Domestic violence: prevalence in pregnant women and associations with physical and psychological health

Association between domestic violence and miscarriage: a population-based cross-sectional study among women of childbearing ages, Sivas, Turkey

Violence against women is a global issue, with ramifications for the reproductive health of women. The current study examined the relation of domestic violence (DV) to miscarriage among women who were victimized during their last pregnancy. The study was conducted in Sivas city center, in Turkey. Associations between self-reported DV and miscarriage were analyzed using multiple regression modeling. Physical and/or sexual DV during the last pregnancy was reported by 10.0% and 6.2% of women, respectively. Women who experienced physical violence were 2.5 times as likely (Odds Ratio (OR) = 2.47, 95% confidence interval [CI]: 1.37-4.84, p = .003) to have experienced a miscarriage than women who did not report physical violence. These findings suggest that victims who experience physical violence during the last pregnancy may be more likely to experience miscarriage. Preventing DV, especially physical violence, may, therefore, be beneficial for avoiding adverse pregnancy outcomes.

Perinatal psychiatric disorders: an overview

Perinatal mental illness has a significant implication on maternal health, birth outcomes, and the offspring's development. Prevalence estimates of perinatal psychiatric illnesses range widely, with substantial heterogeneity in different population studies, with a lower prevalence rate in high- rather than low- or middle-income countries. Because of the potential negative impact on maternal and child outcomes and the potential lability of these disorders, the perinatal period is a critical time to identify psychiatric illnesses. Thus, obstetricians and midwives play a crucial role in assessing women's mental health needs and to refer identified women promptly for multidisciplinary specialist assessment. However, there is still limited evidence on best practice assessment and management policies during pregnancy and postpartum. This review focuses on the prevalence of common perinatal mental disorders and antenatal screening policies to identify women at risk. The effect of these conditions and their management on pregnancy, fetal outcomes, and child development are discussed.

Intimate partner violence and utilization of prenatal care in the United States

Over 1.5 million women are victims of physical, sexual, and emotional abuse by former or present intimate partners. Intimate partner violence (IPV) around pregnancy can lead to devastating health consequences to mothers and infants. While some research suggests that IPV negatively affects the utilization of health services like prenatal care (PNC), inconsistencies in the assessment of PNC utilization, timing of partner violence, and definitions of IPV yield conflicting results. The objective for the present study is to evaluate whether preconception IPV, prenatal IPV, or IPV in the preconception and/or prenatal period affects PNC utilization. This study analyzed the 2004-2008 national Pregnancy Risk Assessment Monitoring System (PRAMS), which included 202,367 women who delivered a live birth in the United States. IPV victimization was measured using four items that addressed physical abuse by a current or former husband/partner in the 12 months before (preconception) and during (prenatal) pregnancy. Responses were categorized as preconception, prenatal, and preconception and/or prenatal IPV. The outcome was PNC adequacy categorized as inadequate, intermediate, adequate, and adequate plus based on the Adequacy of Prenatal Care Utilization index. Separate logistic regression models provided crude and adjusted odds ratios and 95% confidence intervals (CI). Over 6% of women reported preconception and/or prenatal IPV and 26% had less than adequate PNC. Women who reported abuse before and/or during pregnancy were more likely to have inadequate PNC (odds ratio [OR] = 1.4, 95% CI = [1.3, 1.6]). Similarly, women who experienced preconception or prenatal IPV were 30% more likely to have inadequate PNC (OR = 1.3, 95% CI = [1.2, 1.5]; OR = 1.3, 95% CI = [1.1, 1.7], respectively). Adequate PNC is essential in improving pregnancy outcomes; however, women in abusive relationships may face ongoing challenges and difficulties with obtaining appropriate care. Findings underscore a critical problem and health providers are urged to screen and educate women about IPV during all preconception and prenatal visits.

Intimate partner violence and pregnancy: a systematic review of interventions

Background

Intimate partner violence (IPV) around the time of pregnancy is a widespread global health problem with many negative consequences. Nevertheless, a lot remains unclear about which interventions are effective and might be adopted in the perinatal care context.

Objective

The objective is to provide a clear overview of the existing evidence on effectiveness of interventions for IPV around the time of pregnancy.

Methods

Following databases PubMed, Web of Science, CINAHL and the Cochrane Library were systematically searched and expanded by hand search. The search was limited to English peer-reviewed randomized controlled trials published from 2000 to 2013. This review includes all types of interventions aiming to reduce IPV around the time of pregnancy as a primary outcome, and as secondary outcomes to enhance physical and/or mental health, quality of life, safety behavior, help seeking behavior, and/or social support.

Results

We found few randomized controlled trials evaluating interventions for IPV around the time of pregnancy. Moreover, the nine studies identified did not produce strong evidence that certain interventions are effective. Nonetheless, home visitation programs and some multifaceted counseling interventions did produce promising results. Five studies reported a statistically significant decrease in physical, sexual and/or psychological partner violence (odds ratios from 0.47 to 0.92). Limited evidence was found for improved mental health, less postnatal depression, improved quality of life, fewer subsequent miscarriages, and less low birth weight/prematurity. None of the studies reported any evidence of a negative or harmful effect of the interventions.

Conclusions and implications

Strong evidence of effective interventions for IPV during the perinatal period is lacking, but some interventions show promising results. Additional large-scale, high-quality research is essential to provide further evidence about the effect of certain interventions and clarify which interventions should be adopted in the perinatal care context.

Prenatal and mental health care among trauma-exposed, HIV-infected, pregnant women in the United States

Comprehensive prenatal care for HIV-infected women in the United States involves addressing mental health needs. Retrospective quantitative data are presented from HIV-infected pregnant women (n = 45) who reported childhood sexual or physical abuse (66%), abuse in adulthood by a sexual partner (25%), and abuse during pregnancy (10%). Depression and anxiety were the most commonly reported psychological symptoms; more than half of the sample reported symptoms of posttraumatic stress disorder (PTSD), including HIV-related PTSD (PTSD-HIV). There was a strong association between depression and PTSD as well as between anxiety and PTSD-HIV. The majority of infants received zidovudine at birth and continued the recommended regimen. All but one infant were determined to be noninfected. Women improved their CD4(+) T cell counts and HIV RNA viral loads while in prenatal care. Results support the need for targeted prenatal programs to address depression, anxiety, substance use, and trauma in HIV-infected women.

Acceptance of routine or case-based inquiry for intimate partner violence: a mixed method study

Background

The prevalence and detrimental health effects of intimate partner violence have resulted in international discussions and recommendations that health care professionals should screen women for intimate partner violence during general and antenatal health care visits. Due to the lack of discussion on routine or case-based inquiry for intimate partner violence during antenatal care in Germany, this study seeks to explore its acceptability among pregnant German women.

Methods

A mixed methods approach was used, utilizing a self-administered survey on the acceptability of routine or case-based inquiry for intimate partner violence in a university hospital’s maternity ward in Munich and in-depth interviews with seven women who experienced violence during pregnancy.

Results

Of the 401 women who participated in the survey, 92 percent were in favor of routine or case-based inquiry for intimate partner violence during antenatal care. Acceptance of routine or case-based inquiry for intimate partner violence during antenatal care was significantly associated with women’s experiences of child sexual abuse, being young, less educated, single or divorced and smoking during pregnancy. Open-ended survey questions and in-depth interviews stressed adequate training for screening, sufficient time and provision of referral information as important conditions for routine or case-based inquiry for intimate partner violence.

Conclusions

Women in this study showed an overwhelming support for routine or case-based screening for intimate partner violence in antenatal care in Germany. Until adequate training is in place to allow providers to inquire for intimate partner violence in a professional manner, this study recommends that health care providers are made aware of the prevalence and health consequences of violence during pregnancy.

Social context and drivers of intimate partner violence in rural Kenya: implications for the health of pregnant women

More than half of rural Kenyan women experience intimate partner violence (IPV) in their lifetime. Beyond physical consequences, IPV indirectly worsens maternal health because pregnant women avoid antenatal care or HIV testing when they fear violent reprisal from partners. To develop an intervention to mitigate violence towards pregnant women, we conducted qualitative research in rural Kenya. Through eight focus group discussions, four with pregnant women and four with male partners, and in-depth interviews with service providers, we explored the social context of IPV using an ecological model. We found that women experienced physical and sexual IPV, but also economic violence such as forced exile from the marital home or losing material support. Relationship triggers of IPV included perceived sexual infidelity or transgressing gender norms. Women described hiding antenatal HIV testing from partners, as testing was perceived as a sign of infidelity. Extended families were sometimes supportive, but often encouraged silence to protect the family image. The broader community viewed IPV as an intractable, common issue, which seemed to normalise its use. These results resonate with global IPV research showing that factors beyond the individual - gender roles in intimate partnerships, family dynamics and community norms - shape high rates of violence.

Are survivors of intimate partner violence more likely to experience complications around delivery? Evidence from a national Bangladeshi sample

OBJECTIVES

To estimate (i) lifetime prevalence of physical and sexual intimate partner violence (IPV) and (ii) associations of development of complications around delivery and IPV.

METHODS

We used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on the responses of 2001 currently married women having a child younger than five years. Exposure was determined from maternal reports of physical and sexual IPV. Experience of complications around delivery was the main outcome variable of interest.

RESULTS

More than half (53%) of the women had experienced IPV. IPV of any type (adjusted odds ratio [AOR]: 1.86; 95% confidence interval [CI]: 1.35-2.56) was associated with development of complications, as was physical IPV only (AOR: 1.63; 95% CI: 1.14-2.33), sexual IPV only (AOR: 2.0; 95% CI: 1.01-3.99), and both types of IPV (AOR: 2.43; 95% CI: 1.55-3.79). There was a dose-response relationship between the number of varieties of physical IPV suffered and complications developing.

CONCLUSIONS

Experience of IPV is an important risk marker for the development of complications around delivery. Our findings underscore the calls for protecting women from all forms of physical and sexual violence from their husbands as part of the interventions to reduce the risk of complications supervening around delivery. They should be considered a public health research priority.

Risk factors for domestic violence during pregnancy: a meta-analytic review

This article presents the results of a meta-analysis of the existing research literature, in an effort to increase our understanding of the prevalence of domestic violence (DV) among pregnant women, and of risk factors associated with DV during pregnancy. Across 92 independent studies, the average reported prevalence of emotional abuse was 28.4%, physical abuse was 13.8%, and sexual abuse was 8.0%. Composite odds ratio effect sizes were calculated for the demographic, behavioral, and social risk factors identified by 55 independent studies. Both victimization and perpetration risk factors were analyzed. Abuse before pregnancy and lower education level were found to be strong predictors of abuse during pregnancy. Pregnancy being unintended by either the victim or the perpetrator, lower socioeconomic status, and being unmarried were found to be moderate predictors of abuse during pregnancy.

Maternal intimate partner violence victimization and under-five children mortality in Western Ethiopia: a case-control study

OBJECTIVE

This study aimed to compare the association between maternal intimate partner violence and under-five mortality.

METHODS

Matched case-control study was conducted from May to June 2011. A sample of 286 cases and 572 controls were randomly selected from East Wollega Zone, West Ethiopia.

RESULTS

Among cases, 72.7% ever experienced controlling behaviors when compared to 62.4% for controls. All forms of maternal intimate partner violence were experienced by 61.9% of cases and 50.9% of controls. Controlling behavior in marriage and experiences of all forms of intimate partner violence during lifetime were more than four [adjusted odds ratio (AOR) 4.27, 95% confidence interval (CI) 0.97-18.89), and two (AOR = 2.55, 95% CI 1.66-3.92) times as likely to be associated with under-five mortality.

CONCLUSION

Maternal intimate partner violence victimization is strongly associated with under-five mortality. Involving men in maternal and child health programs could be one strategy to address the issue of intimate partner violence against women.

Are there differences in the impact of partner violence on reproductive health between postpartum women and women who had an elective abortion?

The aim of this study was to determine if the effects of intimate partner violence (IPV) in the previous 12 months (current IPV) on newborn's health, pregnancy outcomes and couple's reproductive behaviours were different for postpartum (PP) women as compared to women who had undergone an elective abortion (EA) in Trieste (Italy). This study is part of an unmatched case-control study. The major findings are that current IPV was positively associated with previous stillbirth among both groups of women, but the association was only marginally significant. Among EA women only, current IPV was significantly associated with previous miscarriages (adjusted odds ratio, 2.41; 95 %CI, 1.13-5.14). In both groups of women, current IPV was associated with a lack of joint couple decision making about contraception; however, the magnitude of this effect was higher among PP women. This study reveals that IPV was associated with poor obstetrical history among both groups of women. But the associations of current IPV with previous EA and couple reproductive behaviours were stronger among PP women.

Domestic violence screening of obstetric triage patients in a military population

OBJECTIVE

The objective was to estimate the self-reported prevalence of domestic violence in a pregnant military population presenting for emergency care, and to determine the acceptability of domestic violence screening.

STUDY DESIGN

A prospective observational survey of patients presenting for obstetric emergency care. Women were anonymously screened for domestic violence using the Abuse Assessment Screen.

RESULT

A total of 499 surveys were distributed, with 26 duplicate surveys. After excluding the 12 blank surveys, a total of 461 surveys were included in the final analysis. The lifetime prevalence of domestic violence (including physical, emotional and sexual abuse) was 22.6% (95% CI=19.0 to 26.4) with 4.1% (95% CI=2.3-6.0) of women reporting physical abuse in the past year and 2.8% (95% CI=1.3-4.3) reporting abuse since becoming pregnant. The majority of women 91.8% (95% CI=88.7-94.2) were not offended by domestic violence screening and 88.8% (95% CI=82.0-88.9) felt that patients should be routinely screened.

CONCLUSION

The self-reported prevalence of domestic violence in a pregnant military population presenting for emergency care was 22.6%. Most women are not offended by domestic violence screening and support routine screening.

Women's experiences of important others in a pregnancy dominated by intimate partner violence

BACKGROUND

Being exposed to intimate partner violence (IPV) during pregnancy is a difficult and complex situation. Despite this, there are few studies describing women's own needs for help and support.

AIM

The aim of this study is to gain a deeper understanding of women's experiences of important others in relation to changing their life situation in a pregnancy dominated by IPV.

METHODS

The study has a qualitative phenomenological design. The data were collected through in-depth interviews with seven Norwegian women, who were exposed to IPV during pregnancy.

FINDINGS

Being pregnant and exposed to violence in relation to important others means confronting present life, life history and future life. The essence implies striving for control in an uncontrolled situation, where other people might be experienced as both a rescuer and a risk. This is further described in four constitutions: the child needs protection; my mother is always present for me; an exhausted run for help; and a reduced, but important social network.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

For women exposed to violence, pregnancy can offer an opportunity for change. Midwives play a unique role in relation to care and continuity in this phase of life, as they can support pregnant women, help to identify their needs, possibilities for action and advise them about appropriate services. Midwives can encourage and support women to find people whom they can trust and who can offer assistance. It is vital that midwives ask about the women's relationship to the baby and their social networks, especially the relationship with their mothers. Ethical considerations:  During the whole study process, guidelines for research on violence against women were followed, to respect the integrity, security and confidentiality of the participants. The study is ethically approved.

Fecal incontinence during the first 12 months postpartum: complex causal pathways and implications for clinical practice

OBJECTIVES

To investigate whether postpartum fecal incontinence is less common in women who had a cesarean delivery and more common in women who had an operative vaginal birth compared with women who had a spontaneous vaginal birth for their first newborn, and whether postpartum fecal incontinence is more common in women who report intimate-partner violence.

METHODS

This was a multicenter, prospective, nulliparous pregnancy cohort (n=1,507) using standardized measures to assess frequency and severity of fecal incontinence in pregnancy and at 3, 6, 9, and 12 months postpartum.

RESULTS

Approximately 17% reported fecal incontinence at some point in the first 12 months postpartum, with 12.8% reporting fecal incontinence beyond the first 3 months postpartum. Fecal incontinence at 4 to 12 months postpartum was significantly more common among women who had experienced emotional violence, physical violence, or both in the first 12 months postpartum (18.8% compared with 11.5%, adjusted odds ratio [OR] 1.62, 95% confidence interval [CI] 1.05-2.50). Compared with spontaneous vaginal birth, cesarean delivery (13.1% compared with 11.3%, adjusted OR 0.99, 95% CI 0.65-1.53), and operative vaginal birth (15.0% compared with 11.3%, adjusted OR 1.33, 95% CI 0.86-2.07) did not significantly alter the likelihood of fecal incontinence beyond the first 3 months postpartum.

CONCLUSION

Understanding causal pathways for postpartum fecal incontinence requires attention to the interplay of pregnancy and birth events and upstream factors such as intimate-partner violence. This has implications for how clinicians present evidence and discuss risks associated with vaginal birth and cesarean delivery. In this nulliparous cohort, method of birth was not a major determinant of fecal incontinence status beyond 3 months postpartum.

LEVEL OF EVIDENCE

II.

Experiences of being exposed to intimate partner violence during pregnancy

In this study a phenomenological approach was used in order to enter deeply into the experience of living with violence during pregnancy. The aim of the study was to gain a deeper understanding of women's experiences of being exposed to intimate partner violence (IPV) during pregnancy. The data were collected through in-depth interviews with five Norwegian women; two during pregnancy and three after the birth. The women were between the age of 20 and 38 years. All women had received support from a professional research and treatment centre. The essential structure shows that IPV during pregnancy is characterized by difficult existential choices related to ambivalence. Existential choices mean questioning one's existence, the meaning of life as well as one's responsibility for oneself and others. Five constituents further explain the essential structure: Living in unpredictability, the violence is living in the body, losing oneself, feeling lonely and being pregnant leads to change. Future life with the child is experienced as a possibility for existential change. It is important for health professionals to recognize and support pregnant women who are exposed to violence as well as treating their bodies with care and respect.

Co-occurring intimate partner violence and mental health diagnoses in perinatal women

OBJECTIVES

To describe the co-occurrence of intimate partner violence (IPV) and mental health burden among perinatal mothers attending well-baby visits with their infants in the first year of life. We compare rates of depression, anxiety disorder, and substance abuse diagnoses between mothers who reported IPV within the past year to those who did not.

METHODS

This cross-sectional study of 188 mothers of infants (under 14 months) was conducted in an urban hospital pediatric clinic. Participants reported demographics and IPV and completed a semistructured psychiatric diagnostic interview.

RESULTS

Mothers reporting IPV were more likely to be diagnosed with mood and/or anxiety diagnoses (p<0.05, Fisher's exact test), specifically current depressive diagnoses (p<0.01, Fisher's exact test) and panic disorder (p<0.05, Fisher's exact test). There was a trend for more posttraumatic stress disorder (PTSD) (p<0.06) among abused mothers. Substance abuse and dependence, age, race, insurance status, employment, education, and family arrangements did not differ between groups. Prior major or minor depression increases the odds for perinatal depression threefold (OD 3.18).

CONCLUSION

These findings have implications for practitioners who encounter perinatal women. Findings suggest providers should explore signs and symptoms of depression and anxiety disorders among women reporting IPV. Similarly, when perinatal mothers report symptoms of depression, PTSD, or panic disorder, practitioners should be alert to the possible contributory role of IPV.

Rates of hospital visits for assault during pregnancy and the year postpartum: timing matters

OBJECTIVE

To clarify the risk of violence for women during pregnancy and the first year postpartum, we examined the timing of hospital visits for assault among a population cohort of women in Massachusetts.

METHODS

Using linked natality and hospital data from 2001 through 2007 for Massachusetts, we examined the timing of hospital (i.e., emergency, inpatient, and observation) visits for maternal assault during seven time periods: the three prenatal trimesters and four three-month postpartum periods. To describe the risk of assault for each of the time periods, we calculated the rate as the number of such visits per 100,000 person-weeks. We used the denominator of 100,000 person-weeks to adjust for variable lengths of gestation and for postpartum periods shortened by subsequent pregnancies.

RESULTS

Rates of hospital visits for maternal assault were highest in the first trimester and lowest in the third trimester, with rates of 16.0 and 5.8 per 100,000 person-weeks, respectively. The four postpartum period rates were higher than the third trimester rate but never reached the levels observed in the first and second trimesters.

CONCLUSIONS

These findings suggest a changing rate for assault visits during each prenatal trimester and postpartum period. In addition, the importance of violence prevention strategies as part of women's health care across the life span and the need for preconception care initiatives are reaffirmed.

Relationship between domestic violence and postnatal depression among pregnant Chinese women

OBJECTIVE

To investigate the prevalence of domestic violence during pregnancy and postnatal depression, and to explore the relationship between domestic violence and postnatal depression among Chinese women.

METHODS

In a cross-sectional survey, 846 pregnant women were screened with the Abuse Assessment Screen; 215 women completed the postnatal follow-up. All participants underwent psychosocial assessment, with the Edinburgh Postpartum Depression Scale being used for the evaluation of postnatal depression.

RESULTS

The overall prevalence of domestic violence during pregnancy was 11.3%, and the most common form of domestic violence was psychologic abuse. The follow-up interviews showed a higher prevalence of postnatal depression among women who had been abused during pregnancy (25.1%) than among those who had not (6.0%). Psychologic abuse during pregnancy, an unexpected pregnancy, an attitude of acceptance toward violence, and concern over the newborn's health were related with postnatal depression.

CONCLUSION

Domestic violence during pregnancy and related factors contributed to postnatal depression in a population of Chinese women. The findings emphasize the importance of intervention among vulnerable populations in low-income countries.

Frequency and pattern of intimate partner violence before, during and after pregnancy

OBJECTIVE

To estimate the prevalence and analyze the pattern of intimate partner violence, before and during pregnancy and in the postpartum period.

METHODS

This was a cohort study undertaken on 960 women aged 18 to 49 years, who were registered in the Family Health Program of the city of Recife, Northeastern Brazil, between 2005 and 2006. The women were interviewed during pregnancy and in the postpartum period, using a questionnaire adapted from the World Health Organization's Multi-country Study on Women's Health and Domestic Violence. To assess the pattern of intimate partner violence occurrences between a given time period and the subsequent period, the odds ratio (OR) was calculated with 95% confidence intervals (95%CI).

RESULTS

The prevalence of intimate partner violence before, during and/or after pregnancy was estimated to be 47.4%. For the three periods separately, it was 32.4%, 31.0% and 22.6% respectively. The women who reported violence before pregnancy were 11.6 times more likely to report violence during pregnancy (95%CI: 8.3;16.2). When the women reported violence during pregnancy, the chance of reports in the postpartum period was 8.2 times higher (95%CI: 5.1;11.7). Psychological violence was more prevalent, especially during pregnancy (28.8%; 95%CI: 26.0%;31.7%). Sexual violence was less prevalent, especially after delivery (3.7%; 95%CI: 2.6%;5.0%). Physical violence diminished by almost 50% during pregnancy, in comparison with the preceding period.

CONCLUSIONS

A significant proportion of women of reproductive age experience situations of intimate partner violence. The periods of prenatal and childcare consultations are opportunities for healthcare professionals to identify situations of violence.

[Physical violence during pregnancy in Morocco]

INTRODUCTION

Physical abuse are a serious social problem and an issue of perinatal health.

MATERIAL AND METHODS

This article presents the results of a survey conducted at the CHU Ibn Rochd of Casablanca (Morocco), over a period of one year, in order to determine their frequency, risk factors, maternal diseases and obstetric complications.

RESULTS

The results of our survey found that women who reported physical abuse have a frequency of 12.3% (107 cases). The average age of these women is 22.3 years; 65.6% of parturients are illiterate, 45% are from a disadvantaged socioeconomic status, 47% originated from a rural county; 37% are unmarried; half of the abused are multiparous with an average of 3.2 living children; 23% of the pregnancies are unplanned. Lastly, 37.3% of pregnant partners are unemployed and 67% have toxic habits. Obstetric complications are fairly frequent and mental effects are not negligible with 3 attempted suicides and attempted homicide.

CONCLUSION

Early identification of abuse suffered by pregnant women and taking measures to prevent them could reduce the occurrence of these adverse effects.

Spousal violence against pregnant women from a Bedouin community in Jordan

BACKGROUND

The objective of this study was to estimate the prevalence of spousal violence against pregnant women during their current pregnancy and investigate factors related to violence.

METHODS

A cross-sectional survey was performed with 303 pregnant women who attended antenatal clinics in Al-Mafraq, northern desert of Jordan.

RESULTS

The prevalence of violence (any type) during pregnancy was 40.9%. Physical violence was the highest (34.7 %), followed by psychologic violence (28.1%) and sexual violence (15.5%). Women who resided in the city (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.05-2.79), had six or more pregnancies including the current one (OR 5.4, 95% CI 1.45-20.0), had four or more female children (OR 4.03, 95% CI 1.3- 11.9) and were under pressure to have a male child (OR 1.82, 95% CI 1.07- 3.08) were more likely to be exposed to violence during pregnancy.

CONCLUSIONS

This study attempted to shed light on some of the cultural dimensions behind spousal violence, especially preference for male children. This study is important to the Jordanian and Arab communities in their efforts to protect women's rights and in designing interventions against domestic and spousal violence.

Understanding depressive symptoms among high-risk, pregnant, African-American women

PURPOSE

Depression has been shown to be a risk factor of poor pregnancy outcomes among African-American women. The goal of this study was to examine both risk and protective factors of depressive symptoms among urban, high-risk African-American, pregnant women.

METHODS

Data were drawn from a larger randomized controlled trial, Health Outcomes of Pregnancy Education that was a part of the National Institutes of Health-DC Initiative to Reduce Infant Mortality in Minority Populations in the District of Columbia. For purposes of the present study, a sample of African-American pregnant women (n = 1,044) were recruited from six urban prenatal care clinics. Baseline depressive symptoms were assessed using the Hopkins Symptom Checklist-Depression Scale.

RESULTS

Forty-four percent of women were confirmed as moderately to severely depressed at baseline. In multivariate linear regression analysis among the total sample, maternal age, intimate partner violence, illicit drug and alcohol use during pregnancy, and reproductive history (no live birth/only loss; no live birth/no loss) were associated with increased depressive symptoms. Being very happy about the pregnancy, having emotional support from others, and reporting more positive expectancies about the ability to regulate negative moods were associated with decreased depressive symptoms.

CONCLUSION

Results highlight the importance of attending to the context of high-risk, African-American, pregnant women, paying attention to both risk and protective factors of poor psychological well-being. Implications for future research in this area are discussed.

Impacts of domestic violence on child growth and nutrition: a conceptual review of the pathways of influence

Domestic violence against women is a global problem, and young children are disproportionate witnesses. Children's exposure to domestic violence (CEDV) predicts poorer health and development, but its effects on nutrition and growth are understudied. We propose a conceptual framework for the pathways by which domestic violence against mothers may impair child growth and nutrition, prenatally and during the first 36 months of life. We synthesize literatures from multiple disciplines and critically review the evidence for each pathway. Our review exposes gaps in knowledge and opportunities for research. The framework also identifies interim strategies to mitigate the effects of CEDV on child growth and nutrition. Given the global burden of child malnutrition and its long-term effects on human-capital formation, improving child growth and nutrition may be another reason to prevent domestic violence and its cascading after-effects.

A comparison of the training needs of maternity and sexual health professionals in a London teaching hospital with regards to routine enquiry for domestic abuse

OBJECTIVE

To identify maternity and sexual healthcare professionals' training needs regarding routine enquiry for domestic abuse.

STUDY DESIGN

A cross-sectional survey, part of a theory-based evaluation of a routine enquiry for domestic abuse intervention in a South London teaching hospital.

METHODS

Two hundred and twenty-eight maternity professionals (68% of staff) and 46 sexual health practitioners (45% of staff) attended a 1-day domestic abuse training session. Pre-training questionnaires were completed by 208 respondents (80% response rate). The questionnaire elicited information about previous training experiences, dealing with cases of abuse, general knowledge, attitudes towards victims of abuse and views on routine enquiry. Bivariate and multivariate analyses were conducted to identify differences according to healthcare setting, prior training, and practitioners' demographic and experiential traits.

RESULTS

Maternity and sexual health professionals reported positive attitudes towards women affected by abuse, but had limited domestic abuse training. Previously trained health professionals had good general knowledge, but failed to question attendees about abuse. Sexual health professionals were more likely to enquire about domestic abuse, and were more confident about implementing routine enquiry than maternity staff. Views on routine enquiry were influenced by health setting, demographic, attitudinal and experiential factors.

CONCLUSIONS

Domestic abuse training is necessary in maternity and sexual health services. Educational interventions for routine enquiry should include practice-enabling components in addition to awareness modules and pre-training assessment of individuals' training needs to provide content that is tailored to their clinical practice and working environments. Institutional guidelines are recommended to enhance and sustain the positive effects of training.

Depression during pregnancy: prevalence and risk factors among women attending a public health clinic in Rio de Janeiro, Brazil

Depression is the most prevalent psychiatric disorder during pregnancy and is associated with psychosocial and clinical obstetric factors. Despite being an important public health issue, there are few studies about this issue in Brazil. A cross-sectional study was carried out, involving 331 pregnant women attending a public primary health service over a one-year period in Rio de Janeiro city, Brazil. Participants were interviewed about their socio-demographic status, obstetric/medical conditions, life events and violence during pregnancy. Depression was assessed using the Composite International Development Interview. The prevalence of depression during pregnancy was 14.2% (95%CI: 10.7-18.5) and associated factors included: previous history of depression and any psychiatric treatment, unplanned pregnancy, serious physical illness and casual jobs. These data emphasize the need for screening for depression and its risk factors during pregnancy in settings where care is available. Psychosocial interventions and social policies need to be devised for this population.

Postnatal disclosure of domestic violence: comparison with disclosure in the first trimester of pregnancy

AIMS AND OBJECTIVES

This study explored the prevalence rates of domestic violence reported during the first trimester of pregnancy and in the postnatal period.

BACKGROUND

Domestic violence is known to have a deleterious effect on the physical and psychological well-being of a woman, with an adverse effect on the unborn child.

DESIGN

A validated anonymous and self-administered questionnaire (Abuse Assessment Screen) using five closed questions was used for data collection in all samples. All women were approached alone, and the questionnaire was completed in private.

METHOD

Drawn from the same geographical area, this survey collected data from women accessing hospital clinics, in a large university teaching hospital in the UK.

RESULTS

Comparing self-reporting rates of domestic violence in the first trimester of pregnancy to the postnatal period yielded statistically significant results (p < 0·01). Only 7·3% booking-in clinic and 8% postnatal women reported violence at some stage in their life, whilst higher rates in pregnancy counselling clinic (35·1%) and early pregnancy unit (26%) were reported. However, the reported rates of domestic violence in the year before the women were pregnant revealed a different trajectory. Lower rates of domestic violence were evident in three samples.

CONCLUSIONS

The disparity in disclosure rates of domestic violence suggests that an emotional inhibitory response to disclosure may occur at specific periods of pregnancy and that the timing of asking about domestic violence may be critical to this disclosure. The pandemic nature of domestic violence reflects the need for practice in maternity care to reflect the changing needs of a woman during her gestational experience.

RELEVANCE TO CLINICAL PRACTICE

The primary objective of health care providers should be to engage a pregnant woman in a meaningful relationship, gaining her trust to facilitate the disclosure of domestic violence. Hence, whatever the policies for the provision of maternity care, the changing needs of a pregnant woman must be met.

Intimate partner violence as a risk factor for postpartum depression among Canadian women in the Maternity Experience Survey

PURPOSE

Intimate partner violence is a worldwide public health concern that predominantly affects women of reproductive age. The purpose of this study was to evaluate the effect of exposure to intimate partner violence before, during, or after pregnancy on postpartum depression in a nationally representative sample of Canadian women.

METHODS

A cross-sectional analysis was performed with the use of data from the Maternity Experience Survey conducted by Statistics Canada in 2006. A population-based sample of 8542 women 15 years and older who delivered singleton live births was selected from all Canadian provinces and territories; of those, 6421 completed a computer-assisted telephone interview. Recent experiences with and threats of physical or sexual violence by an intimate partner were examined in relation to postpartum depression assessed through the Edinburgh Postpartum Depression Scale.

RESULTS

The prevalence of postpartum depression was 7.5% (95% confidence interval, 6.8-8.2). Controlling for confounders, odds of postpartum depression were significantly greater among women who reported partner violence in the past two years as opposed to those who did not (adjusted odds ratio, 1.61; 95% confidence interval, 1.06-2.45).

CONCLUSIONS

Intimate partner violence is positively associated with postpartum depression among Canadian women. Implications for healthcare practice are discussed.

Maternal exposure to domestic violence and pregnancy and birth outcomes: a systematic review and meta-analyses

BACKGROUND

Pregnant women who experience domestic violence are at increased risk of adverse outcomes in addition to the risks to themselves. Inadequate prenatal care, higher incidences of high-risk behaviors, direct physical trauma, stress, and neglect are postulated mechanisms. Our objective was to systematically review birth outcomes among women who experienced domestic violence.

METHODS

Medline, Embase, CINAHL, and bibliographies of identified articles were searched for English language studies. Studies reporting rates of low birth weight, preterm birth, small for gestational age births, birth weight, or gestational age at birth were included. Study quality was assessed for selection, exposure assessment, confounder adjustment, analyses, outcomes assessment, and attrition biases. Unadjusted and adjusted data from included studies were extracted by two reviewers. Summary odds ratio (OR) and confidence intervals (CI) were calculated using the random effects model. Population-attributable risk was calculated.

RESULTS

Thirty studies of low to moderate risk of biases were included. Low birth weight (adjusted OR 1.53, 95% CI 1.28-1.82) and preterm births (adjusted OR 1.46, 95% CI 1.27-1.67) were increased among women exposed to domestic violence. As the prevalence of reported domestic violence during pregnancy was low, the population-attributable risk was low. Prospective cohort studies provided robust and consistent results.

CONCLUSIONS

Maternal exposure to domestic violence was associated with significantly increased risk of low birth weight and preterm birth. Underreporting of domestic violence is hypothesized. Effective programs to identify violence and intervene during pregnancy are essential.

Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study

BACKGROUND

Partner violence against women is common during pregnancy and might have an adverse effect on the mental health of women after delivery. We aimed to investigate the association of postnatal depression with psychological, physical, and sexual violence against women by their intimate partners during pregnancy.

METHODS

In a prospective cohort study undertaken in Recife, northeastern Brazil, between July, 2005, and December, 2006, we enrolled pregnant women (aged 18-49 years) in their third trimester of pregnancy who were attending primary health-care clinics. The women were interviewed during pregnancy and after delivery. The form of partner violence in pregnancy was assessed with a validated questionnaire, and the Edinburgh postnatal depression scale was used to measure postnatal depression. Associations were estimated with odds ratios (ORs), adjusted for confounding factors contributing to the association between postnatal depression and intimate partner violence.

FINDINGS

1133 pregnant women were eligible for inclusion in the study, of whom 1045 had complete data for all variables and were included in the analysis. 270 women (25.8%, 95% CI 23.2-28.6) had postnatal depression. The most common form of partner violence was psychological (294 [28.1%, 25.4-31.0]). Frequency of psychological violence during pregnancy was positively associated with occurrence of postnatal depression, and although this association was attenuated after adjustment, women reporting the highest frequency of psychological violence were more likely to have postnatal depression even after adjustment (adjusted OR 2.29, 95% CI 1.15-4.57). Women who reported physical or sexual violence in pregnancy were more likely to develop postnatal depression (OR 3.28, 2.29-4.70), but this association was substantially reduced after adjustment for psychological violence and confounding factors.

INTERPRETATION

Psychological violence during pregnancy by an intimate partner is strongly associated with postnatal depression, independently of physical or sexual violence. This finding has important policy implications since most social policies focus on prevention and treatment of physical violence.

FUNDING

Departamento de Ciência e Tecnologia da Secretaria de Ciência, Tecnologia, e Insumos Estratégicos, and Conselho Nacional de Desenvolvimento Científico e Tecnológico (Brazil).

Partner, workplace, and stranger abuse during pregnancy in Germany

OBJECTIVE

To investigate the prevalence, perpetrators, sociodemographic correlates, and health impacts of psychological, physical, and sexual abuse during pregnancy among women attending a maternity ward in Germany.

METHODS

A written questionnaire was given to pregnant women in a maternity ward of a university hospital in Munich. Abuse during pregnancy was assessed using the Abuse Assessment Screen.

RESULTS

Of 552 women, 401 completed the questionnaire for a response rate of 72.6%. The prevalence of psychological, physical, or sexual abuse during pregnancy by any perpetrator was 6.7% (n = 27); the main perpetrators were women's partners and work colleagues. After controlling for the effect of age, psychological, physical, or sexual abuse during pregnancy was significantly associated with a history of abuse, low education level of the woman and the father of her child, short relationship duration, unintended pregnancy, financial problems caused by the pregnancy, having more than 3 children, and insufficient social support. Women who reported abuse during pregnancy were significantly more likely to smoke and to have adverse maternal health outcomes.

CONCLUSION

Psychological, physical, or sexual abuse during pregnancy was experienced by 1 in 15 women who attended a maternity ward in Munich and adversely affected maternal health outcomes.

Partner violence during pregnancy: prevalence, effects, screening, and management

The purpose of this review is to provide an overview of the current state of knowledge regarding the experience of intimate partner violence (IPV) during pregnancy. Pregnancy IPV is a significant problem worldwide, with rates varying significantly by country and maternal risk factors. Pregnancy IPV is associated with adverse newborn outcomes, including low birth weight and preterm birth. Many mechanisms for how IPV may impact birth outcomes have been proposed and include direct health, mental health, and behavioral effects, which all may interact. Screening for IPV during pregnancy is essential, yet due to time constraints and few clear recommendations for assessment, many prenatal providers do not routinely inquire about IPV, or even believe they should. More training is needed to assist health care providers in identifying and managing pregnancy IPV, with additional research needed to inform effective interventions to reduce the rates of pregnancy IPV and resultant outcomes.

Measuring the best outcome for the least intervention: can the Optimality Index-US be applied in the UK?

OBJECTIVE

to pilot the Optimality Index-US (OI-US) for the first time within a UK maternity setting in a sample of women at mixed risk.

DESIGN

a multidisciplinary group reviewed the items and evidence base of the OI-US. A pilot study was undertaken to compare the availability and quality of data from maternity records to complete the OI-US. Data were collected from maternity records.

SETTING

a maternity unit of an inner city teaching hospital in England.

PARTICIPANTS

clinical midwives, research midwives, midwifery lecturers and consultant obstetricians (n=10) reviewed the items and evidence base of the OI-US. Data were collected from the maternity records of 97 women receiving caseload care and 103 women receiving standard care.

MEASUREMENTS AND FINDINGS

when the multidisciplinary group reviewed the items and evidence base of the OI-US, it was noted that some social and clinical factors should be considered for inclusion as part of the Perinatal Background Index (PBI) and OI. The results suggest that the inclusion of women at higher risk in this sample within the UK maternity setting has not been captured by the OI-US.

KEY CONCLUSIONS

the following social and clinical factors should be included as part of the PBI and OI for the UK setting: measure of social deprivation, woman's ability to speak and understand English in relation to accessing maternity care, mental health problems during pregnancy and history of domestic violence during pregnancy

IMPLICATIONS FOR PRACTICE

availability of items in electronic records is poor and it is recommended that the OI-UK version is a useful research tool in prospective data collection. The development of an international version would be valuable for comparison of background risk and outcomes across a range of care settings.

PTSD and postpartum mental health in a sample of Caucasian, Asian, and Pacific Islander women

To better understand the role of posttraumatic stress disorder (PTSD) in postpartum health, this study investigates the relationship of PTSD and associated perinatal behavioral risk factors in a sample of Caucasian, Asian, and Pacific Islander women. As part of a larger longitudinal study, 54 women (18-35 years of age) were interviewed at their postpartum clinic visit for PTSD, anxiety, depression, and alcohol and substance use. PTSD and subclinical PTSD during the postpartum period were associated with behavioral health risks, with PTSD at the onset of pregnancy being a predictor of postpartum PTSD by a factor of three. Women with PTSD and subclinical PTSD were more likely to also experience stress (73%), anxiety (64%), and depression (73%) during the postpartum period compared to those without PTSD. No significant differences were found by ethnicity for postpartum PTSD, depression, or anxiety. Regardless of ethnicity or PTSD status, one in four women in the sample had a probable mental health disorder or risk behavior of some type during the postpartum period. Given the rates of associated mental health risks with PTSD, these findings suggest further research examining the fluctuations of PTSD symptomatology throughout each pregnancy trimester to determine its role as a potential mediator during the perinatal period. Further research is also needed to elucidate the role of ethnic or cultural differences in trauma and PTSD and perinatal health.

Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: a theoretical framework and research agenda

Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.

Violence during pregnancy: associations with pregnancy intendedness, pregnancy-related care, and alcohol and tobacco use among a representative sample of New Zealand women

AIM

To explore the extent of intimate partner violence during pregnancy and its association with pregnancy intendedness and pregnancy-related behaviours among a representative sample of New Zealand women.

METHODS

Face-to-face interviews were conducted with a representative sample of 2391 women who had ever been pregnant, aged 18-64 years old in two regions (urban and rural) in New Zealand.

RESULTS

Six per cent of urban women and 9% of rural women had ever experienced violence during pregnancy; approximately 40% of these had experienced violence in more than one pregnancy. Women who had experienced violence in pregnancy, compared with those who had not, were less likely to report their last pregnancy had been wanted at that time (28% vs 55%), and less likely to report that their partner wanted the pregnancy (40% vs 57%). Antenatal and postnatal care attendance was almost universal during the last pregnancy. Women who had experienced violence during pregnancy were more likely to smoke tobacco during pregnancy (67% vs 22%, P < 0.0001), and more commonly, consumed alcohol (31% vs 20%, not significant). For the most recent pregnancy in which women had experienced violence, most was perpetrated by the child's biological father (96%), and most women (74%) reported that the same man had also beaten her before she was pregnant.

CONCLUSIONS

Violence during pregnancy is a significant problem for New Zealand women, with negative health implications for both women and their children. Active intervention and support is necessary to mitigate potential consequences.

Prevalence, types, and pattern of intimate partner violence among pregnant women in Lima, Peru

This study assesses the prevalence, types, and pattern of intimate partner violence (IPV) during lifetime and current pregnancy for 2,392 women in Lima, Peru. The reported lifetime prevalence of any IPV (physical, sexual, or emotional) is 45.1%. For women who experienced abuse, the prevalence of lifetime physical, emotional, and sexual IPV is 34.2%, 28.4%, and 8.7%, respectively. Older (>/= 30 years), unmarried, employed, and economically disadvantaged women and those with little education are more likely to experience lifetime and pregnancy IPV. Efforts at universal antepartum IPV screening and appropriate interventions are needed to reduce the burden of violence experienced by pregnant women.

Revision of the Abuse Assessment Screen to address nonlethal strangulation

The Abuse Assessment Screen has been used since 1987 to identify and assess for intimate partner violence in a wide variety of clinical and research settings. It has been translated and successfully used in at least 7 languages in addition to English. Meanwhile, a growing body of research indicates that nonlethal strangulation (commonly called "choking") is a significant form of intimate partner violence and that choking has substantial consequences for the health of the woman. This paper describes the modification of the Abuse Assessment Screen to include "choking."

Fear of an intimate partner and women's health in early pregnancy: findings from the Maternal Health Study

BACKGROUND

Intimate partner violence affects 1 in 4 women at some stage in their lives. Exposure to violence has short- and long-term consequences for women themselves and their children. The objective of this study was to examine associations between fear of an intimate partner and maternal physical and psychological morbidity in early pregnancy.

METHOD

This paper reports baseline measures from a prospective pregnancy cohort study of 1,507 nulliparous women recruited at six public hospitals in Melbourne, Australia.

RESULTS

The study showed that 18.7 percent (280/1,497) of women reported being afraid of an intimate partner at some stage in their lives; 3.1 percent (47/1,497) were afraid in early pregnancy and 15.6 percent (233/1,497) had been afraid before but not during the current pregnancy. Compared with women who had never been afraid of an intimate partner, women who reported being afraid of an intimate partner in early pregnancy (< or = 24 wk gestation) were at increased risk of urinary incontinence (adjusted OR = 1.64, 95% CI 0.9-3.1), fecal incontinence (adjusted OR = 3.32, 95% CI 1.2-9.2), vaginal bleeding (adjusted OR = 2.84, 95% CI 1.5-5.5), anxiety (adjusted OR = 10.22, 95% CI 5.0-21.2), and depression (adjusted OR = 4.43, 95% CI 2.1-9.7). Women afraid of an intimate partner before but not during pregnancy experienced a similar pattern of morbidity.

CONCLUSIONS

Women afraid of an intimate partner both before and during pregnancy have poorer physical and psychological health in early pregnancy.

Antenatal psychosocial assessment for reducing perinatal mental health morbidity

BACKGROUND

Mental health conditions arising in the perinatal period, including depression, have the potential to impact negatively on not only the woman but also her partner, infant, and family. The capacity for routine, universal antenatal psychosocial assessment, and thus the potential for reduction of morbidity, is very significant.

OBJECTIVES

To evaluate the impact of antenatal psychosocial assessment on perinatal mental health morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, the Cochrane Depression, Anxiety and Neurosis Group's Trials Register (CCDAN TR-Studies), HSRProj in the National Library of Medicine (USA), and the Current Controlled Trials website: http://www.controlled trials.com/ and the UK National Research Register (last searched March 2008).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for eligibility; they also extracted data from included trials and assessed the trials for potential bias.

MAIN RESULTS

Two trials met criteria for an RCT of antenatal psychosocial assessment. One trial examined the impact of an antenatal tool (ALPHA) on clinician awareness of psychosocial risk, and the capacity of the antenatal ALPHA to predict women with elevated postnatal Edinburgh Depression Scale (EDS) scores, finding a trend towards increased clinician awareness of 'high level' psychosocial risk where the ALPHA intervention had been used (relative risk (RR) 4.61 95% confidence interval (CI) 0.99 to 21.39). No differences between groups were seen for numbers of women with antenatal EDS scores, a score of greater than 9 being identified by ALPHA as of concern for depression (RR 0.69 95% CI 0.35 to 1.38); 139 providers. The other trial reported no differences in EPS scores greater than 12 at 16 weeks postpartum between the intervention (communication about the EDS scores with the woman and her healthcare providers plus a patient information booklet) and the standard care groups (RR 0.86 95% CI 0.61 to 1.21; 371 women).

AUTHORS' CONCLUSIONS

While the use of an antenatal psychosocial assessment may increase the clinician's awareness of psychosocial risk, neither of these small studies provides sufficient evidence that routine antenatal psychosocial assessment by itself leads to improved perinatal mental health outcomes. Further studies with better sample size and statistical power are required to further explore this important public health issue. It will also be important to examine outcomes up to one year postpartum not only for mother, but also infant and family.