Domestic violence risk during and after pregnancy - Wiley Online Library

BJOG: an International Journal of Obstetrics and Gynaecology August 2005, Vol. 112, pp. 1083– 1089

DOI: 10 .1111/ j.1 471-0528.2 005.006 53.x

Domestic violence risk during and after pregnancy: findings from a British longitudinal study Erica Bowen, Jon Heron, Andrea Waylen, Dieter Wolke and the ALSPAC study team Objective The objectives of this study were to examine the rates of domestic violence reported during and after pregnancy and to assess the importance of family adversity. Design Prospective longitudinal cohort study. Setting Bristol Avon, Southwest England. Population Seven thousand five hundred and ninety-one pregnant women with due dates between 1.4.91 and 31.12.92. Methods Questionnaires administered at 18 weeks of gestation and 8 weeks, 8 months, 21 months and 33 months postpartum. Main outcome measures The experience of emotional or physical cruelty by an intimate partner at each time point. Results Fewer women reported domestic violence victimisation during pregnancy than they did postpartum (18 weeks of gestation: 1% physical cruelty, 4.8% emotional cruelty, 5.1% any victimisation; 33 months postpartum: 2.9% physical, 10.8% emotional, 11% any victimisation). Women who reported being victimised during pregnancy also reported significantly higher levels of social adversity during pregnancy. The number of social adversities reported during pregnancy also predicted postpartum victimisation. Women who reported only one adversity during pregnancy were 2.73 (95% CI, 2.16 –3.45) times more likely to report physical victimisation at 33 months postpartum. Women who reported 5 adversities during pregnancy were 14.69 (95% CI, 7.35– 29.37) times more likely to report such victimisation at 33 months postpartum. For emotional cruelty, women who reported only one adversity during pregnancy were 2.10 (95% CI 1.80 –2.46) times more likely to report emotional victimisation at 33 months postpartum and 6.10 (95% CI 3.51– 10.59) times more likely to report such victimisation when five or more adversities were present during pregnancy. Conclusions Levels of social adversity reported in pregnancy are important predictors of concurrent and future victimisation. Screening for social adversity factors could help identify women at high risk for future domestic violence. INTRODUCTION Domestic violence is defined as a continuum of behaviour ranging from emotional and verbal abuse through threats and intimidation to actual physical and sexual assault.1 It affects one in three women in their lifetime and up to one in nine annually.2 Domestic violence can have long term health consequences for victims including psychiatric illness such as depression, anxiety, post-traumatic stress disorder and varying degrees of sexual and physical trauma and injury.1,3,4 As a result domestic violence is widely acknowledged as one of the most important public health issues facing societies across the world5,6 and the

Unit of Perinatal and Pediatric Epidemiology, University of Bristol, ALSPAC, Bristol, UK Correspondence: Dr E. Bowen, ALSPAC, University of Bristol, 24 Tyndall Avenue, Bristol BS8 1 TQ, UK. D RCOG 2005 BJOG: an International Journal of Obstetrics and Gynaecology

Department of Health has recommended routine screening of women by health professionals to identify cases of domestic violence.1,7 Women in their prime child bearing age are at highest risk of domestic violence victimisation8,9 and pregnancy represents an ideal opportunity for screening as women are more likely to present for obstetric care than any other health service over the course of their lives.1,10 However, there remains significant controversy from empirical research whether pregnancy itself is actually a high risk period for domestic violence and therefore the optimum time for screening. The only consistent finding of this research is that the majority of women who report victimisation during pregnancy have been victimised prior to pregnancy.11 – 14 Aside from attempting to determine whether pregnancy is itself a risk factor for domestic violence, research has also focussed on identifying other potential risk markers. It has been consistently found that pregnant women who report victimisation are typically characterised by low www.blackwellpublishing.com/bjog

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Table 1. Demographic comparisons and m2 analysis. Longitudinal sample (%)

Partial sample (%)

m2

Tenure Mortgage/owned Council owned Other/rented

N ¼ 7503 82.7 8.6 8.7

N ¼ 4378 60.2 22.3 17.5

819.3*

Marital status Married Not married Other

N ¼ 7524 81.8 13.1 5.1

N ¼ 5401 65.3 27.4 7.3

479.7*

Education Less than 0 level 0 level More than 0 level

N ¼ 7486 23.2 36.1 40.7

N ¼ 4776 40.7 32.2 27.1

460.8*

Age at childbirth Teen 20 – 24 years >25 years

N ¼ 7591 1.8 13.5 84.6

N ¼ 6208 8.2 26.4 65.4

751.4*

Variable

from mid-pregnancy until 33 months postpartum. The research question addressed in this study is as follows: Does cumulative family adversity experienced during pregnancy predict domestic violence victimisation both during pregnancy and throughout the 33-month postpartum period? Selective dropout will be examined prior to exploring the association between domestic violence victimisation and multiple social adversities to establish generalisability of findings.

METHODS

Parity 0 1 At least 2

N ¼ 7541 44.8 36.1 19.1

N ¼ 5236 43.8 32.7 23.6

41.0*

Intentional pregnancy Yes

N ¼ 7565 74.9

N ¼ 5336 61.1

277.9*

* P < 0.001.

socio-economic status,4,15 – 17 are young,9,16,18 single,4,16 poorly educated,4,17 having unhealthy lifestyles,15,19 low levels of social support18 and high levels of stress.13 In other words, pregnant women at risk of domestic violence victimisation share characteristics with women who are generally at risk of domestic violence.20 It is surprising that no study has examined the impact of multiple risks or family adversities.21 It has been suggested that in particular the cumulative effect of multiple stressors can affect parental perceptions of newborns, attitudes towards parenting and levels of marital discord,3 and it has been reported that the risk of child abuse increases with the increase in stressors present.22 The present study examines the consistency of domestic violence victimisation reported by a large population of the same women at five time points over three years, ranging

The Avon Longitudinal Study of Parents and Children (ALSPAC) is a large study following a cohort of mothers resident in Avon while pregnant23 and their live offspring; 14,541 mothers with expected dates of delivery between 1.4.91 and 31.12.92 agreed to participate in the study, representing 85 –90% of the eligible population. In total, of those mothers who initially agreed to participate, 13,799 (95%) had children that were alive at 12 months. The target sample in the present study were women who had complete data at all five time points in the present study amounting to 7591/13799 (i.e. 55% of the eligible cohort). Questionnaires were sent to mothers at 18 weeks of gestation, 8 weeks, 8 months, 21 months and 33 months postpartum. Mothers were encouraged to complete the questionnaires by themselves. Included in the pack of questionnaires was a life events inventory with items taken from inventories developed by Barnett et al.24 The items used for the domestic violence analysis were those completed by the mother and included ‘your partner was emotionally cruel to you’ and ‘your partner was physically cruel to you’ since completing the previous questionnaire. In each instance a dichotomous variable (yes/no) was derived. In order to examine the impact of multiple family risk factors on domestic violence during and after pregnancy a Family Adversity Index (FAI25; documentation available on request from the authors) was used. The FAI consists of 18 items taken from questionnaires that were administered throughout pregnancy (8, 12, 18 and 32 weeks of gestation). Each item was scored as 1 if an adversity was present and 0 if not. The item scores are totalled to yield a total FAI score. The family-based risk factors considered in the

Table 2. Relative frequency of women at each data collection period reporting physical or emotional cruelty from a partner. Values are presented as n (%). Pregnancy

Physical Emotional Any

Postpartum

18 weeks

2 months

8 months

21 months

33 months

78 (1.0) 367 (4.8) 390 (5.1)

91 (1.2) 372 (4.9) 397 (5.2)

136 (1.8) 556 (7.3) 585 (7.7)

161 (2.1) 643 (8.5) 666 (8.8)

218 (2.9) 818 (10.8) 835 (11.0)

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Table 3. The number and percentage of women who change victim status at each assessment and resulting Cochran’s Q. Values are presented as n (%).

Physical Emotional

18 weeks – 2 months

2 – 8 months

8 – 21 months

21 – 33 months

Q (4)

119 (1.57) 405 (5.33)

157 (2.07) 499 (6.57)

205 (2.70) 645 (8.50)

245 (3.23) 722 (11.49)

120.91* 427.36*

* P < 0.001.

FAI are the following (the number of items per factor are presented in brackets leading to a total of 18 items): . .

. . .

.

. . . .

Age of mother (1): younger than 20 years old at first pregnancy/child birth Housing (3): (a) inadequacy: crowding index/periods of homelessness; (b) basic living: no availability of hot water or no indoor toilet, bath or shower or no kitchen; (c) major defects/infestation No educational qualifications (1) (mother or father) Financial status (1): (a) financial difficulties Partner relationship (4): (a) single status, (b) low affection and aggression, (c) physical/emotional cruelty, (d) no social support Family (2): (a) family size (>4 children), (b) major caregiving problems (child in care/not with natural mother, or on social services at risk register) Social network (2): (a) no emotional support, (b) no practical/financial support Maternal affective disorder (depression, anxiety or suicide attempts) Substance abuse (1): (a) drugs or alcohol (use of hard drugs, alcoholism, high alcohol consumption) Crime (2): (a) in trouble with police or (b) actual convictions

As each individual item is assigned a value of 1 if an adversity is present and 0 if it is not present there is no a priori weighting as in risk scoring systems, rather the index is self-weighing.26 For example, lack of a partner in the individual case may be associated for one single mother with other adversities such as poor financial status, poor housing and depression, while for another mother recently divorced there may be few financial worries or no poor housing (i.e. no other adversities). However, only items should be included that are, on average, associated with other adversities, and this has been shown for this index. For the purpose of the current analysis the two items reflecting any partner aggression and cruelty (shown in italics) were removed from the FAI. This study received ethical approval from the Ethical Boards of the Bristol and Weston Health Authority, Southmead Health Authority and Frenchay Health Authority. In order to examine potential sample bias the longitudinal sample and partial sample were compared on a range of demographic and socio-economic variables using m2 analysis, and the mean FAI score of the two groups was compared using a Mann –Whitney U test.

In order to identify whether the reporting of domestic violence victimisation was stable throughout the gestation and postpartum periods Cochran’s Q analysis was employed. Cochran’s Q test is the multiple time point equivalent of McNemar’s test, which looks at the number of changes in each direction (i.e. those who move from saying yes to no and no to yes). The statistic can be calculated by summing over subjects the number of changes that each subject makes and then dividing by N(T 1) where T ¼ time points and N ¼ the number of subjects.33 The association between experiencing domestic violence victimisation and FAI scores was initially identified through Kruskal –Wallis comparisons. Further m2 comparisons between women reporting each form of victimisation were conducted for each of the FAI items. Finally, the dependent variables of physical and emotional domestic violence victimisation at each assessment point were predicted from the number of adversities present during pregnancy in a series of univariable logistic regressions. In each model five categories of family adversity were derived (FAI score of 1, 2, 3, 4 and 5) and was used as a sixlevel factor with ‘no adversity’ as the reference category.

RESULTS The women in the longitudinal sample and those with only partial data (dropouts) were compared using m2 analysis on a range of demographic and socio-economic variables available for most dropouts. These included housing tenure, marital status, education level, age at birth of child, parity and whether the recent pregnancy was intentional. Table 1 shows that the women who participated at all five data collection points (longitudinal participants) differed from the women who did not participate consistently. Those women who participated consistently were more

Table 4. Mean FAI scores of mothers reporting each form of domestic violence victimisation and Kruskal – Wallis comparisons.

18 weeks antenatal 8 weeks postpartum 8 months postpartum 21 months postpartum 33 months postpartum

None

Emotional

Physical

Both

m2 (3)

1.01 0.99 0.96 0.95 0.91

2.54 2.37 2.03 1.79 1.61

2.69 1.98 2.12 1.98 1.58

3.34 3.37 2.91 2.46 2.20

679.3* 621.5* 630.4* 454.5* 400.0*

* P < 0.001.


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Table 5. Percentages of women in each victimisation category reporting each form of family adversity during pregnancy and resulting m2. FAI item Early parenthood Inadequate housing Basic amenities in the home Housing defects Low education Financial difficulties No regular partner Family size (>4 children) Major family problems Maternal affective disorder Substance abuse Crime trouble with police Crime convictions No partner support No social emotional support No social practical support

None

Emotional

Physical

Both

m2

6.7 5.8 2.9

15.0 14.8 4.2

22.2 25.0 1.5

23.8 23.0 1.7

127.9* 168.7* 4.27 (NS)

11.0 12.9 8.5 1.4 1.1

16.3 22.8 22.4 9.5 2.0

11.9 23.4 23.8 4.6 6.0

20.8 29.0 32.4 16.8 2.5

25.3* 67.8* 190.5* 318.6* 17.2*

1.7

3.3

6.3

2.8

13.7*

23.6

56.8

54.2

66.7

455.3*

4.7 2.1

16.2 10.6

9.7 22.2

17.5 26.2

176.6* 475.5*

0.2 10.4 4.5

0.7 42.0 15.8

2.9 33.9 22.2

2.4 49.5 23.8

46.8* 582.8* 232.7*

6.6

14.3

14.3

22.9

88.8*

* P < 0.001.

likely to live in houses that they owned or were mortgaged. In addition, they were more likely to be married, to be educated to above O-level, to have been at least 25 years old at the birth of their first child, had fewer children and were more likely to have planned the most recent pregnancy than women who participated inconsistently in the study. In addition to these individual variables, it was found that on average women who participated consistently in the study reported significantly lower levels of family adversity than did women who participated inconsistently in the study (longitudinal sample: M ¼ 0.94, SD ¼ 1.27; partial sample: M ¼ 1.43, SD ¼ 1.54; U ¼ 16714793.0, P < 0.001). In sum, women who participated consistently reported lower levels of social adversity. In order to examine the consistency in the proportion of women reporting emotional and physical cruelty at

18 weeks of gestation, 8 weeks, 8 months, 21 months and 33 months Cochran’s Q was calculated. The prevalence of emotional and physical victimisation across the observation period is presented in Table 2. Table 2 shows that the proportion of women reporting physical or emotional cruelty from an intimate partner is not constant over time. Fewer women reported victimisation during pregnancy and at two months postpartum than they did from 8 months to 33 months postpartum and there was an increase in the number of victims across the five assessment points. Cochran’s Q statistics are calculated on the number of cases that change category from ‘victim’ to ‘non-victim’ or ‘non-victim’ to ‘victim’. The numbers of mothers whose victim status changed between each assessment and the resulting Cochran’s Q are presented in Table 3. Table 3 shows that for both emotional and physical cruelty victimisation, the number of mothers whose status changes increases over time. In combination with the significant Cochran’s Q statistic, these data indicate that pregnancy is not a sensitive period for domestic violence victimisation compared with post pregnancy within this sample of women. Next it was determined whether multiple family adversities are associated with and predictive of domestic violence victimisation during pregnancy. Inspection of the distribution of the FAI scores found that half (50.6%) of the sample reports no family adversity at all. In the remaining half, the majority reports either one (29.2% of total sample) or two (11.9% of total sample) adversities. None of the sample reports more than six adversities. Due to the positive skew of the data, Kruskal – Wallis non-parametric analysis for repeated measures was conducted to examine the association between family adversity and victimisation. Table 4 shows that at each time point there was a significant association between the forms of domestic violence victimisation reported and average FAI scores. Mothers who reported both forms of victimisation had the highest FAI scores during pregnancy. In order to identify which forms of adversity were most strongly discriminated between the forms of victimisation, item by item analysis was carried out. Table 5 shows that all of the FAI variables except having just basic amenities within the home were significantly

Table 6. Odds ratios and (95% CIs) of reporting physical cruelty at each data collection point in relation to the number of family adversities reported in pregnancy. Number of adversities Assessment period 18 weeks a.n. 8 weeks pp 8 months pp 21 months pp 33 months pp

1 3.23 2.68 1.77 3.65 2.73

2

(1.95 – 5.35) (1.67 – 4.32) (1.19 – 2.62) (2.54 – 5.25) (2.02 – 3.71)

7.09 6.65 5.07 5.75 4.27

(4.25 – 11.82) (4.14 – 10.68) (3.46 – 7.41) (3.86 – 8.57) (3.03 – 6.03)

3 14.42 9.52 9.67 9.41 6.96

(8.58 – 24.23) (5.62 – 16.10) (6.47 – 14.45) (6.07 – 14.58) (4.74 – 10.22)

4 27.82 23.29 14.18 17.74 8.31

(16.00 – 48.35) (13.58 – 39.95) (8.81 – 22.85) (10.97 – 28.69) (4.99 – 13.86)

5þ 44.37 47.74 16.11 16.67 14.69

(23.21 – 84.83) (25.86 – 88.11) (8.45 – 30.73) (8.06 – 34.47) (7.35 – 29.37)

a.n. ¼ gestation; pp ¼ postpartum. All odds ratios were significant (P < 0.001).


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Table 7. Odds ratios and (95% CIs) of reporting emotional cruelty at each data collection point in relation to the number of family adversities reported in pregnancy. Number of adversities Assessment period 18 weeks a.n. 8 weeks pp 8 months pp 21 months pp 33 months pp

1 2.73 2.43 2.61 2.08 2.10

(2.16 – 3.45) (1.93 – 3.06) (2.17 – 3.14) (1.75 – 2.48) (1.80 – 2.46)

2 5.79 5.90 4.56 3.42 3.05

(4.53 – 7.39) (4.66 – 7.46) (3.71 – 5.60) (2.80 – 4.18) (2.52 – 3.69)

3 9.09 8.21 7.40 4.95 4.50

(6.94 – 11.90) (6.25 – 10.78) (5.84 – 9.38) (3.88 – 6.32) (3.57 – 5.69)

4 15.91 14.75 8.57 5.81 4.96

(11.59 – 21.83) (10.66 – 20.40) (6.23 – 11.79) (4.20 – 8.04) (3.53 – 6.96)

5þ 27.50 22.69 12.18 8.76 6.10

(18.10 – 41.80) (14.68 – 35.08) (7.83 – 18.95) (5.36 – 14.32) (3.51 – 10.59)

a.n. ¼ gestation; pp ¼ postpartum. All odds ratios were significant (P < 0.001).

associated with victimisation category. Those adversities most strongly associated include a lack of partner support, having been in trouble with the police, maternal affective disorder, no regular partner (check in the table) and reporting a poor social network offering limited emotional support. In most cases women who reported both emotional and physical cruelty were more likely than women who reported either emotional or physical cruelty to report each adversity. However, there are a few notable exceptions. For example, women who reported only physical cruelty were most likely to live in inadequate housing, have large families, major family problems and previous convictions than women who reported experiencing either emotional cruelty or both forms of cruelty. To investigate whether there is an increasing impact of multiple adversity on inter partner cruelty, a series of logistic regression analyses were conducted. The results of these analyses are presented in Table 6 for physical and Table 7 for emotional cruelty separately. At each time point the odds of physical cruelty are higher than the odds of emotional cruelty for each incremental increase in adversity. The only exception to this is at eight months postpartum where reporting only one adversity is associated with greater odds of emotional rather than physical cruelty victimisation. Women who report only one adversity during pregnancy are almost twice as likely to report either emotional or physical abuse at any period. In addition, as the number of adversities increases so too do the odds of reporting either emotional or physical cruelty across time. As might be expected, the number of adversities reported during pregnancy is most strongly associated with reports of cruelty during pregnancy; however, there is also a longitudinal impact of adversity during pregnancy. For example, women who report two adversities during pregnancy are three times more likely to report emotional cruelty and over four times more likely to report physical cruelty when the child is 33 months old compared with women who had no adversity. Moreover, women who report at least five adversities during pregnancy are six times more likely to report emotional cruelty and nearly 15 times more likely to report physical cruelty when the child is 33 months old.

This pattern of results was maintained after controlling for adversity levels during the two years postpartum (data not presented).

DISCUSSION This is the first British longitudinal study to examine the prevalence of domestic violence during and after pregnancy and associated risk factors. The results suggest that, as in previous research that has used national samples,9,27 pregnancy itself represents a period of comparatively low risk for domestic violence. Rather, pregnancy and the early postpartum period appear to be protective against domestic violence. However, the lack of data concerning domestic violence victimisation prior to pregnancy is problematic. It is possible that victimisation prior to pregnancy was even lower than that reported during pregnancy and that in pregnancy women were victimised at a substantially higher rate. However, this is pure supposition. In accordance with previous studies that did not employ face to face or telephone interviews, the prevalence of physical domestic violence reported during pregnancy was low. Indeed, only 1% of women reported physical cruelty during pregnancy in contrast to nearly three percent three years later. Similarly the rate of emotional cruelty reported is lowest during pregnancy and rises steadily over time; however, the rates of emotional cruelty reported are more in line with those reported in previous studies.28 In contrast to the two previous small sample hospital-based studies conducted in the UK,29,30 the data presented here suggest that the prevalence of domestic violence during pregnancy is between a third and one half of that previously identified. However, the strength of longitudinal studies does not lie in estimating prevalence. Selective dropout or attrition is one of the major limitations of longitudinal research designs when used for estimating prevalence, not least because often the variables of interest are those variables that contribute to dropout (e.g. mental or physical health).32 Wolke et al.31 showed those at highest risk are most likely to drop out leading to under-estimations of prevalence in


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longitudinal samples. In our study participants had lower social adversity than dropouts. Considering that in the present longitudinal sample, women with more social adversity more often experienced cruelty, it is plausible that the women who did not participate consistently would have reported higher levels of victimisation than were reported in the longitudinal sample. Thus, the reported prevalence is likely to be an under-estimation. However, this does not affect the validity of the finding of lower rates in pregnancy compared with later postnatal time points. This study further replicates previous findings4,9,15,18 in that women who reported experiencing domestic violence victimisation during pregnancy were more likely to be unmarried, to have had their first child at a young age, to be poorly educated, have financial difficulties and were in relationships in which substance use and crime featured. In addition the most important discriminating characteristics of women who reported victimisation at 18 weeks of gestation included social isolation and a lack of partner support, maternal affective disorder, no regular partner and having had contact with the police. Unique to this study is the identification of the impact of multiple social adversities on risk for victimisation. Not only was the number of family adversities reported by women during pregnancy associated with concurrent victimisation, but they also predicted postpartum abuse up to three years later. This replicates findings from the developmental psychopathology field whereby the accumulation of risk factors rather than single factors has most severe impact on children’s mental health.21,32 However, although these data endorse the value of examining multiple adversities, systematic examination of the predictive accuracy of such cumulative measures is required. Although this study provides insight into the association between social adversities and longitudinal risk for domestic violence, it is not without its limitations. For example, the ALSPAC study was designed as a longitudinal study of the impact of genetic and environmental factors on child development, and included only limited information regarding domestic violence. The use of just two items to assess what is recognised as a complex phenomenon of coercion, control, intimidation, physical and sexual abuse1 is therefore likely to under-represent the true extent of victimisation. In addition it is possible that the responses of women were affected by the presence of a coercive male partner, which might have resulted in lower reports of physical victimisation than expected in light of previous studies. However, the finding that victims are more likely to report having unsupportive partners and being socially isolated indicates that the items used may reflect domestic violence within its wider definition. Furthermore, the same questions were asked over time and are thus directly comparable. A further limitation is that the items used to assess domestic violence asked specifically about emotional and physical cruelty. It is possible that the use of the word ‘cruelty’ within the items led women to report the incidence of more severe forms of victimisation than might have been identified

using more well-defined act-based measures that include frequencies of pushing and/or shoving. This might also have resulted in under-reporting the true extent of victimisation. Indeed, in a previous North American national probability sample-based study that used an act-based measure, the prevalence of domestic violence during pregnancy was 11%, significantly higher than that reported here.33 Thus, although there are reasons to believe that the study may have under-estimated true rates of domestic violence and likely to have focussed on the more severe forms the longitudinal analysis clearly indicates a hitherto poorly studied change in domestic violence rates from antenatal through the first three postnatal years and associated features already detectable in pregnancy. There are important implications for obstetric services. It is evident from the data presented that although pregnancy appears not to be a sensitive period per se for domestic violence victimisation, levels of social adversity identified during pregnancy are important for predicting future victimisation. Therefore, screening during pregnancy is important and should include a variety of social, individual and relationship factors. This study suggests that it is not necessarily specific forms of adversity that are important but the accumulation of multiple adversities during pregnancy that increase the risk of concurrent and future victimisation. Thus, screening should include a checklist of adversities identified in this study that are hitherto often missing or poorly completed in antenatal obstetric records.

Acknowledgments We are extremely grateful to all the mothers who took part and to the midwives for their cooperation and help in recruitment. The whole ALSPAC study team comprises interviewers, computer technicians, laboratory technicians, clerical workers, research scientists, volunteers and managers who continue to make the study possible. This study could not have been undertaken without the financial support of the Wellcome Trust, the Medical Research Council, the University of Bristol, the Department of Health, the Department of the Environment and other funding bodies. The ALSPAC study is part of the WHO initiated European Longitudinal Study of Pregnancy & Childhood. Conflict of interests None.

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