Introduction

Intimate partner violence (IPV) is a serious though preventable public health problem among women of reproductive age (15–49 years) that can have severe consequences for the trajectory of their lives [1]. According to the Centers for Disease Control and Prevention (CDC), IPV encompasses physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner (which may include spouse, boy/girlfriend, dating partner, or sexual partner) [2,3]. Global estimates indicate that about 30% of women who have been in a relationship reported experiencing any physical or sexual IPV at some point in their lives [4]. This percentage varies by region, from 23% in the Western Pacific to 37% in high-income regions of Europe [4]. In the United States (US), about 1 in 4 women has experienced IPV during her lifetime, leading to profound impacts on their physical, mental, and reproductive health [5]. Each year in the U.S., IPV results in over 1,500 deaths [6–8].

Although women of all ages may experience IPV, women of reproductive age are disproportionately affected by physical IPV, leading to various negative health outcomes such as gynecologic disorders, pregnancy complications, unintended pregnancy, and sexually transmitted infections [9]. The lack of control over their reproductive health is identified as a key factor contributing to the elevated risk of unintended pregnancy among abused women [10]. Studies in the United States have shown that 1 in 5 women seeking care in family planning clinics have a history of abuse or have been subjected to pregnancy coercion: with a notable percentage (almost 15%) reporting birth control sabotage [11,12]. Moreover, pregnancy itself is a critical period for the occurrence of IPV. A recent article found that an average of 5.7% of pregnant women were estimated to have experienced any type of IPV during pregnancy in 2016–2018 in the U.S., though the real number could have been much higher than reported [13,14]. The consequences of IPV during pregnancy are severe for both mother and child, including peripartum depression, obstetric complications, preterm birth, low-birth weight infants, and perinatal death [15,16].

Contraceptive utilization is crucial for reducing the likelihood of unintended pregnancy among women experiencing IPV. Research has provided evidence indicating that the primary cause of unintended pregnancy is often attributed to insufficient contraceptive practices [16]. For instance, a survey conducted in the United States revealed that 95% of unintended pregnancies were a result of either not using contraception or using it improperly or inconsistently [17]. Post-partum contraception plays a crucial role in safeguarding women’s health by effectively preventing short interpregnancy intervals (<18 months from delivery), reducing the risk of preterm birth, reducing unintended pregnancy, and minimizing associated health complications [18]. However, little is known about factors contributing to contraceptive use among postpartum women who experience IPV around the time of pregnancy. It is anticipated that the effective and consistent use of contraceptives has the potential to decrease the unmet need for postpartum contraception, particularly among populations with a higher prevalence of unintended pregnancies [18].

Attention has been increasingly focused on the impact of physical IPV on the physical and mental well-being of women on a global scale. Specifically, while the contraceptive prevalence rate for women of reproductive age in the U.S. continues to increase, very few studies have aimed to understand the extent to which physical IPV is associated with contraceptive use among postpartum women. Our research expands upon a previous study that investigated the effect of IPV on postpartum contraceptive practices using PRAMS data from 26 states and one city spanning from 2012 to 2015 [19]. There is no recent study to provide information on current changes in physical IPV and postpartum contraception use in the U.S. To further address the knowledge gap, the objective of this study is to use data collected between 2016–2021, adding all participating states and cities to the analysis, to assess the relationship between physical IPV and contraceptive use among postpartum women in the United States. The rationale of this study is to inform policymakers and stakeholders in planning and implementing policies aimed at improving reproductive and maternal health, with a specific focus on enhancing postpartum contraceptive use among women exposed to physical IPV in the United States.

Methods

This study involved analyzing secondary data from cross-sectional, retrospective surveys conducted by the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is an ongoing city and state-level, population-based surveillance system that focuses on selected maternal behaviors and experiences that occur before, during, and shortly after pregnancy [20]. The PRAMS initiative was carried out in collaboration with state and local health departments by the CDC Division of Reproductive Health.

Measurement

The PRAMS questionnaire, conducted annually, consists of two sections—a set of core questions that are asked by all states (such as preconception health, demographics, physical abuse) are included in the first section. The second section comprises standard questions that are selected from a pretested list developed either by CDC or by states on their own [20]. In addition, interested states have the option to develop additional supplements that can be developed to append to the end of the regular PRAMS survey. The complete PRAMS questionnaires can be accessed online and are also provided in the supplemental material [23].

Outcome variable.

In this study, the outcome variable was the type of postpartum contraceptive method utilized at the time the survey was taken (2–6 months after most recent live birth). These variable measures were derived from core questions of the PRAMS survey. Women participants were asked question “Are you or your husband or partner doing anything now to keep from getting pregnant?”, and if so, asked the following question “What kind of birth control are you or your husband or partner using now to keep from getting pregnant?”. This question was used as a basis to determine the outcome variables in this study. Methods of contraception included in the survey were birth control pills, condoms, shots or injections (Depo-Provera), implants (Nexplanon or Implanon), contraceptive patch (OrthoEvra) or vaginal ring (NuvaRing), IUD (including Mirena, ParaGard, Liletta, or Skyla), tubes tied or blocked (female sterilization or Essure, or tubectomy), vasectomy (male sterilization), natural family planning (including rhythm method), withdrawal (pulling out), abstinence, or other methods. The hierarchy of contraceptive effectiveness in descending order was: tubectomy, vasectomy, IUD, implant, shots, or injections (Depo-Provera) every 3 months, contraceptive patch or vaginal ring, birth control pills, condom, abstinence, rhythm, withdrawal, and “other” [24–26].

Exposure variable.

The primary exposure variable of interest is the experience of physical IPV (yes/no), measured by asking the following questions: “During the 12 months before you got pregnant you’re your new baby, did your husband or partner push, hit, slap, kick, choke, or physically hurt you in any other way?” and “During your most recent pregnancy, did your husband or partner push, hit, slap, kick, choke, or physically hurt you in any other way?”. Women were classified as having experienced physical IPV around the time of pregnancy if they answered ‘yes’ to either question. This is defined as the response to being “pushed, hit, slapped, kicked, choked, or physically hurt” by a current or former husband or partner during the 12 months before pregnancy, during pregnancy, and since the new baby was born.

Covariates.

Demographic and socioeconomic factors for the analysis were selected based on prior literature, preliminary analysis, and the Direct Acyclic Graph (DAG) diagram [27] (Fig 1). These variables included maternal age (categorized as < 24, 25–29, 30–34, and ≥ 35 years), race/ethnicity (categorized as ‘Black non-Hispanic’, ‘White non-Hispanic’, all other races (e.g., Asian, American-Indian, Chinese, Japanese, Philipino, mixed races, other non-White) as ‘Other, non-Hispanic’, and ‘Hispanic’), marital status (married/cohabitated or other), place of residence (urban/rural), educational attainment (< 12 grade, high school graduate, college/beyond), and employment status at any time during last pregnancy (yes/no). The ‘state of residence’ variable was categorized into four geographic regions based on US Census divisions: Northeast, Midwest, South, and West [28], with the aim to reduce the potential confounding effects of individual state-level differences that many not be pertinent to the scope of this study. Connecticut, Rhode Island, Massachusetts, New Hampshire, Vermont, Maine, New York, Pennsylvania, and New Jersey are in Northeast region; North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Wisconsin, Illinois, Michigan, Indiana, and Ohio are included in the Midwest region; Oklahoma, Texas, Arkansas, Louisiana, Mississippi, Alabama, Tennessee, Kentucky, Florida, Georgia, YC, North Carolina, Virginia, West Virginia, Maryland, Delaware, District of Columbia, and Puerto Rico are in the South geographic region; and Alaska, Washington, Oregon, Idaho, Montana, Wyoming, California, Nevada, Utah, Arizona, New Mexico, Colorado, and Hawaii are in the West geographic region [28]. Household income in the 12 months before last live childbirth was categorized as ‘less than or equal to the average median household income’ or ‘above average median household income’ created from the poverty scale based on the HHS Poverty Guidelines for years 2016–2021 [29]. On average, the median household income over 2016–2021 was approximately $69,878 [29]. Additionally, a reproductive health variable was included, with the intentionality of the last pregnancy, categorized as yes for intended pregnancy, and no for unintended pregnancy. An ‘intended pregnancy’ was characterized by the respondent wanted to be pregnant at that time or sooner and an ‘unintended pregnancy’ was described as a pregnancy that was wanted at a later time, not wanted at that moment or at any point in the future, or ‘uncertain/not sure’.

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Fig 1. Direct Acyclic Graph (DAG) of association between IPV and contraceptive use.

https://doi.org/10.1371/journal.pone.0314938.g001

All variables were derived from the linked birth certificate. Only annual household income was obtained from the PRAMS survey questionnaire. All measures are current status (i.e., at the time of the survey), unless stated otherwise.

Results

Experience of IPV, as well as demographic and socioeconomic characteristics of women who gave birth in the United States between 2016 and 2021 are provided in Table 1. According to the data collected from 46 states, the District of Columbia, New York City, and Puerto Rico, the overall prevalence of reporting physical IPV during and/or 12 months before pregnancy was 3.2%. The majority of women in the sample were aged between 20 and 39, accounting for 93% of the participants. In terms of racial and ethnic identification, 14% identified as Black non-Hispanic, 58% identified as White non-Hispanic, 19% identified as Hispanic, and 9% identified as belonging to other racial/ethnic groups. The ‘Other’ race was categorized as Other Asian (4.3%), American Indian (3.6%), Chinese (1.2%), Japanese (0.2%), Philipino (0.8%), Hawaiian (0.1%), Ak Native (0.8%), mixed race (5.7%), and other non-white (5.5%). Women from the South constituted 41% of the sample, while 84% of the participants resided in urban areas. Approximately 64% of the women had attended college or beyond and had a household income of less than or equal to the 2021 median in 61% of cases. More than one-third of women were unmarried/not cohabitating at the time of the survey (38%). Slightly more than half of the pregnancies (57%) were intended. Women’s employment status at any time during last pregnancy was the only variable included in the DAG diagram that did not show a statistically significant difference by IPV status.

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Table 1. Characteristics of women with a recent live birth, stratified by self-reported exposure to physical IPV during pregnancy or 12 months before last pregnancy in the United States, PRAMS 2016–2021^*.

https://doi.org/10.1371/journal.pone.0314938.t001

Fig 2 illustrates the variation in the prevalence of physical IPV, ranging from 2.2% (in Connecticut, Georgia, New Jersey, and Washington) to 5.5% (in Arkansas). The Midwest region had the highest reported prevalence of physical IPV at 3.5%, followed by the South at 3.3% and the Northeast at 3.0%. Conversely, West exhibited the lowest prevalence at 2.9%. The national prevalence of physical IPV was 3.2%.

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Fig 2. Prevalence of IPV among women with a recent live birth in the United States, PRAMS, 2016–2021.

https://doi.org/10.1371/journal.pone.0314938.g002

Table 2 illustrates the bivariate analysis of contraceptive use during the postpartum period among women who have and have not experienced physical IPV before and during their last pregnancy. The overall utilization of any method of contraception during the postpartum period was 94%, with a slightly higher rate at 95% among women who had not experienced physical IPV, and a somewhat lower rate at 91% among women who had experienced physical IPV during pregnancy or 12 months before last pregnancy. The most commonly used methods were condoms (19%) and birth control pills (14%); while withdrawal (16%) and abstinence (11%) were two commonly used methods. A notable difference between women exposed to IPV and women who were not was observed in the use of birth control pills (14% vs. 8%, respectively) and condoms (19% vs. 9%, respectively), with statistically significant at 5% level (p<0.001). For the long-acting-reversible and permanent methods (LARC-PM), IUD and vasectomy use were higher among IVP non-exposed group, whereas implants, shots, and tubectomy use were more common among the IPV-exposed group compared to their counterparts.

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Table 2. Postpartum contraceptive use by experience of physical IPV during pregnancy or 12 months before pregnancy in the United States, PRAMS 2016–2021.

https://doi.org/10.1371/journal.pone.0314938.t002

Results of the logistic regression models are presented in Table 3, which presents both the unadjusted (also known as crude models), and the adjusted model that considered the effect of confounders from different categories, such as, demographic, socioeconomic, and reproductive health factors. In the multivariable regression models, we have selected the category with the lowest prevalence of physical IPV as the reference group for each variable. From the unadjusted models, we found that exposure to physical IPV during pregnancy or 12 months before last pregnancy, mother’s age, race-ethnicity, region, urban/rural residence, marital status, employment, and intention of last pregnancy were statistically significant predictors of postpartum contraceptive use without adjusting for other covariates. Interestingly, two important demographic and socioeconomic factors—educational attainment and household income for the year before last childbirth, were not statistically significant in the crude models.

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Table 3. Association of IPV with postpartum contraceptive use, unadjusted and adjusted Logistic Regression Models [unweighted N = 165,204], PRAMS 2016–2021.

https://doi.org/10.1371/journal.pone.0314938.t003

After adjusting for demographic, socioeconomic, and reproductive health variables, our analyses revealed that women who experienced physical IPV during or 12 months before their last pregnancy had 42% lower odds of using any forms of contraceptive methods (aOR: 0.58; 95% CI: 0.48–0.70) compared to women who did not experience physical IPV during the same period. Additionally, we observed that the odds of using postpartum contraception were significantly higher for women aged 20 years or younger compared to women aged 40 or older (aOR: 3.13; 95% CI: 2.22–4.41), indicating a strong positive association between age and postpartum contraceptive use.

Ethnicity also played a role, as Black non-Hispanic women had 29% lower odds of using post-partum contraception (aOR: 0.71; 95% CI: 0.60–0.83) compared to Hispanic women, while other non-Hispanic women had 55% lower odds (aOR: 0.45; 95% CI: 0.37–0.52) as compared to the same. Geographically, women living in the Northeast, Midwest, and South regions had lower odds of contraceptive use compared to those in the West. Education level was a strong positive predictor of contraceptive use, with women who pursued college education or beyond being 50% more likely (aOR: 1.50; 95% CI: 1.26–1.77) to use contraception, compared to those with educational attainment was below 12^th-grade. Marital status also had an impact, as unmarried or cohabitating women were 24% less likely (aOR: 0.76; 95% CI: 0.68–0.84) to use contraception compared to married or cohabitating women. Employment during pregnancy also increased the likelihood of contraceptive use by 15% (aOR: 1.15; 95% CI: 1.06–1.25). Women whose last pregnancy was unintended had 20% higher odds of using contraceptive methods during their postpartum period compared to those with an intended pregnancy (aOR: 1.20; 95% CI: 1.09–1.32). Household income and place of residence status did not affect postpartum contraception use

Discussion

Our study findings suggest that physical IPV during pregnancy or 12 months before pregnancy can have an impact on the use of postpartum contraception. Women who experienced physical IPV during that period were significantly less likely to use postpartum contraception compared to those who did not report physical IPV during the same period; even after controlling for factors associated with post-partum contraceptive use. This finding aligns with existing evidence that physical IPV is associated with adverse sexual and reproductive health outcomes, such as unintended pregnancy, sexually transmitted diseases, or other reproductive health concerns among sexually active post-partum women in the United States [34]. Our research builds on this evidence by demonstrating that physical IPV is associated with nonuse of contraception in the postpartum period, further highlighting the public health importance of addressing IPV in maternal health interventions. Similar results have been observed in earlier studies, such as an analysis of PRAMS data from 2004 to 2008 that found that women who reported physical IPV were significantly less likely to use postpartum contraception than those who did not (cOR, 0.66; 95% CI, 0.61–0.71) [34]; research from 2012 to 2015 also had similar findings [34,35]. Our findings suggest that the likelihood of postpartum contraceptive use among women who have experienced physical IPV has since decreased. Additionally, our analyses demonstrated that the prevalence of IPV was higher among postpartum women who were predominantly younger, of lower socioeconomic status, and in non-marital or cohabitating relationships.

The contraceptive method-mix varied significantly between women who reported physical IPV and those who did not. Our analyses indicated that women who experienced IPV had significantly lower usage rates for partner-dependent contraceptive methods such as condoms, natural family planning (including rhythm), and vasectomy, compared to their counterparts. The reduced usage of these methods could be attributed to partner negotiation, potentially resulting in higher rates of nonuse, as suggested in the CDC’s NISVS report [35]. Furthermore, women who have experienced IPV may experience additional challenges to accessing and using effective contraception that is not subject to partner interference and negotiation [36]. However, almost one-quarter of women who had experienced physical IPV during pregnancy or 12 months before pregnancy were abstinent at the time of the PRAMS survey. This disparity in circumstance may underscore the complex interplay between intimate partner violence (IPV), the dynamics of power within relationships, and the decision-making processes regarding reproduction, thereby highlighting the necessity for interventions that consider these broader contexts [37,38].

The higher rate of nonuse of postpartum contraception among women who have experienced physical IPV during pregnancy or 12 months before last pregnancy, compared to those who had not, indicates an unmet need for family planning resources before, during and shortly after pregnancy. Healthcare providers can play a crucial role in addressing this issue by following physical IPV screening guidelines during pregnancy [37], and providing family planning, education, and resources to all patients, regardless of disclosure [39]. Screening by itself might not fully address the impact of physical IPV on postpartum contraceptive use. However, proactive violence prevention could potentially make a significant difference on this reproductive health outcome. Patient-centered contraceptive counselling by healthcare providers during pregnancy and assistance in accessing desired methods after delivery [40], including contraceptive methods that are less detectable by partners, like implants, IUDs, and injectables, may be particularly beneficial for women experiencing physical IPV [37]. Moreover, the prevalence of physical IPV varies significantly across different states in the USA. Some states have more robust support systems and legal protections for IPV survivors, which can influence reporting rates and overall prevalence of IPV [41].

Our research highlights the association between exposure to physical IPV during pregnancy or 12 months before pregnancy and its influence on postpartum contraceptive use. This underscores the importance of preventing IPV to support women’s reproductive autonomy. Our findings also suggest that reducing IPV exposure around the time of pregnancy could empower women to make autonomous contraceptive decisions. Comprehensive IPV interventions, aligned with recommendations from the American College of Obstetricians and Gynecologists (ACOG) [9,40], USPSTF [42], and CDC [3], may play a crucial role in promoting women’s overall health and well-being. Ensuring pregnant women’s access to comprehensive family planning services can serve as a critical intervention for those experiencing IPV, by supporting their autonomy, and promoting their overall health and well-being.

Conclusion

The study findings reveal the impact of physical IPV on postpartum contraceptive use, highlighting the need for IPV screening during pregnancy including the provision of person-centered post-partum family planning education and counseling, which is vital for ensuring women’s reproductive autonomy and well-being. These findings also call for integrating IPV prevention into maternal health strategies and enhancing support for affected women, building on existing policies. Further research should continue to explore the long-term effects of IPV on maternal health to inform clinical and policy initiatives further.

Supporting information

Acknowledgments

This article was made possible by thousands of women in the United States who shared their personal experiences by mail or telephone conversations with the research teams throughout the country who carried out the surveys, provided access to data, and prepared the dataset according to the study requirements. We would also like to thank the CDC PRAMS Team, Applied Sciences Branch, Division of Reproductive Health. PRAMS working group representatives listed by State: Alabama—Danita Crear, DrPH; Alaska—Kathy Perham-Hester, MS, MPH; Arkansas—Mary McGehee, PhD; Colorado—Alyson Shupe, PhD; Connecticut—Jennifer Morin, MPH; Delaware—George Yocher, MS; District of Columbia–Pamela Oandasan; Florida—Jerri Foreman, MPH; Georgia—Jenna Self, MPH; Hawaii—Emily Roberson, MPH; Illinois—Theresa Sandidge, MA; Indiana–Jenny Durica, MPH; Iowa—Sarah Mauch, MPH; Louisiana—Jane Herwehe, MPH; Maine—Tom Patenaude, MPH; Maryland—Diana Cheng, MD; Massachusetts—Emily Lu, MPH; Michigan—Cristin Larder, MS; Minnesota—Judy Punyko, PhD, MPH; Mississippi—Brenda Hughes, MPPA; Missouri—Venkata Garikapaty, MSc, MS, PhD, MPH; Montana—JoAnn Dotson; Nebraska—Brenda Coufal; New Hampshire—Paulette Valliere, MPH; New Jersey—Lakota Kruse, MD; New Mexico—Eirian Coronado, MPH; New York State—Anne Radigan-Garcia; New York City—Candace Mulready-Ward, MPH; North Carolina—Kathleen Jones-Vessey, MS; North Dakota—Sandra Anseth; Ohio—Connie Geidenberger, PhD; Oklahoma—Alicia Lincoln, MSW, MSPH; Oregon—Kenneth Rosenberg, MD, MPH; Pennsylvania—Tony Norwood; Rhode Island—Sam Viner-Brown, PhD; South Carolina—Mike Smith, MSPH; Texas—Rochelle Kingsley, MPH; Tennessee—Angela Miller, PhD, MSPH; Utah—Lynsey Gammon, MPH; Vermont—Peggy Brozicevic; Virginia—Marilyn Wenner; Washington—Linda Lohdefinck; West Virginia—Melissa Baker, MA; Wisconsin—Mireille Perzan, MPH; Wyoming—Amy Spieker, MPH.