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(1) What were 3 of the most important points made in the chapters/presentations/videos in the past week?
(2) What controversial issues or information (include 2) challenged your assumptions or surprised you?

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Violence Against Women http://vaw.sagepub.com/ Honor Killings in the Middle East and North Africa: A Systematic Review of the Literature Andrzej Kulczycki and Sarah Windle Violence Against Women 2011 17: 1442 DOI: 10.1177/1077801211434127 The online version of this article can be found at: http://vaw.sagepub.com/content/17/11/1442 Published by: http://www.sagepublications.com Additional services and information for Violence Against Women can be found at: Email Alerts: http://vaw.sagepub.com/cgi/alerts Subscriptions: http://vaw.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://vaw.sagepub.com/content/17/11/1442.refs.html >> Version of Record - Feb 6, 2012 What is This? Downloaded from vaw.sagepub.com at SYRACUSE UNIV LIBRARY on August 10, 2013 434127 ulczycki and WindleViolence Against Women © The Author(s) 2012 VAWXXX10.1177/1077801211434127K Reprints and permission: http://www. sagepub.com/journalsPermissions.nav Article Honor Killings in the Middle East and North Africa: A Systematic Review of the Literature Violence Against Women 17(11) 1442­–1464 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801211434127 http://vaw.sagepub.com Andrzej Kulczycki1 and Sarah Windle1 Abstract A systematic review of the research literature on honor killings in the Middle East and North Africa (MENA) indicates a paucity of studies relative to the presumed magnitude of the problem. Forty articles were reviewed and critically appraised, of which only 9 contained primary data and 11 presented original secondary analyses. Despite a recent increase in published studies, persistent methodological limitations restrict the generalizability of findings. Most studies focus on legal aspects, determinants, and characteristics of victims and perpetrators.Victims are mostly young females murdered by their male kin. Unambiguous evidence of a decline in tolerance of honor killings remains elusive. Keywords honor crimes, honor killings, Middle East, North Africa, systematic review A decade ago, the United Nations Population Fund (UNPF) estimated that “perhaps as many as 5,000 women and girls” were killed each year worldwide in the name of “honor” by members of their own families (United Nations Population Fund, 2000). A more recent estimate does not exist for this woefully underreported phenomenon. Victims are often buried in unmarked graves, records of their existence may be eradicated, and perpetrators frequently go unpunished or receive token sentences. Many such murders are disguised as suicides or accidents, and no one from outside of a particular family or community will know what really happened. Rooted in social standing, cultural mores, and institutions, the concept of family honor provides a socially sanctioned justification for murder because a woman is regarded as a vessel of the family reputation. 1 University of Alabama at Birmingham, AL, USA Corresponding Author: Andrzej Kulczycki, Department of Health Care Organization and Policy, Maternal and Child Health Concentration, University of Alabama at Birmingham, 320 Ryals School of Public Health, 1665 University Blvd., Birmingham, AL 35294-0022, USA Email: andrzej@uab.edu Downloaded from vaw.sagepub.com at SYRACUSE UNIV LIBRARY on August 10, 2013 Kulczycki and Windle 1443 Honor killings are perpetrated for a range of offenses related to the perceived misuse of female sexuality, most notably marital infidelity and premarital sex. Unacceptable behaviors may also include contacting persons of different faiths, initiating a separation or divorce, being a victim of rape, and even such alleged misdemeanors as flirting, or otherwise impugning the family honor. Such murders mainly occur in the Middle East and North Africa (MENA), and parts of South Asia (United Nations [UN], 2000). The problem has recently surfaced in North America and Europe, with a spate of headline-grabbing cases concerning the murder or mutilation of immigrant or second-generation Muslim women by their close relatives in the name of family honor. This has pushed these countries to slowly recognize honor killings as a distinct crime and to question the limits of multicultural tolerance (Chesler, 2009; Korteweg & Yurdakul, 2009; Meetoo & Mirza, 2007). Such murders may be the most extreme end of a much larger problem that includes unlawful confinement, coerced marriages, forced abortions, rape, and other physical and emotional abuse. The MENA region is a geographically large area that comprises countries at different levels of socioeconomic development, but which also exhibits many commonalities in language, religion, and in their sociocultural contexts more generally. Most of these societies retain rigid gender stratification systems, with laws and customs that reinforce the subordinate position of women. Although the status of women has in many cases improved, violence against women remains a major problem (Boy & Kulczycki, 2008; Freedom House, 2005; United Nations Development Programme [UNDP], 2005). Honor killings have historically occurred in many deeply patriarchal cultures, including the Balkans1 and other parts of Mediterranean Europe (Gilmore, 1987; Peristiany, 1966). The ongoing existence of the problem in the MENA region remains shrouded in taboo, but has recently attracted more attention. International media and human rights groups have helped raise social consciousness of the issue, as has the work of a number of local human and women’s rights activists, and various publicized accounts of honor killings.2 In addition, there has been an increase in the number of published studies on the topic, as highlighted here. This systematic review presents a critical synthesis of the research literature on honor killings within the MENA region. It draws several general and methodological observations concerning this research literature, summarizes and interprets findings, and highlights gaps in knowledge and opportunities for the advancement of knowledge and interventions. In terms of substantive foci, the review is organized around the key issues of the incidence of honor killings, the characteristics of victims and perpetrators, public opinion, sociostructural causes, and possible strategies toward reducing and eliminating honor killings in the region. Method Search Strategy and Selection Criteria The literature search was conducted in mid-/late 2008 using multiple sources, so as to consider all available and eligible evidence. First, published literature was sought from six electronic bibliographic databases (PubMed, Google Scholar, CWI [Contemporary Women’s Issues], ASSIA [Applied Social Sciences Index and Abstracts], PAIS International, and Popline), as well as the online archive of the journal, Violence Against Women. Second, Downloaded from vaw.sagepub.com at SYRACUSE UNIV LIBRARY on August 10, 2013 1444 Violence Against Women 17(11) the bibliography of each article was inspected as a potential source of additional publications of interest, which were then examined further. Third, we reviewed pertinent publications and website materials from relevant international development agencies (UN, UNFPA, and the World Health Organization [WHO]), nongovernmental organizations (NGOs) and advocacy groups involved in women’s rights, reproductive rights and human rights (including Human Rights Watch, Amnesty International, the Center for Reproductive Rights, the International Women’s Health Coalition, and the International Center for Research on Women). No restrictions were imposed on publication date or language. All articles were independently assessed by both authors according to a priori criteria. Selected articles had to cover honor killings in the MENA region as their main subject, or present original data about such killings. We used a broad definition of the region, searching for “Middle East,” “North Africa,” and all 22 members of the League of Arab States as well as Israel, Iran, and Turkey. Included articles also had to be peer-reviewed or to have at least documented their sources of evidence in a verifiable manner if the study’s peer-review status was unclear. We followed up grey literature where applicable; these materials (such as conference proceedings and local NGO reports) tended to be elicited through Google Scholar. Search terms used were paired combinations of the following terms: honor, honour, or customary with killing, crime, or murder (e.g., “honor killing,” “honour killing,” “customary murder”) as well as femicide and honor/honour. Data extraction and quality assessment were carried out on studies selected for full-text appraisal. Given the heterogeneous nature of the studies identified, we could not use a single quality assessment tool, but a checklist was developed using the following criteria: (a) relevance to the systematic review, (b) validity and appropriateness of the methodology, (c) quality of evidence, (d) quality of reporting, and (e) limitations of the study. Findings Search Outcomes and Quality Appraisal Six hundred seventy-eight search results were initially examined, including those from database searches (165), organization websites (141), and the journal Violence Against Women (24). Google Scholar results were viewed until 50 articles in a row had no relevance, ending at 348 results. Most documents initially identified were excluded due to a lack of relevance. Common reasons included coverage of another region or type of violence against women, consideration of honor killings in only an incidental manner, or discussion of the notion of honor rather than honor killings. A total of 40 full-text articles met our selection criteria for inclusion; all were published in English, and none were written in languages (Arabic, Hebrew, or other) native to the region. This outcome may reflect both the operational aspects of our search tools and the controversial and incendiary nature of the social problem discussed, rendering it both difficult to study and to publish on within the region. Approximately half the articles had at least one author based in North America or Europe, with the rest written by authors from within the MENA region. Nine of the studies were set in Jordan, seven in Turkey, five in Gaza/West Bank, three in Israel and the occupied Palestinian territories, one in Israel alone, two in Egypt, two among Kurdish populations in Downloaded from vaw.sagepub.com at SYRACUSE UNIV LIBRARY on August 10, 2013 Kulczycki and Windle 1445 Iraq and Turkey, and one in Lebanon. Ten more articles referred to the Middle East in general. Four authors each had 2 articles meeting the inclusion criteria (Abdo, Kulwicki, Sev’er, and Welchman), and 2 additional authors had 3 articles included (Mojab and ShalboubKevorkian), tying 6 authors to 14 articles. No systematic review of the literature has been published, although many articles presented narrative accounts of previous studies.3 Almost all (37 of 40) articles included in the review were published since 2000, although we did not exclude earlier references. Most studies were descriptive rather than analytic. Eleven articles included an analysis of secondary data and only nine articles presented primary data on honor killings, be they statistics on incidence or characteristics, or qualitative data (Table 1). Most articles discussed notions and definitions of honor killings, the pervasive nature of the phenomenon, and some potential causes. Nearly half the articles focused primarily on either legal aspects of the crimes (6), the characteristics of victims and perpetrators (6), or both (6). We make three more methodological observations about this literature. First, in addition to the scarcity of primary data on honor killings and the difficulty of data collection, the rigor of such data is frequently problematic. Many studies have questionable validity and reliability. Data were obtained mainly from interviewed police, lawyers, government representatives, NGO workers, laypersons, and potential victims (Table 1). Other analyses reporting primary data were based on verbal autopsies, survey data, and case studies. However, data validity may have been compromised by the willingness of threatened women, victims’ families, the police, and other knowledgeable informants to share their true opinions with researchers. Data derived from case studies and small or nonrepresentative samples are also problematic because the method of sampling or case finding is not always reported, and the results may not be generalizable. Second, analyses of secondary data also have severe limitations, not always sufficiently acknowledged by the authors. A commonly adopted study design involves analyzing court and police records, mortality reports, NGO reports, and newspaper accounts for the incidence of honor killings in relation to other homicides, characteristics of victims and perpetrators, circumstances of the murder, and for how the cases were processed in court. Such studies typically lament the general inadequacy of police and court record keeping. However, honor killings also go unreported, or are misreported, and therefore may never appear in court or other records that constitute secondary data. Similarly, newspaper and other media accounts only describe reported cases, and likewise may not be representative. Third, the literature is characterized by a large amount of duplicated material, be it of data or commentary. This is particularly problematic with regard to the reporting of honor killing estimates based on poorly verified data. Such duplication of material may stem from a lack of data and of a systematic literature review. Some articles with no original data do present original ideas, but others contribute little to advancing the knowledge base and discussion. Terms and Concepts For the purposes of this review, because of its clarity and general acceptance, the term honor killing is used to refer to any homicide where the perpetrators’ motivation is given as Downloaded from vaw.sagepub.com at SYRACUSE UNIV LIBRARY on August 10, 2013 1446 Violence Against Women 17(11) Table 1. Articles Containing Primary Data on Honor Killings in MENA Countries Reference Al-Adili, Shaheen, Bergstro, and Johansson (2008) Araji and Carlson (2001) Begikhani (2005) Glazer and Ras (1994) Kardam (2007) Nanes (2003) Population characteristics Method and year of data collection Verbal autopsy; West Bank, 2000-2001 Palestine; single women of reproductive age Jordan; students at two universities Survey of perceptions of the seriousness of family violence; 1998 Interviews; 2004 Iraqi Kurdistan; judges, politicians, lawyers, police officers, women activists, survivors, and witnesses Case study of Israel; Israeli gossip; no year Arab Muslim women, Masdar given El-Nabea village Interviews; 2005 Turkey; NGOs, professionals and laypersons in four cities (Istanbul, Şanlıurfa, Adana, and Batman) Jordan; executive Case study, interviews committee and personal members of communications; the Campaign 2000-2001 to Eliminate So-called Crimes of Honor Sample size 154 625 52 NA 195 (18 group interviews, with total sample ~250) NA Key findings Seven honor-related deaths (4 homicides and 3 suicides) suspected (5% of all single female deaths), with other suspicious homicides, suicides, and unintentional injuries 13% of males and 11% of females reported personal exposure (not defined) to an honorrelated female homicide Few honor killings prosecuted, with considerable judicial discretion for leniency and judgments of local councils preferred. Religious leaders and judiciary view reform attempts as motivated by Western values and as an opening for immoral behavior Women’s gossip may instigate honor killings, renders lower status women more vulnerable to its effects, and maintains women’s subordinate position Perceptions of honor vary by age, background, residence, education, and social relationships. Most interviewees had witnessed an honor killing or could relate a story; not all dishonorable conduct results in murder, with key determinants being marital status and nature of the behavior; few had ideas on how to reduce honor killings, and many expressed hopelessness Experience of campaign members suggests the difficulties and possibilities for autonomous civil society in Jordan (continued) Downloaded from vaw.sagepub.com at SYRACUSE UNIV LIBRARY on August 10, 2013 1447 Kulczycki and Windle Table 1. (continued) Reference Population characteristics Method and year of data collection Sample size Key findings Interviews; 2003 Peratis (2004) Jordan; females in protective custody at a facility in Amman Interviews; no West Bank and Shalhoubyear given Gaza, Palestine; Kevorkian victims, (2005) therapists, doctors, and legal personnel   4 Structured Sheeley (2007) Jordan; adults interviews; from urban 2005-2006 areas (Amman, Zarqa, and Irbid) and some smaller localities 200 Women may be detained against their will for protection from honor killing; release only possible if family guarantees safety Criminal justice personnel collaborate with local leaders to reach a resolution; legal personnel use forced virginity testing regularly to preserve family unity; courts view victims as not free of guilt 28% personally knew an honor killing victim; 4% reported an honor killing in their extended family; 1% reported an honor killing in their immediate family; 95% disagreed/strongly disagreed with the statement that “honor killings are morally just” — Note: NA indicates not applicable honor, that is, for reasons of suspected or known culturally defined sexual impropriety. The term honor crime is used to refer to the infringement of a broader variety of personal liberties for stated reasons of honor, such as forced marriage, expulsion from place of residence and community, rejection by the family, disfiguration and other emotional, social, or physically coercive acts (Begikhani, 2005; Faqir, 2001; Kardam, 2007; Peratis, 2004; Sen, 2005; Sirman, 2004; Welchman & Hossain, 2005). However, many authors use the terms honor killing, honor crime, honor murder, and honor-based crime interchangeably, to refer to an intrafamilial murder or attempted murder of a female by a male relative for reasons of honor. Nevertheless, pervasive discomfort with these terms is evident from the number of authors who use quotation marks when using them (Abdo, 2004; Begikhani, 2005; Centre for Egyptian Women’s Legal Assistance [CEWLA], 2005; Connors, 2005; Hassan & Welchman, 2005; Hoyek, Sidawi, & Mrad, 2005; Khan, 2006; Peratis, 2004; Sheeley, 2007; Touma-Sliman, 2005; Welchman & Hossain, 2005). Most authors characterize honor killings as communal in nature, resulting from a family council decision and plan to restore honor (An-Na’im, 2005; Arin, 2001; Cinthio & Ericsson, 2006; Sev’er, 2005; Sev’er & Yurdakul, 2001; Warrick, 2005). In Turkey, this quality is emphasized further in the case of torë (custom) killings, which many urban residents view as pertaining to disputes such as family blood feuds, distinct from honor Downloaded from vaw.sagepub.com at SYRACUSE UNIV LIBRARY on August 10, 2013 1448 Violence Against Women 17(11) killings, which they perceive more as individual actions committed when family members are confronted with behavior they neither expect nor approve of. However, most other Turks do not differentiate between the two, considering the basic motives to be the same because both types of murder are committed with the justification of honor (Kardam, 2007; Sirman, 2004). Several authors also refer separately to crimes of passion that occur in the context of a private relationship between a man and a woman and as a result of passionate anger. This would exclude honor crimes committed by a male blood relation in the context of a familial and/or communal decision (Abu-Odeh, 1996; Khan, 2006). Likewise, some courts distinguish between crimes committed “in the heat of passion” and crimes “in defense of the family honor;” the latter is socially understood and justified as the loss of both conjugal and family honor caused by the woman (Khan, 2006; Warrick, 2005). However, many studies reviewed here treat crimes of passion and crimes of honor as equally motivated by the systemic subjugation of women by men (CEWLA, 2005; Khafagy, 2005; Hadidi, Kulwicki, & Jahshan, 2001; Hoyek et al., 2005; Shalhoub-Kevorkian, 2002; Welchman & Hossain, 2005). Frequently, lack of information about the circumstances surrounding the murder and the inability to draw firm conclusions about the motive of the perpetrator make it impossible to be certain about the degree of similarity or dissimilarity between crimes of honor and crimes of passion. Most articles ascribe the existence and perpetuation of honor killings to the control of female sexuality, of women in general, and of resources within the family. Honor for men rests on socioeconomic status within the community, and on the closely policed honor of their female blood relations. Honor for women is based on unquestionable sexual propriety, namely sexual activity only within marriage. Family honor is further rooted in economic and legal systems that emphasize material wealth remaining in the family, underscoring the importance for men of ensuring the paternity of their wives’ children. Consequently, families consider women their property, and women may themselves become involved in policing the behavior of related females, as the consequences of dishonor affect the entire family. A family may attempt to keep the community unaware of an act that violated the honor code; however, discussion and gossip about any honor misconduct bring shame to the family, which may kill to regain social status. Incidence Both the quantity and quality of data on the incidence of honor killings are very limited, owing to the lack of accurate case identification. This is mostly due to underreporting and misreporting of such deaths to authorities, including their disguise as disappearances, accidents, or suicides that may often have resulted from the victim being forced into such a position (Al-Adili, Shaheen, Bergstro, & Johansson, 2008; Begikhani, 2005; Faqir, 2001; Hassan & Welchman, 2005; Hoyek et al., 2005; Kardam, 2007; Khan, 2006; Kressel et al., 1981; Mojab, 2004; Peratis, 2004; Sev’er, 2005; Warrick, 2005). Honor killings are rarely used as an explicit classification category, and homicide cases may not contain sufficient information to determine motive (Begikhani, 2005; Hoyek et al., 2005; Shalhoub-Kevorkian, 2001). Consequently, there are major difficulties in using police, court, and medical records Downloaded from vaw.sagepub.com at SYRACUSE UNIV LIBRARY on August 10, 2013 Kulczycki and Windle 1449 to estimate honor killings. Persons with knowledge of killing may not want to discuss an issue deemed private and sensitive and may fear reprisals (Peratis, 2004). Many articles cited estimates of honor killings that were difficult to trace and often appeared uncorroborated. Only five articles presented estimates based on primary data or original secondary analysis, with four pertaining to the occupied Palestinian territories and Israel. Reported deaths among women of childbearing age in the West Bank, 2000-2001, were examined by Al-Adili et al. (2008) through interviews with the families (n = 154) of unmarried women (Table 1). The authors concluded that at least seven deaths of single women (four suspected homicides and three alleged suicides) and two confirmed homicides of married women were honor related, accounting for 5% of reported single female deaths and 80% of women victimized during pregnancy have also experienced violence prior to pregnancy.6 Other research has shown a significant increase in sexual coercion and psychological abuse during pregnancy among women who experience prior physical violence.7 Physical and sexual violence during pregnancy increases women’s risk of psychological and physical health outcomes, including pregnancy complications and adverse birth outcomes. This unique type of violence threatens both maternal and child health because it is often chronic and ongoing during and after the pregnancy. IPV affects the mortality and morbidity of both infant and mother and is associated with other health and economic risk factors.8 For example, IPV during pregnancy is associated with perinatal health consequences, including low weight gain, anemia, kidney infections, and first and second trimester bleeding.9,10 Reproductive health problems, such as sexually transmitted diseases (STD) including HIV infection, are also more common among pregnant women who experience coercively controlling, severe physical violence,11 perhaps related to the fact that nearly 40%–50% of women in these relationships are forced to have sex.12 Adverse pregnancy outcomes associated with IPV include low birth weight, preterm birth,5 increased risk of cesarean delivery,9 uterine rupture, hemorrhage,13 and antenatal hospitalization.14 IPV during pregnancy is also linked to intermediary risks for women, including unintended 1 Syracuse University, Syracuse, New York. State University of New York Upstate Medical University, Syracuse, New York. 3 Centers for Disease Control and Prevention, Atlanta, Georgia. 4 Royal College of Physicians, National Clinical Guideline Centre, London, England. 2 1501 1502 pregnancy, depression and other psychological problems,14,15 and increased risk of femicide13,16 and neonatal death.13,17 Placental abruption, the premature separation of the placenta from the uterus during pregnancy, is a significant contributor to both maternal and fetal mortality and accounts for approximately 12% of all perinatal deaths.18 Placental abruption has been discussed as a potential consequence of IPV19; however, empirical evidence linking the two is sparse. Common risk factors for placental abruption include advanced maternal age, hypertension, trauma, and maternal substance use. Some of these risk factors are also either directly or indirectly associated with IPV. For example, violence and assault (e.g., blunt force to the abdomen) by a partner is the second leading cause of pregnancy trauma and represents 22% of all pregnancy trauma cases.20 IPV victims also report higher tobacco, alcohol, and illicit drug use,10,14 which may stem from increased levels of stress and fear associated with victimization.9 El Kady et al.13 reported a significant link between IPV and placental abruption among nearly 5 million women identified through maternal discharge records in California between 1990 and 1999. To date, however, no study has empirically linked IPV to placental abruption after statistically controlling for other known biological risk factors for placental abruption. The current study examines factors associated with reporting IPV during prenatal care and the extent to which IPV and other risk factors (i.e., tobacco, alcohol, and drug use; preeclampsia; and gestational diabetes) are associated with pregnancy trauma and placental abruption. Materials and Methods Study design and sample The database for these analyses was developed for the evaluation of the Syracuse Healthy Start (SHS) program. SHS is an infant mortality reduction initiative funded by the Health Resources and Services Administration (HRSA), and the SHS evaluation was funded by the Centers for Disease Control and Prevention (CDC). IRB approval was obtained from State University of New York (SUNY) Upstate Medical University. Current analyses used all births at a large urban hospital of residents in a 9-ZIP code high-risk area in the City of Syracuse, New York, from January 1, 2000, to March 31, 2002. Prenatal and hospital obstetrical charts were reviewed, and a data abstraction form was generated for each mother and infant. Prenatal charts were reviewed in outpatient settings, including publicly funded clinics, high-risk referral clinics, and private offices. If a private provider did not grant access to that office’s prenatal charts, the review was performed on the prenatal summary transmitted to the hospital for delivery (30% of prenatal charts). The documentation of prenatal screening was comparable across different settings because all clinical sites use the same prenatal record form. This form was developed by one of the co-authors on this article (R.H.A.) and sent to the birth hospitals before the birth for inclusion in the hospital delivery chart. Items abstracted from the prenatal chart included screening tests performed, symptoms, conditions, treatments, pregnancy complications, and risk factors for prematurity. Inpatient charts were reviewed at the delivery hospital, and items abstracted included symptoms, conditions, and treatments during the delivery hospitalization, and perinatal, postnatal, and postpartum outcomes. LEONE ET AL. Chart reviewers, blind to the purpose of the review, were recruited from among the major delivery hospital’s obstetrical nursing and paraprofessional clinical staff and attended two 3-hour training sessions. The first 10 charts a reviewer abstracted were rereviewed by one of the co-authors (K.D.M.), and 5% of all charts were rereviewed by the same co-author (K.D.M.). Prenatal chart reviewers were blind to birth outcomes, and inpatient chart reviewers were blind to prenatal conditions. All charts were abstracted onto a scannable form (Cardiff Teleform, Plymouth, MI) to facilitate data entry. Data from the chart reviews were merged with existing electronic databases: the Electronic Birth Certificate, the Regional Perinatal Data System, SHS enrollment, and the neonatal intensive care (NICU module). In addition to the quantitative data described, the data abstraction form included three open comment sections that allowed chart reviewers (i.e., nurses) to write in anecdotal information. These anecdotes are rich with information but were not recorded on each chart in a uniform manner. Many of these anecdotes record details about IPV. The total sample included 2873 women for whom IPV data were available. Data about placental abruption were available for all of the 2873 women, and data about pregnancy trauma were available for 2860 of these women. Independent variables Sociodemographic characteristics. The current study included seven patient sociodemographic characteristics. These variables were collected in patient medical charts as part of the standard medical procedure. Maternal race, highest education level, and marital status were coded as categorical variables; maternal employment was measured as a dichotomous (Yes/No) variable; maternal socioeconomic status (SES) was measured as a dichotomous (Yes/No) variable based on whether or not the patient received Medicaid (indicating lower income); and maternal age was measured as a continuous variable in years for descriptive purposes and as a dichotomous variable based on a median split (
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