Acta Pædiatrica, 2005; 94:
Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low-income mothers

Abstract
Aim: This study explored maternal history of perinatal loss relative to risk of child physical abuse and neglect.
Methods: The 518 study participants included 118 abusive mothers, 119 neglecting mothers, and 281 mothers with no known history of child maltreatment...

Interviews and observations were conducted in the participants’ homes, and comparisons were made between women without a history of perinatal loss and women with one and multiple losses relative to risk for child maltreatment.

Results: Compared to women with no history of perinatal loss, those with one loss (voluntary or involuntary) had a 99% higher risk for child physical abuse, and women with multiple losses were 189% more likely to physically abuse their children.

Compared to women with no history of induced abortion, those with one prior abortion had a 144% higher risk for child physical abuse.

Finally, maternal history of multiple miscarriages and/or stillbirths compared to no history was associated with a 1237% increased risk of physical abuse and a 605% increased risk of neglect.

Conclusion: Perinatal loss may be a marker for elevated risk of child physical abuse, and this information is potentially useful to child maltreatment prevention and intervention efforts.

Background
Pregnancy loss through miscarriage, stillbirth, and induced abortion has been linked with pronounced psychological problems in at least 10–25% of women [1–3].

Among those negatively impacted by voluntary and involuntary forms of perinatal loss, many stress-related responses have been identified including grief reactions [4,5], anxiety [6,7], depression [8,9], sleep disturbances [10,11], post-traumatic stress disorder symptoms [12,13], and, in the case of induced abortion only, increased risk of substance use [14,15] and suicide [16].

Emotional difficulties and unresolved grief responses associated with perinatal loss may hinder effective parenting by reducing parental responsiveness to child needs [1,17], interfering with attachment processes [18], instilling anger, which is a common component of grief [19], or by increasing parental anxiety about child well-being [17].

The existing studies, designed to examine relations between maternal history of perinatal loss and aberrant parenting behavior, have focused nearly exclusively on either involuntary forms of loss (miscarriage and stillbirth) or voluntary forms of loss (induced abortion) with comparison studies currently absent from the published research. One study did reveal an elevated risk of child abuse with both types of perinatal loss; however, due to data constraints, no distinction was made between stillbirth and induced abortion in assessing risk [20].

In a study of parents of stillborn infants, Phillips found that both mothers and fathers frequently showed low levels of pleasure and attachment in conjunction with a subsequent pregnancy [21].

Involuntary perinatal loss has also been found to be associated with heightened risk for child abuse [22]. Paradoxically, other studies of involuntary loss indicate a higher risk for over-protective parenting behavior as well as an inclination to become excessively concerned about the physical health of surviving children [17].

Finally, due to lingering parental grief, children born to mothers with a history of involuntary forms of perinatal loss are apparently more prone than children of mothers without such a history to experiencing emotional and behavioral problems [17,21].

The link between voluntary perinatal loss and parenting behaviors has been less systematically examined, presumably because of the generally held belief that women who freely choose termination are unlikely to be negatively affected [23]. However, recent research on the psychological effects of abortion suggests that this assumption may be ill founded [2,5,6,8,10,13–16] as women who opt for abortion often do so with much ambivalence and under the pressure of others and/or situational constraints [24].

Nevertheless, a few recent studies have identified relations between maternal history of abortion and problematic parenting, including lower emotional support and heightened risk for both child abuse and neglect [18,20,23].

While both voluntary and involuntary forms of loss have been found to be associated with adverse psychological effects as described above, there are several reasons to believe that induced abortion may have a more pronounced negative impact on women’s mental health and parenting behavior.

First, because abortion is a voluntary act, many women may experience a considerable amount of guilt, with moral or religious conflicts likely to precipitate such feelings [24,25]. Abortion-related guilt has been estimated to range from 29.7% to over 75% [24,25].

Second, professionals who work with women who have experienced a miscarriage or stillbirth are inclined to encourage healing focusing on the loss of the fetus [12], but this is rarely a part of routine post-abortion care.

Third, feelings of shame and secrecy that may surround an abortion experience might preclude reaching out to others for needed support, and studies clearly suggest that the presence of a continuously available, informed, and sympathetic social support system is a vital component to recovery for the bereaved [26].

Fourth, although very few studies have examined the long-term effects of abortion, miscarriage, and stillbirth, there is some preliminary evidence indicating that negative abortion-related emotions are more difficult to resolve than those associated with involuntary forms of loss. For example, a Norwegian team of researchers led by Broen [27] recently reported that women who had an abortion 2 y earlier were more likely than those who had miscarried to be suppressing thoughts and feelings about the event. Specifically, nearly 17% of 80 women who had an abortion scored highly on a scale measuring avoidance symptoms, compared with about 3% of those who miscarried.

The purpose of this study was to explore the extent to which perinatal loss operates as a risk factor for child physical abuse and neglect.

Based on the previously reviewed literature, the following hypotheses were tested: (1) women with a history of one perinatal loss, when compared to women without a prior perinatal loss, were expected to be at a higher risk for engaging in child physical abuse and neglect; (2) when examined separately, both maternal history of one induced abortion and maternal history of one miscarriage/stillbirth were hypothesized to be associated with a higher risk for both child physical abuse and neglect than not having experienced either form of loss; and (3) induced abortion was expected to be associated with a greater risk for both forms of maltreatment when compared to miscarriage and stillbirth.

Various environmental, personal, and social factors enhance the risk for child maltreatment [28]; therefore, many variables (described below) were explored as potential covariates to be included in the primary analyses. Finally, exploratory analyses were conducted to examine the extent to which risk for child maltreatment is elevated when women experience more than one perinatal loss compared to no prior losses.

Very little previous research attention has focused on multiple losses, precluding specific hypotheses pertaining to possible associations between multiple perinatal losses and elevated risk for child maltreatment.

Material and methods
Participants
The respondents in this study consisted of 518 women who were residents of Baltimore, Maryland, in the mid-1980s and were receiving Aid to Families with Dependent Children (AFDC). Each participant had at least one living child age 12 or under. Exactly 100 women (19.3%) had experienced one abortion, and 59 women (11.4%) experienced two or more abortions; whereas 99 women (19.1%) had experienced one miscarriage or stillbirth, and 34 women (6.6%) had experienced multiple miscarriages or stillbirths. The majority of the participants were single (78.8%), with the remainder separated from spouses (18.9%) or married (2.3%). The 518 study participants included 118 abusive mothers, 119 neglecting mothers, and 281 mothers who had no history of substantiated child maltreatment offenses. At the time of testing, the participants ranged in age from 18 to 50 y (mean 27.31, SD 5.65). The average number of children was 2.64 (SD 1.71), with a range extending from 1 to 11.

The sample was predominantly Black (79.9%), with 19.7% White, and 0.4% Asian or Native American...For the 100 women who had experienced one prior abortion, a mean of 6.50 (SD 4.11) y had elapsed since the procedure; whereas for the 99 women who had experienced a miscarriage or stillbirth, a mean of 7.16 (SD 5.37) y had elapsed since the loss.

Data description and procedure...
Physical abuse segment. The 118 mothers comprising the final physical abuse segment were self-selected from a sample of 152 abusive mothers (78% interview completion rate) who were identified from a cohort of 1744 families receiving Child Protection Services (CPS) from the Baltimore City Department of Social Services (BCDSS) during January 1984. All women who were known or suspected abusers were included in the original sample of 152 mothers in addition to a
random sample of remaining cases where someone else was known or suspected of being the abuser. The operational definition of physical abuse used in this study was as follows: “Respondent had as of January 1984 at least one natural child who was the victim of excessive inappropriate physical force by the respondent herself and/or another caretaker and, as a result of the force, sustained injuries at a minimum severity level of 4 on the 6-point Magura-Moses Physical Discipline Scale” [29, p. E5-2]. Severity-level 4 injuries include bruises, welts, cuts, abrasions, or first-degree burns that are restricted to one or two bodily areas. The principle investigator reported that information derived from CPS case records of 105 of the abusive respondents revealed that, in 59% of the situations, the mother was the one who inflicted the injuries and, for 60% of the situations, child neglect was also a problem.
Finally, 39% of the injuries were mild, involving injuries not requiring medical intervention such as bruises, welts, and abrasions; 45.7% of the situations involved moderate injuries such as second-degree burns, mild concussions, breaks of small bones, etc.; and 15.2% of the situations were classified as severe, involving third-degree burns, internal injuries, severe concussions, breaks of long bones, etc. [29].
Neglect segment. The 119 mothers included in the final neglect segment were self-selected from a sample of 164 neglectful mothers (73% interview completion rate) who were identified from the same cohort of families receiving CPS from the BCDSS during January 1984 that was used to identify the abusive mothers.

The original sample