J Fam Viol (2011) 26:453458 DOI 10.

1007/s10896-011-9379-z

ORIGINAL ARTICLE

Violence during Pregnancy: Investigating Infanticidal Motives

Nicola Graham-Kevan & John Archer

Published online: 27 May 2011 # Springer Science+Business Media, LLC 2011

Abstract This study aimed to investigate whether potentially infanticidal violence by men toward their pregnant partners is motivated by jealousy, and hence paternity uncertainty. It was predicted that men who used potentially infanticidal violence (directing their physical aggression towards their pregnant partners abdominal region) would have younger partners as this is associated with greater reproductive value; would be in relationships of shorter duration as this may indicate less stable relationships; and would be more jealous and restrictive of their partners movements and friendships than violent men who directed their aggression to other regions of their pregnant partners body. Relationship behaviors were provided from 43 women in domestic violence shelters (n = 43), using measures of the following: (1) partner physical aggression (2) victim fear and injury, (3) areas of bodily assault (when pregnant and when not pregnant), (4) controlling behaviors, and (5) topics of disagreement. Violence directed towards the fetus was associated with shorter relationships where both partners were younger. In such relationships, there was more physical aggression from the male partner, he used more controlling behaviors to isolate his partner, and the partners had more disagreements arising from his jealousy, compared with when physical aggression was not directed towards the fetus. These findings are consistent with an infanticidal motive for mens aggression directed towards their pregnant partners. If paternity uncertainty is a primary

cause of this dangerous form of domestic violence, it should form an important element in any screening instrument. Keywords Partner violence . Domestic violence . Pregnancy . Infanticide . Evolutionary . Mate-guarding, Controlling behavior

Introduction Research suggests that domestic violence may commence or even escalate in pregnancy and is more common than complications that are subject to routine screening, such as pre-eclampsia, placenta praevia, twins or gestational diabetes (Mezey and Bewley 1997). Prevalence rates for domestic violence during pregnancy vary greatly, but have been estimated by Torres et al. (2000) as ranging from 3.9% to 8.3%, although younger women may be at a higher risk (e.g. Berensen et al. 1992). Samples from battered women shelters also show higher frequencies, typically between 40 and 60% (Campbell et al. 1993). Violence has been identified as a significant contributor to perinatal and maternal morbidity and mortality, through both direct and indirect means. It directly affects fetal distress and fetal death (e.g., Dye et al. 1995), particularly where blows are to the abdomen in the third trimester (Ribe et al. 1993). It is also related to behavior that indirectly affects fetal health. Dietz, Gazmararian, Goodwin, Bruce, Johnson, and Rochat (1997) found that experiencing physical violence doubled the chance of delayed entry into prenatal care. Amaro et al. (1990) found that victims of violence during pregnancy were more likely to use alcohol and drugs, with their partners being more likely to use cocaine and marijuana, than were non-victims.

N. Graham-Kevan (*) : J. Archer School of Psychology, University of Central Lancashire, Preston PR1 2HE, UK e-mail: ngraham-kevan@uclan.ac.uk J. Archer e-mail: jarcher@uclan.ac.uk

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Research has indicated that violence towards a pregnant woman is more likely to be found in relationships where severe partner aggression is also reported (Campbell et al. 1993). Severe violence to a partner frequently co-occurs with a high frequency use of controlling behaviors such as trying to isolate a partner, being emotionally abusive, intimidating, threatening, and controlling access to money or employment or study opportunities (Graham-Kevan and Archer 2003a, b; Johnson 1995; Pence and Paymar 1986). Therefore, we would expect that abused pregnant women will experience high frequencies of both physical aggression and controlling behaviors from their partners, which will lead to frequent fear and injuries. Campbell et al. (1993) suggested that violence during pregnancy followed four themes: (1) jealousy towards the future child, (2) pregnancy-specific violence not directed towards the fetus, (3) anger towards the fetus, and (4) business as usualwhere violence continues in the same manner as before pregnancy. Broadly speaking these themes can be categorized as either being directed towards the fetus (33%) or the mother (77%). Campbells proposal was based on an exploratory study of womens anecdotal reports. However, there is a lack of empirical research that has investigated the dynamics of relationships where physical aggression is used against pregnant women. Most studies have instead involved demographic comparisons of women abused during pregnancy and those who are not (e.g., Torres et al. 2000). Where physical aggression is directed towards a fetus, one would expect blows to the abdominal region to be used. This is consistent with research that has asked pregnant women about their own attempts at fetal abuse (Kent et al. 1997). Indeed, some authors suggest that partner violence by the man may also be specifically directed towards the abdominal region during pregnancy (Mezey and Bewley 1997). However, where physical aggression is directed towards the mother it may be expected that abdominal blows would be absent. Where domestic violence is directed towards the mother it may be expected that a range of topics of disagreement would be reported as having precipitated the physical aggression. However, where the fetus is the target of the assault it may be expected that arguments would concern the man s jealousy. There is an explanation of why a man may direct physical aggression towards a fetusas an attempt to inflict infanticide. Infanticide is common in animals where the male is required to invest his time and resources in helping to rear his offspring (e.g., red howler monkeys: Agoramoorthy and Rudan 1995; Old World monkeys and apes: Angst and Thommen 1997). It occurs where offspring are biologically not the infanticidal males own. Men

appear to be more sensitive to cues indicating genetic resemblance than women (Platek et al. 2002, 2003), which is consistent with the asymmetrical cuckoldry risk for men and women. Therefore, we would expect men who are sexually jealous to be more sensitive to cues that indicate a likelihood of paternity uncertainty. Cues such as paternal resemblance are a risk marker for mens physical aggression towards a partner (Burch and Gallup 2000), and where a child is known to be unrelated to the male partner, physical and sexual abuse of the stepchild is more likely (Daly and Wilson 1998; Daly et al. 1982). Therefore, men who doubt their paternitydue to either known or suspected infidelitymay be more likely to endanger the fetus by directing their physical aggression to their partners abdominal region. Indeed, accounts from pregnant women support this. Based on a narrative review of the literature, Mezey and Bewley (1997) suggested that pregnancy may acts as a trigger for accusations of infidelity among very jealous men. Barcroft (1998) interviewed women who were physically assaulted during pregnancy. One woman stated: The day I had my first scan, he [her husband] attacked me outside the hospital and accused me of being pregnant by somebody else. (p. 23). Therefore we would predict that men who direct their physical aggression towards their pregnant partners abdominal region will be more jealous and restrictive of their partners movements and friendships than violent men who direct their aggression to other regions of their partners body.

Method Participants and Procedure Questionnaires were administered to women in a shelter for domestic violence (N =43) as part of a larger study (Graham-Kevan and Archer 2003a). The shelter sample consisted of volunteers from Womens Aid shelters. Each shelter was approached to obtain consent to distribute questionnaires. Two hundred were posted to a total of 11 shelters in the North of England, and a total of 43 respondents returned correctly-completed questionnaires (no return rate can be calculated as it is not clear how many of the 200 questionnaires sent to coordinators were actually distributed). Each respondent was required to self complete the questionnaire and place it in a sealed prepaid envelope which was then returned to the first author. All samples involved the respondent only, reporting on their partners behaviors. Mean age of the participants was 31 years (SD = 9.75). Mean age of participants partners was 34 years (SD = 10.3). Length of relationships ranged from 24 to 504 months, with a mean of 108 (SD = 110).

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Measures Physical Aggression A modified version (Morse 1995) of the Conflict Tactics Scales (CTS: Straus 1979) physical aggression scale was used to assess the occurrence of acts of physical aggression. The respondent was required to indicate whether their partner had used any of the eight items listed during a conflict in the past year, which were rated on a 5-point scale indicating the frequency of aggressive acts, from never (0) to always (4). Cronbachs alpha for the scale for the womens reports about their partners was .93. The range of scores was 024. The CTS has been shown to be sensitive to different rates of partner aggression in different samples, including those from shelters for domestic violence victims (Archer 2000). Parts of the Body Targeted Respondents were asked: If your partner used some type of physical force (including pushing, slapping, throwing things) towards you at any time during the relationship please answer the following questions. The respondents were then asked to indicate whether they had experienced physical aggression from their partner within a pregnancy. Those that indicated that they had were coded as being physically assaulted during pregnancy. These women were then asked to indicate which parts of the body were struck during conflicts in pregnancy? They were asked to respond using the following format: never (0), rarely (1), sometimes (2), often (3), always (4). The parts of body listed were: (1) the face/head, (2) chest, (3) abdomen/stomach, (4) arms/legs, and (5) back. They were then asked to indicate the parts of the body that were struck during conflicts when the woman was not pregnant, using the same response format. Injuries There was one item addressing partner injury which was During these disputes, how often were you physically injured, e.g., knocked down, bruised, scratched, cut, choked, bones broken, eyes or teeth injured? This item was taken from the additional questions concerning injury included in the modified CTS used in the 1986 National Youth Survey (NYS: Morse 1995). Respondents were required to answer on a 5-point scale ranging from never (0) to always (4). The range for injuries was 04.
Table 1 Frequency of physical aggression to specific areas of womens bodies when pregnant (N =20)

Controlling Behaviors Controlling behaviors were measured using a 24-item behavioral scale, the Controlling Behaviors Scale (CBS: Graham-Kevan and Archer 2003a). The CBS was constructed from studies using the Duluth model (Pence and Paymar 1986). This is an intervention program for domestically violent men that focuses upon the use of physical aggression as a means of control. The CBS can be used to derive scores for five subscale scores, each of which involves a particular type of control tactic. The subscales are using economic control, using coercion and threats, using intimidation, using emotional abuse, and using isolation. Cronbachs alpha for the subscales were: economic =.58; threats =.64, intimidation =.66, emotional abuse =.76, and isolation =.80. Although some of these values are low, they are acceptable for scales with only four or five items (Graham-Kevan and Archer 2003b). Respondents were required to indicate whether their partner had used any of the behaviors. They were given a 5-point scale on which to indicate the occurrence and frequency of controlling acts ranging from never (0) to always (4). Disagreements Frequency of disagreements between the respondent and her partner stemming from either (1) money, (2) partners jealousy, (3) respondents commitment, (4) partners commitment, and (5) children, were assessed using a 5-point scale ranging from never argue about this (0) to always argue about this (4).

Results All 43 women were subject to physical aggression from their partner to a total of 20 women reported being subjected to physical aggression during their pregnancies, a prevalence rate of physical aggression during pregnancy in this shelter population of 47%. This figure is consistent with other samples of battered women (Campbell et al. 1993). The remaining analysis focuses on relationships where physical aggression was used during pregnancy: thus, only reports from the 20 women who were victims of pregnancy violence were be used.

Part of body physically struck Frequency PA Never Rarely Sometimes Often Always Face/head 30% 5% 25% 30% 10% Chest 35% 25% 20% 15% 5% Abdomen 35% 30% 30% 0% 5% Arms/legs 20% 0% 30% 25% 25% Back 25% 15% 30% 20% 10%

Frequency PA Frequency of partners use of physical aggression during to specific parts of the body

456 Table 2 Means (SD) and d values for paired samples t-tests comparing the frequency of physical aggression to specific parts of womens bodies by pregnancy status (N =20)

J Fam Viol (2011) 26:453458 Mean frequency of physical aggression to specific parts of womens body Pregnant Yes No t(19 df) d Face/head 1.85 (1.42) 2.50 (1.47) 2.67** .43 Chest 1.30 (1.26) 1.65 (1.42) 1.61 .25 Abdomen 1.10 (1.07) 1.50 (1.50) 1.63 .29 Arms/legs 2.35 (1.42) 2.60 (1.57) 1.75 .17 Back 1.75 (1.42) 2.35 (1.39) 2.57** .41

Preg Status Pregnancy status. * p <.05. ** p <.01. Range 04

The parts of the body hit during pregnancy were varied. Eighty percent of women reported being struck on the arms and legs, 75% on the back, 70% in the face or on the head, and 65% on the chest and abdomen. For all body parts, at least 30% of women reported being struck sometimes (Table 1). To assess whether men may target the abdominal region during pregnancy, we compared the frequencies with which parts of the womans body was targeted during pregnancy and when not pregnant (Table 2). Our data suggest a reduction in frequency of physical aggression to all the specified parts of the body when pregnant compared with when not pregnant. Values for the face and head, the arms or legs, and for the back were statistically significant. The majority (65%) of the women reported being struck on the abdomen. To investigate the difference between relationships where physical aggression was directed towards the fetus and those where it was directed towards the mother, the sample was divided into women who had been struck on the abdomen during pregnancy and those who had not. Those who were struck on the abdomen were significantly younger, had younger partners and were in relationships of shorter duration than those who were not struck on the abdomen (Table 3). Although all the women reported very high levels of physical aggression from their partners, the abdominal assault group reported receiving significantly higher physical aggression than did those without abdominal assaults. The abdominal assault group also reported more fear and injuries, although these differences were not statistically significant (Table 4). The frequency of controlling behaviors was also high in these groups, although only isolation control was
Table 3 Means (SD) and independent t-test comparison of womens age, male partners age and length of relationship (N =20) Mean Abdominal assault Yes (n =13) No (n =7) t(18 df) d Womans age 27.7 (6.30) 36.7 (12.61) 2.16* 1.10 Partners age 30.7 (7.90) 39.7 (12.22) 2.01* .91 LOR 67.7 (38.54) 182.6 (159.6) 2.52* 1.14

significantly higher in the abdominal assault group than those without abdominal assault (Table 4). As predicted, the abdominal assault group reported significantly more conflicts arising from their partners jealousy than did those without abdominal assault (Table 4). There were no other significant differences between the two groups, although the direction of differences between the groups was in the reverse direction for all of the other argument topics (Table 5).

Discussion This study investigated relationships where physical aggression was used against a pregnant woman. We found that the 47% of a sample of battered women had experienced physical abuse during a pregnancy. This prevalence rate is high for a general population but is consistent with previous research using selected samples such as battered women (e.g., Campbell et al. 1993). Consistent with previous studies, we found that the bodily sites for assaults on pregnant women were varied, with all areas reported to be targeted by the majority of women. Frequency of physical aggression to all areas studied was less when pregnant than when not pregnant, blows to the back, arms and legs, and head area significantly so. Whether this is due to increased concern by the male partner for the woman when she is pregnant, or to increased concern over the possibility of alerting outside agencies to the presence of violence, is not clear, and requires future study. Sixty-five percent (n = 13) of the women reported abdominal blows during their pregnancies. They reported being subjected to higher overall frequencies of physical aggression and more control involving isolation (e.g., their partners restricted their contact with friends or family) than did women who were not struck on the abdomen. The abdominally assaulted women also reported more disagreements over their partners jealousy but not over other issues. They were also younger and had been in their relationships for a shorter time. These findings are consistent with an infanticidal explanation of abdominal assault because abdominal assault coincides with greater reproductive value and fertility value, partner control and

Age in years. LOR length of relationship in months. Range 04. * p <.05

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Table 4 Means (SD) and independent t-test comparisons of the frequency of partners use of physical aggression, infliction of injury, and controlling behaviors for women who reported either incidence or absence of abdominal assault (N= 20) Controlling and aggressive behaviours Abdominal assault Yes (n =13) No (n =7) t(18 df) d PA 21.23 (7.52) 14.00 (10.54) 1.79* .80 Fear 3.15 (1.07) 2.71 (1.50) .76 .34 Injury 3.00 (1.56) 2.00 (1.92) 1.47 .56 Econ 12.23 (4.87) 10.57 (5.26) .71 .22 Threat 7.08 (1.89) 7.43 (4.43) .03 .11 Intimid 13.85 (4.34) 13.71 (4.46) .06 .03 Emot 15.46 (3.38) 14.71 (4.68) .41 .18 Isolate 17.85 (2.19) 13.14 (3.93) 2.04* 1.55

PA physical aggression by womans partner. *p <.05. The range for the scores were PA 024, fear 04, injury 04, economic 016, threats 016, intimidation 020, emotional 020, isolatory 020

jealousy, all of which fit a paternity uncertainty view. Therefore, while Campbell et al. suggested that much violence is due to anger towards the fetus, our findings are consistent with the view that it is associated with a suspicion that the child is not the male partners. Campbell et al. subsumed this explanation within the category anger at the unborn child, but it may well be the main motivation for abdominal assaults. Further research is clearly needed to test this hypothesis definitively. Future research should seek to explore this explicitly. This may include asking the pregnant woman and/or their male partners about both past suspected or actual infidelity and, in the case of the woman, infidelity that occurred around the time of conception. A computer assisted, rather than face to face, data collection method is preferable for such sensitive questions (Whisman and Snyder 2007). Alternative explanations for the current findings should also be explored. Abdominal blows during pregnancy may be related to the male partners general dissatisfaction with pregnancy related changes in the relationship such as a reduction in sexual activity and/or the womans reduced sexual interest (von Sydow 1999). Research has found that these factors may increase the likelihood of a mans infidelity (Whisman and Snyder 2007) and it is therefore possible that it may also motivate more direct behavior enacted to rectify the perceived problem (the pregnancy). In addition the current analysis did not differentiate between sexual and

emotional jealousy. Guerrero et al. (2004) explain that . [I]n the case of sexual jealousy, this threat emanates from knowing or suspecting that ones partner has had (or desires to have) sexual activity with a third party. In the case of emotional jealousy, an individual feels threatened by her or his partners emotional involvement with and/or love for a third party (p. 311). Both types of jealousy could be related to isolatory controlling behaviors. Sexual jealousy motivations would be consistent with a paternity uncertainty explanation, whereas emotional jealousy would not. Future research should seek to explore the emotions and cognitions of men who use abdominal blows towards a pregnant partner. If paternity uncertainty is a primary cause of this dangerous form of domestic violence, it should also be evaluated for its predictive powers for postnatal child abuse as other factors such as substance use have been (Zelenko et al. 2001). Condon (1987) suggested that it was important to screen for fetal abuse as an abused fetus was at an elevated risk of becoming a victims of child, a point support by more recent research also (Kent et al. 1997). Fetal abuse should also form an important element in any screening instrument and should be added to the existing list of risk factors for child abuse (Wu et al. 2004). This study has several limitations including its retrospective nature, and the absence of an estimate of the time since the violence had occurred during pregnancy. Although pregnancy outcomes were not assessed, any violence during pregnancy,

Table 5 Means (SD) and d values for independent t-test comparisons of the frequency of disagreements about money, jealousy, commitment and children for women who reported either incidence or absence of abdominal assault (N =20) Disagreement topic Abdominal assault Yes (n =13) No (n =7) t(19 df) d Money 2.85 (1.07) 3.14 (1.22) .57 .25 Jealous partner 3.23 (.73) 2.29 (1.25) 2.17* .96 Commit self 1.31 (1.11) 1.86 (1.35) .98 .44 Commit partner 1.54 (1.23) 2.00 (1.53) .77 .33 Children 2.15 (1.21) 2.43 (1.27) .48 .22

Commit self commitment to relationship by respondent. Commit partner commitment to relationship by respondents partner. * p <.05

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J Fam Viol (2011) 26:453458 Graham-Kevan, N., & Archer, J. (2003a). Physical aggression and control in heterosexual relationships: The effect of sampling. Violence and Victims, 18, 181198. Graham-Kevan, N., & Archer, J. (2003b). Patriarchal terrorism and common couple violence: A test of Johnsons predictions in four British samples. Journal of Interpersonal Violence, 18, 1247 1270. Guerrero, L. K., Spitzberg, B. H., & Yoshimura, S. M. (2004). Sexual and emotional jealousy. In J. H. Harvey, A. Wenzel, S. Sprecher, J. H. Harvey, A. Wenzel, & S. Sprecher (Eds.), The handbook of sexuality in close relationships (pp. 311345). Mahwah: Lawrence Erlbaum Associates Publishers. Johnson, M. P. (1995). Patriarchal terrorism and common couple violence: Two forms of violence against women. Journal of Marriage and the Family, 57, 283294. Kent, K., Laidlaw, J. D. D., & Brockington, I. F. (1997). Fetal abuse. Child Abuse & Neglect, 21, 181186. Mezey, G. C., & Bewley, S. (1997). Domestic violence and pregnancy. British Journal of Obstetrics and Gynaecology, 104, 528531. Morse, B. J. (1995). Beyond the conflict tactics scale: Assessing gender differences in partner violence. Violence and Victims, 10, 251272. Pence, E., & Paymar, M. (1986). Power and control: Tactics of men who batter. Duluth: Minnesota Program Development, Inc. Platek, S. M., Burch, R. L., Panyavin, I. S., Wasserman, B. H., & Gallup, G. G., Jr. (2002). Reactions to childrens faces: Resemblance affects males more than females. Evolution and Human Behavior, 23, 159166. Platek, S. M., Critton, S. R., Burch, R. L., Frederick, D. A., Meyers, T. E., & Gallup, G. G., Jr. (2003). How much paternal resemblance is enough? Sex differences in hypothetical decisions but not in detection of resemblance. Evolution and Human Behavior, 24, 8187. Ribe, J. K., Teggatz, J. R., & Harvey, C. M. (1993). Blows to the maternal abdomen causing fetal demise: Report of three cases and a review of the literature. Journal of Forensic Sciences, 38, 10921096. Torres, S., Campbell, J., Campbell, D. W., Ryan, J., King, C., Price, P., et al. (2000). Abuse during and before pregnancy: Prevalence and cultural correlates. Violence and Victims, 15, 303321. von Sydow, K. (1999). Sexuality during pregnancy and after childbirth: A metacontent analysis of 59 studies. Journal of Psychosomatic Research, 47, 2749. Whisman, M. A., & Snyder, D. K. (2007). Sexual infidelity in a national survey of American women: Differences in prevalence and correlates as a function of method of assessment. Journal of Family Psychology, 21(2), 147154. doi:10.1037/0893-3200.21.2.147. Wu, S. S., Ma, C., Carter, R. L., Ariet, M., Feaver, E. A., Resnick, M. B., et al. (2004). Risk factors for infant maltreatment: A populationbased study. Child Abuse & Neglect, 28, 12531264. Zelenko, M. A., Huffman, L. C., Brown, B. W., Daniels, K., Lock, J., Kennedy, Q., et al. (2001). The child abuse potential inventory and pregnancy outcome in expectant adolescent mothers. Child Abuse & Neglect, 25, 14811495.

especially directed towards the abdominal region, is a serious cause for concern. Future research should seek to investigate the dynamics of relationships where physical aggression is used during pregnancy, and to investigate directly jealousy and paternity uncertainty by partners, e.g. by using estimates of whom the child resembles. Mothers could be asked if they had been unfaithful in the last year or whether they had been separated from their partner just prior to conception. The present study categorised domestic violence during pregnancy according to whether blows were directed towards the abdominal area or elsewhere. This distinction was both theoretically and clinically driven, and may prove a useful one for future research. References
Agoramoorthy, G., & Rudan, R. (1995). Infanticide by adult and subadult males in free-ranging red howler monkeys, Alouatta seniculus, in Venezuela. Ethology, 99, 7588. Amaro, H., Fried, L. E., Cabral, H., & Zuckerman, B. (1990). Violence during pregnancy and substance use. American Journal of Public Health, 80, 575579. Angst, W., & Thommen, D. (1997). New data and a discussion of infant killing in old world monkeys and apes. Folia Primatolgia, 27, 198229. Archer, J. (2000). Sex differences in aggression between heterosexual partners: A meta-analytic review. Psychological Bulletin, 126, 651 680. Barcroft. (1998). When joy turns to horror. The Big Issue, 14, 2223. Berensen, A. B., Miguel, V. V. S., & Wilkinson, G. S. (1992). Prevalence of physical and sexual assault in pregnant adolescents. The Journal of Adolescent Health, 13, 466469. Burch, R. L., & Gallup, G. G., Jr. (2000). Perceptions of paternal resemblance predict family violence. Evolution and Human Behavior, 21, 429435. Campbell, J. C., Faan, C. O., & Bullock, L. (1993). Why battering during pregnancy? AWHONNs Clinical Issues in Perinatal and Womens Health Nursing, 4, 343349. Condon, J. T. (1987). The battered fetus syndrome. The Journal of Nervous and Mental Disease, 175, 722725. Daly, M., & Wilson, M. (1998). Violence against stepchildren. Current Directions in Psychological Science, 5, 7781. Daly, M., Wilson, M., & Weghorst, S. J. (1982). Male sexual jealousy. Ethology and Sociobiology, 3, 1127. Dietz, P. M., Gazmararian, J. A., Goodwin, M. M., Bruce, F. C., Johnson, C. H., & Rochat, R. W. (1997). Delayed entry to prenatal care: effect of physical violence. Obstetrics and Gynecology, 90, 221224. Dye, T. D., Tollivert, N. J., Leet, R. V., & Kenney, C. J. (1995). Violence, pregnancy and birth outcome in Appalachia. Paediatric and Perinatal Epidemiology, 9, 3547.