Prenatal abuse is defined as the mother failing to take adequate care of her body, whether knowingly or not, consuming illicit substances or psychotropic drugs, or being physically abused by another party.1,2 This concept is still not well known, although it has been regulated by Catalonian law since 2010 with the introduction of Law 14/2010 of May 27,3 which recognises the rights of the unborn child and places an unprecedented value on the foetus.

Some cases may be difficult to detect and risk indicators may be useful, such as the lack of prenatal care, the use of illegal substances, alcohol or psychotropic drugs without a prescription, unwanted pregnancy or indifference towards the pregnancy, a history of previous children in foster care, the presence of psychiatric disorders or untreated illnesses that may lead to congenital anomalies or infection in the foetus, physical abuse of the mother, maternal involvement in criminal activity or prostitution, or maternal neglect of her own body in terms of health, nutrition and hygiene. After birth, clinical manifestations of neonatal abstinence syndrome (NAS) should be considered a red flag suggestive of potential prenatal abuse.2,4

The consequences of prenatal abuse may be dire and alter the subsequent growth and development of the child. The potential deleterious effects on the foetus of drug exposure during gestation are well known, and include changes in neural proliferation, differentiation and migration, preterm birth, low birth weight, length and head circumference and NAS (with an increased incidence in newborns exposed to opiates). Potential postnatal consequences include psychomotor retardation and behavioural disorders. Furthermore, a history of prenatal abuse is a risk factor for future child abuse.5,6

Pregnancy provides an opportunity to detect situations where there is a higher risk of prenatal abuse due to the increased contact with health care providers (midwives, obstetricians, nurses). Social workers, psychiatrists and professionals employed in substance use treatment and recovery services should assess any situation indicative of risk in pregnant women. The early detection of risk factors makes it possible to inform the mother of the potential adverse effects on the foetus, redirect the situation, or activate the established protocol for the protection of the foetus or newborn.

The aim of the study was to analyse the cases of prenatal abuse documented in Catalonia between 2011 and 2014 to identify the risk profile for prenatal abuse in the population in our catchment area and determine its social impact.

We conducted a cross-sectional descriptive study of 222 cases of prenatal abuse reported to the Dirección General de Atención a la Infancia y Adolescencia (General Directorate of Child and Adolescent Services [DGAIA]) in Catalonia between 2011 and 2014. We extracted data for the variables of interest from the electronic records of each subject held in the Childhood and Adolescence database: medical reports with clinical and laboratory data, and social services reports based on interviews with parents and other kin, as well as the outcome of social intervention. We assigned a code to each case to safeguard the confidentiality of the individuals included in the study.

We structured the variables into three categories: maternal, perinatal and social intervention.

Maternal variables: age, nationality, occupation, number of previous children, prenatal care (considered appropriate if the mother made a minimum of 5 prenatal visits; poor in case of <5 visits; and absent if no visits were made),7 wanted or unwanted pregnancy, past history of voluntary termination of pregnancy, desire to terminate current pregnancy, support from partner, support from family, gender violence during pregnancy as reported by the mother), removal of previous children, previous involvement of social services, infectious diseases (the study considered HIV, HCV and syphilis), mental disorders (grouped according to the DSM-IV),8 substance use during gestation (reported by the mother), maternal history of foster care under DGAIA as a minor, and maternal history of deprivation of liberty (incarceration or placement in juvenile correctional facility before, during or after the pregnancy).

Perinatal variables: type of delivery (normal/complicated); gestational age at birth (extremely preterm, <32 weeks; moderately preterm, 320 to 366 weeks; full term, 370 to 420 weeks; post term, >420 weeks); birth weight, length and head circumference; Apgar score at 1 and 5minutes; perinatal complications during hospital stay.

Social intervention variables: professional that detected the case, measures taken at birth (placement with mother in nuclear family, placement in kinship care, emergency placement with a foster care family or foster care facility), whether the decision for the intervention was made before or after birth, and lastly, the current placement of the child (mother, kinship care, foster/adoptive family, emergency foster care family or children's home) and time when the current custody arrangement was established.

We performed the statistical analysis with the software SPSS for Windows (version 22). We have expressed categorical variables as absolute frequencies and percentages. We compared qualitative or categorical variables by means of the chi square test or Fisher's exact test as appropriate. We analysed quantitative variables with the Mann–Whitney U test when the normality assumption was not met. We defined statistical significance as a P-value of less than 0.05.

The study was approved by the research ethics committee of the hospital.

The results of our study were consistent with the risk factors for prenatal abuse described in the literature.1,2

The mean age of the mothers (28.11 years) was low compared to the mean age of mothers in Catalonia in 2014 (31.7 years),9 with a considerable difference in the proportion aged less than 20 years (16.2% in our study compared to 2.45% in Catalonia in 2014).9 Young maternal age is a risk factor for foetal abuse, which may be due to a lack of awareness about health, greater substance use, unwanted/unplanned pregnancy or lower economic resources.10,11

The employment rate in Catalonia in women aged 16–64 years between 2011 and 2014 ranged from 54.7% to 59.7%,9 while only 24% of the women in our study were employed.

Although there is no consensus in the literature as to what constitutes appropriate prenatal care, for the purpose of this study we used the pregnancy care protocol of the Government of Catalonia as reference.7 A study conducted in Barcelona in 2013 found that 98.6% of pregnant women had at least 6 obstetrics appointments.12 The absence of care is in itself an indicator of risk and a reason to report prenatal abuse. In our study, this factor was strongly associated with the decision made at birth: babies were twice as likely to stay with the mother if the prenatal care had been adequate.

Gender violence against the pregnant mothers was 10 times as frequent as the violence experienced in the past 12 months reported by women residing in Spain in a large-scale survey conducted between September and November 201413 (20% vs 1.9%), and is considered prenatal abuse and neglect in and of itself based on Law 14/2010 of May 27.3

In Spain, the prevalence in of HIV infection in mothers of live newborns is estimated at 1.41‰ based on a study conducted in 2008,14 while the prevalence in our group was as high as 49.55‰. There was also a significantly higher prevalence of HCV infection (9%) compared to pregnant women in the general population (of around 1% based on the reviewed sources).15,16 The rate of HIV-HCV coinfection in our study was 36.36%, compared to an estimated 20–25% in the general population.17,18 This could be related to the high prevalence of substance use in our study.

The prevalence of substance use in pregnant women is typically much lower than that in the general population. Although the published data are scarce, a study conducted in the United States found that 5.4% of pregnant women used illicit drugs, compared to 11.4% of women in the same age group who were not pregnant.19 The proportion in our group was much higher. In Spain, the EDADES study of 2013 found that in the general population, the prevalence of cannabis, cocaine and heroin use was 9.2%, 2.2% and 0.1%, respectively, figures that were considerably lower than those found in our study.11

The effects of these drugs on the foetus, in terms of preterm birth and alterations in foetal growth and development, are well known and were observed in our study. The percentage of preterm birth was considerably higher than the percentage reported for Catalonia in 2014 (6.3%).9 This difference was greater in the subset of mothers that used substances and manifested as an increase in the rate of moderately preterm birth. Also consistent with the above, the percentage of low birth weight of less than 2500g was also greater compared to infants born in the same year (7.4%)9: the children of substance-using mothers had a lower birth weight, length and head circumference than the children of non-using mothers.

Heroin was the drug associated with the greatest number of foster care placements, probably due to the problems associated with heroin addiction: social and family problems, marginalisation, and lack of economic resources, among others.

The age of the minor at the time the last placement decision is made has a significant impact on former: greater age is directly correlated to social and neurobehavioural problems and hinders bonding with the family.20 In our series, nearly in half the cases where there were changes in the placement of the minor, these occurred after age 12 months.

Since a high percentage of mothers did not seek any form of prenatal care, it was neonatologists that detected most of the cases. Thus, we need to emphasise the importance of the efforts of other professionals that interact with pregnant women in detecting prenatal abuse, especially in the field of social services, as a high percentage of the pregnant women in our study had a history of social intervention.

While current law recognises the rights of the foetus and calls for the detection of prenatal abuse, in cases involving maternal substance abuse its detection may be hindered by the need to obtain consent to collect biological samples for testing, a method that is considerably more reliable than the use of questionnaires.21,22 The current protocol for prenatal care does not include performance of laboratory tests aimed at detecting maternal substance use, and only stipulates that clinicians should ask about it, so a high level of suspicion is required for its detection.

One of the limitations of this study is that we extracted the data from the reports included in the DGAIA database, some of which were based on interviews with mothers and other relatives (social services reports). Thus, the responses may be biased due to subjective perception or concealment of information on the part of interviewees. Another limitation is the large number of interrelated variables, which hinders their analysis and interpretation, as each case is highly complex; this requires an individualised and multidisciplinary approach.

In conclusion, based on the results of this study, the profile of mothers that engage in prenatal abuse in our catchment area is that of a woman aged approximately 28 years, of Spanish nationality, unemployed, who does not adhere to adequate prenatal care, does not want the pregnancy, in many cases reports being abused by her partner, with a high incidence of HIV/HCV, uses substances (cannabis, cocaine, heroin) and a personal history of social intervention. There was a significantly high proportion of history of deprivation of liberty (prison or juvenile detention centre) and substance use (heroin) among mothers who had themselves been in the custody of the DGAIA.

We ought to highlight that prenatal abuse has a considerable impact on Spanish society and that there is still little awareness of it. Its detection is essential, and its prevention even more so, as once abuse occurs, the foetus may suffer consequences in the short as well as the long term. Adequate knowledge of risk indicators alerting of potential harmful situations is essential for the purpose of activating the established inter-institutional networks and implement the intervention that is most suitable to each case.

The authors have no conflicts of interest to declare.