Orofacial injuries in pregnant women victims of domestic violence: a cross-sectional study at a forensic medicine service in Southern Brazil, 2015-2023Abstract
Objectives To describe the prevalence and investigate whether demographic and circumstantial factors might be associated with the presence of orofacial injuries in cases of family violence against pregnant women examined at the Pelotas Forensic Medicine Service.
Methods This was a cross-sectional study, developed based on the analysis of expert witness examination reports in cases of family violence against pregnant women between 2015 and 2023. Presence of orofacial injuries was taken as the outcome variable. Predictor variables related to the demographic characteristics of the victims and the violent episodes described in the reports were collected. Descriptive and bivariate association analyses were conducted considering a 5% significance level.
Results A total of 103 reports were included in this study. Most of the reports were recorded between 2016 and 2018 (61.1%). Following expert witness examination, 77.7% of the investigations were conducted by the Police Station for Women. Regarding age, 29.1% of the victims were between 19 and 25 years old. The perpetrator was named in 30.1% of the reports. Orofacial injuries were found in 46.6% of the victims, being the second most frequent type after injuries to the upper limbs (59.2%). The upper third of the face was affected in 62.5% of the cases, with injuries predominantly to extra-oral soft tissues. No associations were found between the predictor variables analyzed and the presence of injuries.
Conclusion High prevalence of orofacial injuries was found among pregnant women victims of domestic violence examined at the Pelotas Forensic Medicine Service, with no associations found with the predictor variables analyzed.
Keywords
Domestic Violence; Violence Against Women; Pregnant People; Health Information Systems; Cross-Sectional Studies
Resumo
Objetivos Descrever a prevalência e investigar se fatores demográficos e circunstanciais estariam associados à presença de lesões orofaciais em casos de violência familiar contra mulheres gestantes periciadas no Posto Médico Legal de Pelotas.
Métodos Tratou-se de estudo transversal, desenvolvido a partir da análise dos laudos das perícias em casos de violência familiar contra gestantes entre 2015 e 2023. A presença de lesões orofaciais foi considerada a variável de desfecho, e foram coletadas variáveis preditoras relacionadas às características demográficas da vítima e do episódio violento presentes no laudo. Foram conduzidas análises descritivas e de associação bivariada considerando o nível de significância de 5%.
Resultados Foram incluídos 103 laudos neste estudo. A maioria dos laudos foi registrada entre 2016 e 2018 (61,1%). Após a perícia, 77,7% dos inquéritos foram conduzidos pela Delegacia da Mulher. Em relação à idade, 29,1% das vítimas tinham entre 19 e 25 anos. O perpetrador foi citado em 30,1% dos laudos. Lesões orofaciais foram observadas em 46,6% das vítimas, sendo o segundo tipo mais frequente após as lesões nos membros superiores (59,2%). O terço superior da face foi afetado em 62,5% dos casos, em lesões predominantemente de tecidos moles extraorais. Não foram observadas associações entre as variáveis preditoras analisadas e a presença de lesões.
Conclusão Observou-se alta prevalência de lesões orofaciais entre gestantes vítimas de violência familiar periciadas no Posto Médico Legal de Pelotas, não sendo observadas associações com as variáveis preditoras analisadas.
Palavras-chave
Violência Doméstica; Violência Contra a Mulher; Gestantes; Sistemas de Informações em Saúde; Estudos Transversais
Resumen
Objetivos Describir la prevalencia e investigar si factores demográficos y circunstanciales se asociarían con la presencia de lesiones orofaciales en casos de violencia familiar contra embarazadas examinadas en el Servicio de Medicina Legal de Pelotas.
Métodos Estudio transversal, basado en el análisis de informes periciales en casos de violencia familiar contra embarazadas entre 2015 y 2023. La presencia de lesiones orofaciales se consideró la variable de resultado, y se recopilaron variables predictoras relacionadas con las características demográficas de la víctima y el episodio violento presentes en el informe. Se realizaron análisis de asociación descriptivos y bivariados, considerando un nivel de significancia del 5%.
Resultados Se incluyeron en este estudio un total de 103 informes. La mayoría de los informes se registraron entre 2016 y 2018 (61,1%). Después de la evaluación pericial, el 77,7% de las investigaciones fueron realizadas por la Comisaría de la Mujer. En cuanto a la edad, el 29,1% de las víctimas tenían entre 19 y 25 años. El agresor fue citado en el 30,1% de los informes. Se observaron lesiones orofaciales en el 46,6% de las víctimas, siendo el segundo tipo más frecuente después de las lesiones en los miembros superiores (59,2%). El tercio superior de la cara se vio afectado en el 62,5% de los casos, con lesiones predominantemente de tejidos blandos extraorales. No se observaron asociaciones entre las variables predictoras analizadas y la presencia de lesiones.
Conclusión Se observó una alta prevalencia de lesiones orofaciales entre las mujeres embarazadas víctimas de violencia doméstica que fueron examinadas en el Servicio de Medicina Legal de Pelotas, sin observarse asociaciones con las variables predictoras analizadas.
Palabras clave
Violencia Doméstica; Violencia contra la Mujer; Personas Embarazadas; Sistemas de Información en Salud; Estudios Transversales
This research respected ethical principles, having obtained the following approval data:
Research Ethics Committee: Universidade Federal de Pelotas
Opinion number: 6,505,512
Approval date: 14/11/2023
Certificate of Submission for Ethical Appraisal: 50199621.7.0000.5318
Informed Consent Form: Exempted, the study used secondary data from services that make their medical records available for data collection and subsequent analysis.
Introduction
Violence against women is a human rights violation and a significant public health problem that affects one in three women globally and also in the Americas, in the form of physical violence, sexual violence, or both (1). Among the factors that increase vulnerability to violence, pregnancy can represent a period when violent episodes begin or escalate (2). Global prevalence of intimate partner violence during pregnancy has been estimated at 25.0% (3). In Brazil, some locations have presented high percentages: in Caxias, in the state of Maranhão, between 2019 and 2020, 24.1% of pregnant women reported psychological violence, 9.5% physical violence, and 3.0% sexual violence (4). In Cariacica, in the state of Espírito Santo, in 2017, the respective percentages were 16.1%, 7.6%, and 2.7% (5).
In addition to its high prevalence, maternal-fetal exposure to violence has repercussions on poorer mental health, physical injuries, reproductive complications, and maternal-fetal death (6,7). Regarding physical injuries, a multicenter study conducted with hospital data from California, United States, between 2016 and 2021, found that injuries to the head and abdomen were highly prevalent among pregnant women victims of intimate partner violence (8). However, that study did not address orofacial injuries (8). In data on hospital care (9) and expert witness examinations (10-13) related to women victims of domestic violence, information on oral and maxillofacial injuries is not specifically linked to the gestational period.
As such, this study aimed to describe the prevalence and investigate whether demographic and circumstantial factors are associated with the presence of orofacial injuries arising from cases of family violence against pregnant women examined at the Pelotas Forensic Medicine Service.
Methods
In this study we followed “The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement (14).
Study design and setting
This was a cross-sectional study based on digital expert witness examination reports from the Pelotas Forensic Medicine Service. This service is subordinated to the Rio Grande do Sul State General Institute of Expert Witness Examinations, responsible for expert examinations that serve to inform criminal prosecution proceedings (15).
Study participants and size
All expert witness examination reports recorded from January 2015 to December 2023 on the Pelotas Forensic Medicine Service system, referring to bodily injuries to pregnant women resulting from domestic violence, were considered eligible. In accordance with the service’s internal protocols, classification of reports as relating to this type of violence is done by a forensic physician, based on the victim’s verbal report on the existence of a family relationship with her aggressor (for example, partner, ex-partner or other family member), during her consultation with this physician.
Data source and collection and bias
The data were collected from the internal system of the Pelotas Forensic Medicine Service by a trained researcher, with subsequent review by a researcher experienced in secondary data. This double check sought to minimize information biases.
Variables and categories
The outcome variable was the presence of orofacial injuries (no, yes). The characteristics of the injuries were described based on their location in the upper third (forehead to zygoma), middle third (zygoma to upper lip) and lower third of the face (mandibular region) and based on the involvement of extra-oral soft tissues, intra-oral soft tissues, presence of bone fractures and traumatic dental injuries, all categorized dichotomously (no, yes).
The predictor variables included: the year of the report (categorized as: 2016-2018, 2019-2021, 2022-2023); the police station that requested the expert witness examination and the police station that conducted the investigation (categorized as: non-specialized police station, Police Station for Women, Police Station for Children and Adolescents); the place in which the expert witness examination requisition was made (Pelotas, other municipality); whether there was of discussion of the expert witness examination report, this being a field filled in by the forensic physician when additional examinations are necessary (no; yes, request for additional obstetric or fetal examination; yes, request for obstetric or fetal and other examination); the age of the victim (in years: 15-18, 19-25, 26-30, 31-40, 41 or over); the perpetrators being named in the report (no, yes); and the presence of injuries to the skull, neck, thorax, abdomen, upper limbs and lower limbs, all categorized dichotomously (no, yes).
Statistical analysis
The STATA 18.0 statistical package (STATA Corp., College Station, Texas, United States), was used to obtain absolute and relative frequencies and 95% confidence intervals of the variables of interest. Bivariate associations were tested using Fisher’s exact test, considering a 5% significance level.
Results
Between 2015 and 2023, 110 expert witness examination reports were recorded as cases of domestic violence against pregnant women. Of these, six cases were excluded, given that the individuals examined were male (four in 2016, one in 2017 and one in 2019), and one case was excluded due to the incompatibility of the age of the person examined with the possibility of pregnancy. This resulted in 103 (93.6%) expert witness examination reports comprising the sample of this study.
A descriptive analysis of the variables related to the records is shown (Table 1). 61.1% of the expert witness examinations were performed between 2016 and 2018. 73.8% of the victims were referred by non-specialized police stations, however the investigations were predominantly conducted by the Police Station for Women (77.7%). 29.1% of the victims were between 19 and 25 years old. The perpetrators were named in 30.1% of the reports. No associations were found between these variables and the presence of orofacial injuries (Table 1).
Absolute frequencies (n), relative frequencies (%) and 95% confidence intervals (95%CI) of the study variables and bivariate analysis with the presence of orofacial injuries. Pelotas, 2015-2023 (n=103)
Among the pregnant women examined, 46.6% presented orofacial injuries (Table 2). This was the second most frequent injury site, after the upper limbs (59.2%). The abdomen was the least affected region (6.8%). No associations were found between the presence of injuries in other body regions and orofacial regions.
Absolute frequencies (n), relative frequencies (%) and 95% confidence intervals (95%CI) of the body region in which injuries were recorded and bivariate analysis with the presence of orofacial injuries. Pelotas, 2015-2023 (n=103)
Absolute frequencies (n), relative frequencies (%) and 95% confidence intervals (95%CI) of the orofacial injury characteristics. Pelotas, 2015-2023 (n=48)
The characteristics of the reported orofacial injuries are shown in detail (Table 3). The upper third of the face was affected in 62.5% of cases, and extraoral soft tissues in 91.7% of cases. One case presented traumatic dental injury.
Discussion
This study identified high prevalence of orofacial injuries among the pregnant women victims of domestic violence examined, but no significant associations were observed with the predictor variables analyzed. Considering the demographic and circumstantial profile, most of the reports referred to young adult pregnant women, with expert witness examinations carried out between 2016 and 2018, whereby the perpetrator was not named for the most part and referrals were frequently made by non-specialized police stations, but investigations were mostly conducted by the Police Station for Women.
Expert witness examination reports are an important source of secondary data on the repercussions of physical violence, representing the category of cases of violence that are taken to court (13,15). The findings of this study provide relevant evidence about the prevalence and pattern of orofacial injuries in pregnant victims examined at a forensic medicine service in Southern Brazil. However, some limitations should be noted. Due to the characteristics of the records, ethnic-racial and socioeconomic information and unfavorable maternal-fetal health outcomes were not available for collection. Few of the records included in the study provided identification of the perpetrators, this being a result very similar to that found in a study carried out on examination reports of violence against women held at the São Luís Forensic Medicine Service in Northeast Brazil (10). In both studies, it was also not possible to directly establish the relationship between the perpetrator and the victim (10).
At the São Luís Forensic Medicine Service, it was identified that 26.0% of women victims of physical violence between 2010 and 2013 had suffered oral and maxillofacial injuries (10). In our study, prevalence of orofacial injuries among pregnant women was 46.6%. This higher prevalence rate found by us may reflect both a more recent period of data collection, 2015 to 2023, and potential particularities of physical violence against pregnant women that should be better investigated in future studies.
Higher proportions of extra-oral injuries were observed, mainly in the upper third of the face, which includes the orbital and forehead regions, which corroborates previous findings (10,11). The lower prevalence of reported intra-oral injuries and traumatic dental injuries may be a combined result of the characteristics of the data source – a Forensic Medicine Service that does not have a forensic dentistry department –, as well as the sample size of this study (12,13).
Although the descriptive pattern of the circumstances of the violent episodes recorded in the reports corroborates information already reported in the literature, such as the higher prevalence of violence against women in young adulthood (10-12), this study did not find associations with any of the predictors assessed. Potentially, the sample size of this study influenced this finding. The lack of association between orofacial injuries and those in other regions of the body may further suggest that the patterns of physical injuries in pregnant women vary, which implies the need for multidisciplinary health care to ensure adequate guidance and support (7). Most of the subsequent investigations were conducted by the Police Station for Women. This scenario reflects the importance of the specialized care network in situations of family violence through specific public policies (13).
To conclude, there was a 46.6% prevalence rate for orofacial injuries among pregnant women victims of domestic violence and examined at the Pelotas Forensic Medicine Service between 2015 and 2023. The upper third of the face and extra-oral soft tissues were the most affected. There was no association with the predictors assessed.
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Associate editor:Alberto Pereira Madeiro (https://orcid.org/0000-0002-5258-5982)
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Peer review administrator
Izabela Fulone (https://orcid.org/0000-0002-3211-6951)
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Peer reviewers
Cristiane Colonese (https://orcid.org/0000-0002-7637-8419)
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Data availability
The database and analysis codes used in this research will be provided upon request to the corresponding author.
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Use of generative artificial intelligence
Not used.
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Funding
This research was partially funded by the Coordination for the Improvement of Higher Education Personnel (funding code – 001) (LRMS) and by the Scholarship Program – Institutional Strategic Programs (Tutorial Program – PET) (HFJ). LRMS receives a Junior Postdoctoral Fellowship from the Rio Grande do Sul State Research Support Foundation, No. 23/2551-0001864-0.
References
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» https://www.who.int/publications/i/item/9789240022256 - 2 Ribeiro MRC, Pessoa BPT, Sauaia GA, Schraiber LB, Queiroz RC de S, Batista RFL, et al. Violence against women before and during gestation: differences in prevalence rates and perpetrators. Rev Bras Saude Mater Infant. 2020;20(2):491–501.
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15 Governo do Estado do Rio Grande do Sul, Secretaria de Segurança Pública, Instituto-Geral de Perícias. Departamento Médico-Legal [Internet]. 2024 [cited 2025 Apr 6]. Available from: https://igp.rs.gov.br/departamento-medico-legal.
» https://igp.rs.gov.br/departamento-medico-legal.
Edited by
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Editor-in-chief
Jorge Otávio Maia Barreto (https://orcid.org/0000-0002-7648-0472)
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Scientific editor
Wildo Navegantes de Araújo (https://orcid.org/0000-0002-6856-4094)
The database and analysis codes used in this research will be provided upon request to the corresponding author.
