17% are violence victims during pregnancy (7-27). A review of studies that examined the prevalence of violence during pregnancy reported that most of the prevalence estimates ranged between 4% and 8% (28). Community-based studies also have found high rates of violent victimization of women before and during their pregnancies. For example, a statewide survey of a representative sample of postpartum North Carolina women found that 7% had been physically abused during the year before pregnancy, whereas 6% had been physically abused during pregnancy (29,30).

Violence at any time in a woman's life, regardless of whether or not she is pregnant, can result in a myriad of health problems, including violence-related injuries, physical health problems, mental health problems, and substance use problems (21,31-34). Although it is clear that intimate partner violence is the direct cause of some of these types of health problems (e.g., a hit may cause an injury such as a black eye), the relationship between intimate partner violence and other types of health problems is less straightforward. For example, there is not one well-accepted, empirically documented explanation concerning why female domestic violence victims may abuse substances more than other women; however, several ideas on the topic have been put forth in both the clinical and scientific literature (35). One of the most popular of these explanations is the self-medication hypothesis, which contends that violence victims turn to substances as a means of coping with the emotional and physical pain caused by violence. In this perspective, violence is viewed as the cause of the women's substance abuse. Another explanation that has been used to understand potential links between intimate partner violence victimization and women's substance abuse contends that substance abusing women are at elevated risk for domestic violence since their substance use behaviors may be viewed by their partners (and other members of society) as being inappropriate, in particular, "obnoxious" or "unfeminine" (36,37), views that may lead the partner to physically "punish" the woman for her "unladylike" behavior. Thus this perspective views the women's substance abuse as triggering violent episodes.

Although substance abuse at any time during a woman's life is problematic because of the devastating negative health effects it may have, substance abuse during pregnancy is of special concern for a number of reasons. For example, substance abuse during pregnancy has been linked to poor pregnancy and birth outcomes (38-40). Moreover, after the birth of the infant, substance abuse by the mother may negatively impact on her ability to care for her infant, a situation that may ultimately result in impairment of the infant's development (41).

Even though both substance abuse and violence that occur during pregnancy may adversely affect the well-being of the mother and later the infant, only a limited amount of research has simultaneously examined violence and substance use in the lives of pregnant women. Several prenatal care based studies have found that women who have been victimized either before or during pregnancy are more likely than other women to drink alcohol or use illicit drugs before and/or during pregnancy (7-10,16,21,26,32). However, most of this past research has focused on only one form of violence, most typically physical assault. Thus less is known about how other important forms of intimate partner violence, such as psychological aggression and sexual coercion, may be associated with women's use of substances before and during pregnancy. Furthermore, additional research is needed to examine whether, among the women who use substances before or during pregnancy, various types of intimate partner violence are associated with the women having symptoms of substance abuse disorders (e.g., having delirium tremens after heavy drinking, having "blackouts" or "flashbacks" as a result of drug use), symptoms that may impair the women" s functioning and limit their ability to care for themselves and their newborn infants.

This article extends our knowledge in these areas by examining associations between women's experiences of various forms of intimate partner violence (including psychological aggression, physical assault, and sexual coercion) and substance use (including alcohol and illicit drug use), both before and during pregnancy. Studying a convenience sample of 85 pregnant women from North Carolina, this study asks whether, during the year before pregnancy and during pregnancy:

* Were the women who experienced various types of intimate partner violence more likely to use alcohol or illicit drugs compared with women who did not experience such violence?

* Among the women who drank alcohol, did those who experienced various types of partner violence drink more frequently and have a greater number of alcohol disorder symptoms compared with women who did not experience such violence?

* Among the women who used illicit drugs, did those who experienced various types of partner violence use drugs more frequently and have a greater number of drug disorder symptoms compared with women who did not experience such violence?

METHODS

Sample

Eighty-five research participants recruited from North Carolina prenatal care clinics that predominately serve low-income women were studied. After obtaining the women's clinical histories (including clinically screening for physical violence) and providing clinical care, the prenatal clinicians described the research study to eligible study participants and invited them to take part in the project. Patients were eligible to enter the study if they were at least 18 years of age, spoke English, and began prenatal care some time before their sixth month of pregnancy. In addition, because we hoped to have somewhat similar numbers of women who had experienced partner violence during pregnancy and those who had not experienced such violence during pregnancy, the clinicians were asked to recruit a nonvictimized woman for study after they had recruited each violence victim for study.

Measures

A structured research interview was administered to the study participants by well-trained female research staff. This assessment occurred when the women were approximately 6 to 7 months pregnant. Study interviews were conducted in private rooms in the health care clinics to help assure confidentiality. Great care was taken to establish rapport with the study participants prior to interview administration. The study was described to the women, and it was stressed that truthful answers were needed to potentially sensitive questions in order to gain accurate insights concerning women's health. An informed consent form was administered to the participants to assure them that their responses would be treated confidentially and that their participation (or nonparticipation) in the study would not affect their or their family's health care. All respondents were provided with a brochure describing several types of health-related services that they could access free of charge (including domestic violence services and substance abuse services) and they were given a modest monetary "thank you gift" for their involvement in the study.

The study interview included a wide range of topics. Information was collected concerning the women's experiences of intimate partner violence, their use of substances, and their sociodemographic characteristics.

The women's experiences of intimate partner violence were assessed using the Conflict Tactics Scales 2 (CTS2) (42), a revision and expansion of the original Conflict Tactics Scales (CTS) (43). The CTS2 is a listing of behaviors that may have occurred during the women's relationships with their partners, either within the context of a disagreement or at some other time. This study used CTS2 items that assessed the male partner's violent behaviors toward the female respondents. For each item, the respondent indicated whether or not the behavior occurred within each of two specified periods during the couple's relationship, namely, during the 12 months before the woman became pregnant and during the pregnancy. This analysis includes responses to particular items that are used to create the following CTS2 scales: psychological aggression (comprising 8 items including behaviors such as insulting/swearing at one's partner, shouting/yelling at one's partner); physical assault (comprising 12 items including behaviors such as pushing/shoving one's partner, beating up one's partner); and sexual coercion (comprising 7 items including behaviors such as making one's partner have sex without a condom, physically forcing one's partner to have sex). Following the suggestions of Straus (44), for each of the CTS2 scales used in this study, women were classified as having been victims of the particular type of violence under consideration if they reported having experienced one or more of the items comprising the scale within the relevant time period. For example, a woman who reported having experienced one or more of the eight items comprising the psychological aggression scale during the year before pregnancy would be classified as having been a victim of psychological aggression during the year before pregnancy.

Women were asked about their alcohol use during each of two periods: 1) the year before they became pregnant and 2) during pregnancy. For each of these periods, women were asked if they ever drank alcohol. Those who drank were asked about their frequency of drinking, and were classified as being "frequent drinkers" if they drank four or more times a week. In addition, a short-form of the Michigan Alcohol Screening Test (SMAST-13) (45) was used to assess the alcohol using women for symptoms of alcohol disorder. Each of the 13 items in this shortened version of the original MAST (46) describes one symptom of alcohol disorder (e.g., having delirium tremens after heavy drinking, neglected obligations to family or work for 2 or more days in a row because of drinking). A SMAST-13 score is computed by summing all endorsed items; thus, the SMAST-13 score can range from 0 through 13, with higher scores indicating higher levels of alcohol disorder symptoms. Scores equal to, or greater than, an empirically derived cut point of 3 are suggestive of a clinically relevant alcohol disorder (45). The SMAST-13 has been shown to have acceptable levels of internal consistency and diagnostic accuracy (47).

Women also were asked about their use of illicit drugs during each of two periods: 1) during the year before they became pregnant and 2) during pregnancy. For each of these time periods, women were asked if they had used each of three types of illicit drugs: 1) marijuana, 2) cocaine, and 3) some other type of drug (including the use of illicit drugs and nonmedical use of prescribed or over-the-counter drugs). Those who used drugs were asked about their frequency of drug use, and, for analysis purposes, were classified as being "frequent drug users" if they used some type of drug four or more times a week. In addition, women who used drugs were administered the 20-item version of the Drug Abuse Screening Test (DAST) (48) to assess the women for drug disorder symptoms. Each DAST item describes a specific problem/symptom associated with a drug disorder (e.g., could not get through the week without using drugs, having "blackouts" or "flashbacks" as a result of drug use). A DAST score is computed by summing all endorsed items; thus, DAST scores may range from 0 through 20, with higher scores indicating higher levels of drug disorder symptoms. Scores equal to, or greater than, an empirically derived cut point of 6 are suggestive of a clinically relevant drug disorder (49). The DAST has been shown to have high levels of internal consistency, concurrent validity, sensitivity, specificity, and diagnostic accuracy when drug disorder diagnoses based on the DAST were compared to "gold standard" DSM-III drug disorder diagnoses using the Diagnostic Interview Schedule (49,50).

In addition, the study interview asked women about their sociodemographic characteristics. Information was collected concerning each woman's age, education level, employment status, race/ethnicity, marital status, whether or not she had previous children, and her poverty status (as assessed by whether or not she received Medicaid benefits during pregnancy).

Analysis

Descriptive statistics were used to examine the sociodemographic characteristics of the study women, as well as to describe the women's use of substances before and during pregnancy. Descriptive statistics and bivariate analyses, including odds ratios (ORs) and 95% confidence intervals (95% CIs), were used to examine the women's use of substances by their experiences of the various types of violence. Similar procedures were used in analyses restricted to the women who used substances to examine the women's frequencies of substance use and their symptoms of substance abuse disorders by their violence experiences.

Institutional Review Board for Human Subjects Approval

All procedures used in this study were approved by the Institutional Review Board for Human Subjects Research of the University of North Carolina at Chapel Hill.

RESULTS

Sociodemographic Characteristics of the Women

Examination of the sociodemographic characteristics of the 85 women at the time of the study interview found that the women ranged from 18 to 45 years of age (with their mean age being 27 years, SD = 6.5 years). Twenty-four percent of the women were younger (less than 21 years of age) and 76% of the women were older (21 years of age or more). Eighty-two percent of the women had at least a high school graduate level of education and 82% were employed. Fifty-five percent of the women were African-American, whereas the others were non-Hispanic white. Although only 25% of the women were married, 61% already had one or more children. Many of the women were poor, as evidenced by 84% having received Medicaid benefits during pregnancy.

Alcohol and Illicit Drug Use Before and During Pregnancy

Most of the women drank alcohol before pregnancy, but many quit using alcohol once they found out that they were pregnant. More specifically, during the year before pregnancy, 65% (n = 55) of the 85 women drank alcohol, but during pregnancy, only 20% (n = 17) of the women drank alcohol.

Thirty-eight percent of the women (32 of 85) used some type of illicit drug during the year before they became pregnant, with 29% (n = 25) using marijuana, 18% (n = 15) using cocaine, and 5% (n = 4) using some other type of drugs. Similar to the decline in alcohol use seen when the women became pregnant, many women stopped using illicit drugs during pregnancy. More specifically, only 15% of the women (13 of 85) used illicit drugs while pregnant, with 9% (n = 8) using marijuana, 10% (n = 9) using cocaine, and 1% (n = 1) using some other type of illicit drugs.

Intimate Partner Violence Related to the Women's Use of Alcohol

Table 1 shows that, during the year before pregnancy, women who were physically assaulted by their partners were somewhat more likely to drink alcohol compared with women who did not experience this type of violence, although this difference did not reach the traditional level of statistical significance. However, during pregnancy, women who were victims of each type of violence were more likely to drink alcohol, with two of these differences being statistically significant. More specifically, women's alcohol use before pregnancy was somewhat more likely among those physically assaulted before pregnancy (OR = 1.8, 95% CI = 0.7-4.5, P =.2561),. but was not more likely among those who experienced psychological aggression (OR = 0.6, 95% CI = 0.1-3.0, P = .7065) or sexual coercion (OR = 0.7, 95% CI = 0.3-1.8, P = .6488) before pregnancy. Women's alcohol use during pregnancy was more likely if they experienced any of the types of violence during pregnancy, including psychological aggression (23% of the victims drank alcohol compared with none of the women who did not experience this violence, P = .2003), physical assault (OR = 7.8, 95% CI = 2.3-26.8, P = .0006), and sexual coercion (OR = 4.6, 95% CI = 1.4-15.7, P = .0136).

Among the women who drank alcohol before or during pregnancy, there were generally slight, but non significant tendencies for those who experienced violence to be more likely to be frequent drinkers (drinking four or more times per week) compared with those who did not experience such violence. In particular, among the 55 women who drank alcohol during the year before pregnancy, frequent drinking was somewhat more common among those who experienced each type of violence compared to women who did not experience such violence (for psychological aggression, 18% vs. 0%, P = .5744; for physical assault, 19% vs. 13%, P = .7196; and for or sexual coercion, 21% vs. 12%, P = .4751). Among the 17 women who drank alcohol during pregnancy, 8% of those who experienced psychological aggression drank frequently, whereas none of the women who did not experience psychological aggression drank, 8% of those physically assaulted drank frequently compared with 0% of those who did not experience such violence (P = 1.0), but 0% of the sexual assault victims drank frequently compared with 25% of those who did not experience such violence (P = .2352).

In general, among the women who drank alcohol before or during pregnancy, those who experienced each type of partner violence tended to evidence a greater number of symptoms of alcohol disorder compared with women who did not experience such violence, with two of these differences approaching the traditional level of statistical significance (Table 2). More specifically, before pregnancy, among the 55 women who drank alcohol, those who experienced each type of violence had somewhat greater numbers of alcohol disorder symptoms compared with those who did not experience such violence (for psychological aggression, 1.8 symptoms vs. 0.5 symptoms, P = .4408; for physical assault, 2.2 symptoms vs. 0.9 symptoms, P = .1060; for sexual coercion, 2.0 symptoms vs. 1.3 symptoms, P = .7637). A somewhat similar pattern is seen among the 17 women who drank alcohol during pregnancy (all of the 17 alcohol drinkers experienced psychological aggression and had a mean of 2.8 symptoms; for physical assault, 3.5 symptoms vs. 0.8 symptoms, P =.0660; for sexual coercion, 2.9 symptoms vs. 2.8 symptoms, P=.7227). It is interesting to note that the women who experienced psychological aggression, physical assault, or sexual coercion during pregnancy had a mean number of alcohol disorder symptoms close to or surpassing the number of symptoms that is suggestive of having a clinically relevant alcohol disorder (i.e., three or more symptoms).

Intimate Partner Violence Related to the Women's Use of Illicit Drugs

Table 3 shows that, during the year before pregnancy, women who experienced psychological violence and physical assault were somewhat more likely to use illicit drugs compared with women who did not experience these types of violence, with the physical assault-drug use association approaching statistical significance; furthermore, during pregnancy, women who were victims of each type of violence were much more likely to use illicit drugs compared with women who did not experience such violence. More specifically, women's drug use before pregnancy was somewhat more likely among those who experienced psychological aggression (OR = 1.9, 95% CI = 0.4-10.1, P = .7042) or physical assault (OR = 1.9, 95% CI = 0.8-4.6, P = .1867), but was not more likely among those who experienced sexual coercion (OR = 0.9, 95% CI = 0.42.1, P = .8236). Women's drug use during pregnancy was more strongly related to each type of violence experienced during pregnancy, including psychological aggression (17% of the victims used drugs compared with none of the women who did not experience this violence, P=.3481), physical assault (OR = 4.5, 95% CI = 1.3-16.1, P = .0274), and sexual coercion (OR = 2.8, 95% CI = 0.8-10.0, P = .1346).

Among the 32 women who used illicit drugs before pregnancy, women who experienced each type of partner violence were somewhat more likely than women who did not experience such violence to be frequent drug users (using four or more times a week), with one of these associations being statistically significant; however, examination of the 13 women who used drugs during pregnancy did not demonstrate this same pattern of frequency of use. More specifically, among the 32 women who used illicit drugs before pregnancy, frequent drug use was more common among those who experienced each type of violence compared with women who did not experience such violence (for psychological aggression, 37% vs. 0%, P = .5343; for physical assault, 40% vs. 25%, P = .4647; and for or sexual coercion, 59% vs. 7%, P = .0028). Among the 17 women who used illicit drugs during pregnancy, 15% of those who experienced psychological aggression used drugs frequently, whereas none of the women who did not experience psychological aggression used drugs at all; however, only 11% of those physically assaulted used drugs frequently compared with 25% of those who did not experience such violence (P = 1.0), and 0% of the sexual assault victims used drugs frequently compared with 50% of those who did not experience such violence (P = .0769).

In general, among the women who used illicit drugs before or during pregnancy, those who experienced each type of partner violence tended to evidence a somewhat greater number of drug disorder symptoms compared with women who did not experience such violence, with one of these associations being statistically significant (Table 4). More specifically, among the 32 women who used drugs before pregnancy, those who were sexually coerced before pregnancy had a significantly higher mean number of drug disorder symptoms compared with women who had not experienced such violence (7.6 symptoms vs. 3.3 symptoms, P = .0264); furthermore, among these women who used drugs before pregnancy, those experiencing psychological aggression and physical assault had elevated levels of drug disorder symptoms compared with women who did not experience such violence, even though these differences did not reach the traditional level of statistical significance (for psychological aggression, 5.8 symptoms vs. 1.5 symptoms, P = .3206; for physical assault, 6.3 symptoms vs. 4.4 symptoms, P = .2309). Among the 13 women who used drugs during pregnancy, all of them had experienced psychological aggression and had a mean of 7.7 symptoms, and those who experienced physical assault had 8.2 symptoms vs. 6.5 symptoms among those who did not experience such assault (P = .4420); however, those who experienced sexual coercion had a somewhat lower number of drug disorder symptoms than did women who did not experience such violence (7.6 symptoms vs. 8.0 symptoms, P = .9105). It is interesting to note that the average number of drug disorder symptoms evidenced by the violence victims, regardless of whether the violence occurred before or during pregnancy, always approached and usually surpassed the clinically derived cut-point of six symptoms, which indicates the existence of a clinically relevant drug disorder.

DISCUSSION

Consistent with past investigations, this research found that women were more likely to use alcohol rather than illicit drugs, both before and during pregnancy. Furthermore, after women became pregnant, many of them quit using substances, so that the prevalence of substance use was higher during the year before pregnancy compared to during pregnancy, a pattern seen in previous research (21).

Examination of women's experiences of partner violence in relation to their use of substances during the year before pregnancy found that women who were physically assaulted by their partners were somewhat more likely to drink alcohol and use illicit drugs compared with women who did not experience such violence, even though these differences did not reach the traditional level of statistical significance. However, examination of the women who used substances during the year before pregnancy found that the women who experienced each type of violence were more likely to be frequent users of substances compared with the nonvictims. Similarly, among the substance using women, the victims of all types of violence evidenced a greater number of substance disorder symptoms compared to the nonvictims. This pattern of findings suggests that even though many women, violence victims and nonvictims, may use some type of substance when they are not pregnant, those who are violence victims may use substances more frequently, resulting in a greater likelihood of them having severe substance disorder problems that could negatively affect many aspects of their health and well-being.

After the women became pregnant, the links between women's experiences of intimate partner violence and their use of substances became stronger, with the women who experienced each type of partner violence being more likely to use both alcohol and illicit drugs. This pattern may have resulted if some of the women violated during pregnancy were using substances to cope with the pain of partner violence, making it more difficult for them to quit using substances after they found out that they were pregnant. Because of the relatively smaller number of women who engaged in alcohol and drug use during pregnancy (because many women quit using substances while they were pregnant), it is more difficult to characterize relationships between the substance using women's experiences of intimate partner violence and their frequency of substance use during pregnancy. However, the data suggest that the women who were psychologically and physically abused during pregnancy had somewhat elevated levels of substance disorder symptoms during pregnancy compared with women who did not suffer such victimization.

These findings should be viewed in light of the methodological constraints of this study. One limitation of this research is that it was based solely on the women's interview responses, which are prone to various forms of recall and response biases. Such biases are especially likely given the sensitive nature of the topics under study (e.g., substance use, intimate partner violence). Therefore, this study could have benefited from additional information sources. Another limitation of this research is that it is based on a relatively small sample of women (n=85) that resulted in even smaller "cell-sizes" in some analyses that limited the power of the analyses. Furthermore, the research examined a convenience sample of women from North Carolina prenatal care clinics that serve predominately low-income women; thus, these findings may not be generalizable to other groups of women.

Despite the methodological limitations of this investigation, the study results may be helpful in informing health care practitioners, and other concerned with the health of women, concerning violence in women's lives. The findings underscore the importance of providing routine screening for various types of violent victimization (including psychological, physical, and sexual) as well as substance use within the context of women's health care and other types of services, including those provided to pregnant women. Although many health care organizations and agencies have endorsed such screening, it is clear that not all female patients are screened for violence, even during the provision of prenatal care (51). In addition, in light of the ties between intimate partner violence and problem-level substance use among women, substance abuse treatment providers should incorporate violence screening into their history-taking procedures, and should offer identified violence victims suitable violence-related services. Similarly, professionals who provide services to abused women (such as staff of domestic violence programs) should assure that their clients are assessed for substance abuse, and that appropriate services are provided to those in need. For such screening and referral procedures to be successful, women's care providers need to be cross-trained concerning both substance abuse and violence issues. These would be important steps towards assuring that women experiencing intimate partner violence and having substance abuse problems are provided with optimal care for these important health concerns.

Table 1. The women's use of alcohol by their experiences of intimate
partner violence.

                                        Any alcohol use

Intimate partner violence     Percentage     OR (95% CI)     P value (a)

Before pregnancy (n = 85)
  Psychological aggression
    Yes (n = 77)                  64       0.6 (0.1-3.1)     .7065
    No (n = 8)                    75       (referent)
  Physical assault
    Yes (n = 45)                  71       1.8 (0.7-4.5)     .2561
    No (n = 40)                   58       (referent)
  Sexual coercion
    Yes (n = 47)                  62       0.7 (0.3-1.8)     .6488
    No (n = 38)                   68       (referent)
During pregnancy (n = 85)
  Psychological aggression
    Yes (n = 75)                  23       --                .2003
    No (n = 10)                    0
  Physical assault #
    Yes (n = 33) #                39 #     7.8 (2.3-26.8) #  .0006 #
    No (n = 52) #                  8 #     (referent)
  Sexual coercion #
    Yes (n=41) #                  32 #     4.6 (1.4-15.7) #  .0136 #
    No (n=44) #                    9 #     (referent)

Boldface indicates statistically significant findings (P < .05).

(a) P value based on Fisher's exact test.

Note: Statistically significant findings indicated with #.

Table 2. Among women who drank alcohol, the mean number of alcohol
disorder symptoms by their experiences of intimate partner violence.

                                Number of alcohol disorder symptoms

Intimate partner violence               Mean (SD)    P value (a)

Before pregnancy (n = 55)
  Psychological aggression
    Yes (n = 49)                       1.8 (2.9)     .4408
    No (n = 6)                         0.5 (0.8)
  Physical assault
    Yes (n = 32)                       2.2 (3.1)     .1060
    No (n = 23)                        0.9 (2.2)
  Sexual coercion
    Yes (n = 29)                       2.0 (3.0)     .7637
    No (n = 26)                        1.3 (2.5)
During pregnancy (n = 17)
  Psychological aggression
    Yes (n = 17)                       2.8 (3.2)     --
    No (n = 0)                         --
  Physical assault
    Yes (n = 13)                       3.5 (3.3)     .0660
    No (n = 4)                         0.8 (1.5)
  Sexual coercion
    Yes (n = 13)                       2.9 (3.1)     .7227
    No (n = 4)                         2.8 (3.8)

(a) P value based on Wilcoxon rank-sum test.

Table 3. The women's use of illicit drugs by their experiences of
intimate partner violence.

                                        Any illicit drug use

                                                                 P
Intimate partner violence     Percentage   OR (95% CI)        value (a)

Before pregnancy (n = 85)
  Psychological aggression
    Yes (n = 77)                  39       1.9 (0.4-10.1)      .7042
    No (n = 8)                    25       (referent)
  Physical assault
    Yes (n = 45)                  44       1.9 (0.8-4.6        .1867
    No (n = 40)                   30       (referent)
  Sexual coercion
    Yes (n = 47)                  36       0.9 (0.4-2.1)       .8236
    No (n = 38)                   40       (referent)
During pregnancy (n = 85)
  Psychological aggression
    Yes (n = 75)                  17       --                  .3481
    No (n = 10)                    0
  Physical assault #
    Yes (n = 33) #                27 #     4.5 (1.3 - 16.1) #  .0274#
    No (n = 52) #                  8 #
  Sexual coercion
    Yes (n=41) #                  22       2.8 (0.8 - 10.0)    .1346
    No (n=44) #                    9

Boldface indicates statistically significant findings (P < .05).

(a) P value based on Fisher's exact test.

Note: Statistically significant findings (P < .05) indicated with #.

Table 4. Among women who used illicit drugs, the mean number
of drug disorder symptoms by their experiences of intimate partner
violence.

                                   Number of drug disorder symptoms

Intimate partner violence              Mean (SD)      P value (a)

Before pregnancy (n = 32)
  Psychological aggression
    Yes (n = 30)                       5.8 (5.1)       .3206
    No (n = 2)                         1.5 (0.7)
  Physical assault
    Yes (n = 20)                       6.3 (5.2)       .2309
    No (n = 12)                        4.4 (4.9)
  Sexual coercion #
    Yes (n = 17) #                     7.6 (5.6)#      .0264 #
    No (n = 15) #                      3.3 (3.3)#
During pregnancy (n = 13)
  Psychological aggression
    Yes (n = 13)                       7.7 (4.8)         --
    No (n = 0)                         --
  Physical assault
    Yes (n = 9)                        8.2 (5.0)       .4420
    No (n = 4)                         6.5 (4.8)
  Sexual coercion
    Yes (n = 9)                        7.6 (4.9)       .9105
    No (n = 4)                         8.0 (5.5)

Boldface indicates statistically significant findings (P < .05).

(a) P value based on Wilcoxon rank-sum test.

Note: Statistically significant findings (P < .05) indicated with #.

ACKNOWLEDGMENTS

This project was funded by Grant 5 R29 MH56540-03 from the National Institute of Mental Health. The authors acknowledge the assistance provided by the following individuals during this study: Drs. John Thorpe and Andrea Torsone of the Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC; and Dr. Seth Brody of the Department of Obstetrics and Gynecology, WakeMed, Raleigh, NC.

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Sandra L. Martin, (1),* Jennifer L. Beaumont, (2) and Lawrence L. Kupper (2)

(1) Department of Maternal and Child Health and

(2) Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA

* Correspondence: Sandra L. Martin, Department of Maternal and Child Health, CB # 7445, University of North Carolina, Chapel Hill, NC 27599-7445, USA; Fax: (919) 966-0458; E-mail: sandra_martin@unc.edu.

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