Children of women who experience physical or sexual violence--whether before, during or after pregnancy--are significantly more likely to die before age five, according to a study in Leòn, Nicaragua.¹ The odds of losing a child among women who had ever been physically or sexually abused by an intimate partner or a nonpartner were two to four times as high as they were among women who had not been abused; women who had experienced both physical and sexual partner violence had an even higher risk of child loss.

To examine the association between violence against mothers and deaths among their children, the researchers searched a demographic database of nearly 10,000 households in and around Leòn for all live-born children who had died before the age of five between January 1993 and June 1996. Each such child was matched for sex and age at death to two randomly selected live children. Trained interviewers collected social and demographic information from the mothers of all the children in the sample and asked about their exposure to physical violence and sexual violence within 12 months before and after the index pregnancy; in addition, the mothers of children who had died were asked about the circumstances leading to their child's death. Overall, 313 mothers--110 of children who had died before age five and 203 of living children--completed questionnaires. The data were analyzed using logistic regression analyses.

Of the children who had died before age five, 84% died within a year of birth. Forty-three percent of deaths within the first 29 days after birth were caused by complications of prematurity and low birth weight, whereas 37% of deaths before age five were attributed to diarrhea and infection.

Among mothers of children who had died before age five, 61% had ever experienced some type of violence, compared with 37% of mothers of living children. Half of the mothers of children who had died and one-third of mothers of living children had been abused by a current or former intimate partner; smaller proportions (3-7%) had experienced nonpartner violence from relatives, friends or strangers. Ninety percent of women who had experienced physical abuse reported it as being severe (i.e., punches, kicks, bites, blows with objects, or any type of forced sex).

In bivariate analyses, researchers found significant associations between violence and child mortality. Mothers who had ever been physically abused by an intimate partner, a nonpartner or both, or sexually abused by a partner were significantly more likely than others to have had their child die before age five (odds ratios, 2.2-4.3). Having experienced severe violence was associated with elevated odds of losing a child (2.3), as was having been abused before becoming pregnant, or during pregnancy and the 12 months preceding the child's death (2.1-2.5). Furthermore, children born to mothers who had had no formal education, had had more than five births, were aged 35-49 or lived in a rural area were more likely than others to die before their fifth birthday (3.0-3.4).

In a multivariate analysis adjusted for education, parity, area of residence and socioeconomic status, the loss of a child before age five was associated with the mother having experienced physical or sexual violence from either an intimate partner (odds ratio, 2.1) or a nonpartner (4.1); women who had experienced both physical and sexual violence from an intimate partner had even higher odds of losing a child (6.3). Using these findings, the researchers estimate that approximately one-fourth of the deaths among children younger than five could be attributed to physical or sexual violence toward women by their partners.

The researchers suggest various explanations for the association between violence against women and child mortality. First, mothers exposed to physical or emotional stress are more likely than others to have low-birth-weight infants, who in turn have an increased risk of dying during childhood. Another theory is that the capacity of women to raise a child may be diminished because of emotional issues associated with abuse, such as depression, anxiety and post-traumatic stress, or because they are physically prevented from obtaining care for their children.

The authors of an accompanying commentary note that the study questionnaire did not include items regarding whether a child's birth was intended and whether the child was abused.² They comment that in the absence of such data, the findings are "likely to overestimate substantially the true association" between violence against women and the risk of death among their children.--J. Rosenberg

REFERENCES

1. Åsling-Monemi K et al., Violence against women increases the risk of infant and child mortality: a case-referent study in Nicaragua, Bulletin of the World Health Organization, 2003, 81(1):10-16.

2. Butchart A and Villaveces A, Violence against women and the risk of infant and child mortality, Bulletin of the World Health Organization, 2003, 81(1):17.