"Keep a blank face. I need to tell you what has been happening to me

The Intersection of Maternal Morbidity and Mortality and Intimate Partner Violence in the United States

Background:

In the United States, rates of maternal morbidity and mortality (MMM) are high compared with other high-income countries and are characterized by significant racial/ethnic disparities. Typically, research on MMM focuses on obstetrical problems. Less research examines the role of intimate partner violence (IPV). Maternal health, IPV, and their intersection are linked with the impacts of social determinants of health.

Objective:

We sought to understand the intersection of MMM and IPV in the United States, particularly data issues that hinder research in this area and the resulting knowledge gaps.

Methods:

We identified major articles of interest regarding maternal morbidity and mortality and IPV in the United States and drafted a mini review based on relevant information.

Results:

Despite the prevalence of IPV during pregnancy, the intersection of maternal health and IPV has not been widely reviewed or discussed.

Conclusion:

There are a number of limitations in surveillance activities and data collection that underestimate the impact of IPV on MMM. Importantly, women who die by homicide or suicide— which in many cases is linked with IPV—are not counted as pregnancy-related deaths in the United States under the current definition. Establishing separate panels of local experts in maternal health or maternal mortality review committees (MMRCs) that are dedicated to examining violent deaths and use of the Maternal Mortality Review Information Application system would likely improve data accuracy of pregnancy-associated deaths. Based on the literature reviewed and limitations of current data, there are significant knowledge gaps on the effects of IPV and maternal health.

No straight lines - young women's perceptions of their mental health and wellbeing during and after pregnancy: a systematic review and meta-ethnography

Background

Young mothers face mental health challenges during and after pregnancy including increased rates of depression compared to older mothers. While the prevention of teenage pregnancy in countries such as the United States and the United Kingdom has been a focus for policy and research in recent decades, the need to understand young women’s own experiences has been highlighted. The aim of this meta-ethnography was to examine young women’s perceptions of their mental health and wellbeing during and after pregnancy to provide new understandings of those experiences.

Methods

A systematic review and meta-ethnographic synthesis of qualitative research was conducted. Seven databases were systematically searched and forward and backward searching conducted. Papers were included if they were from Organisation for Economic Co-operation and Development countries and explored mental health and wellbeing experiences of young mothers (age under 20 in pregnancy; under 25 at time of research) as a primary research question – or where evidence about mental health and wellbeing from participants was foregrounded. Nineteen papers were identified and the Critical Appraisal Skills Programme checklist for qualitative research used to appraise the evidence. Following the seven-step process of meta-ethnography, key constructs were examined within each study and then translated into one another.

Results

Seven translated themes were identified forming a new line of argument wherein mental health and wellbeing was analysed as relating to individual bodily experiences; tied into past and present relationships; underpinned by economic insecurity and entangled with feelings of societal surveillance. There were ‘no straight lines’ in young women’s experiences, which were more complex than dominant narratives around overcoming adversity suggest.

Conclusions

The synthesis concludes that health and social care professionals need to reflect on the operation of power and stigma in young women’s lives and its impact on wellbeing. It adds to understanding of young women’s mental health and wellbeing during and after pregnancy as located in physical and structural factors rather than individual capacities alone.

Young Mothers' and Fathers' Perceptions of Relationship Violence: A Focus Group Study

Teens and young adults who are pregnant or parenting are important targets for efforts to prevent intimate partner violence (IPV). To intervene appropriately and effectively, we need to fully understand the unique issues and contexts for IPV in this population. This focus group study examined young parents' ( N = 28) perceptions of their relationships, stressors and sources of conflict, forms of IPV, and help-seeking behaviors. We examined data using template, content, thematic, and framework analyses. Findings about relationships and violence between young parents provide valuable insights for future intervention programs designed to prevent or address IPV among teen parents.

Teen Mothers' Experience of Intimate Partner Violence: A Metasynthesis

Pregnant and parenting teens suffer higher rates of intimate partner violence (IPV) than older mothers. This qualitative metasynthesis explores teen mothers' experience with IPV during pregnancy and postpartum. Organized by the metaphor of a web, findings highlight how pervasive violence during childhood contributes to teen pregnancy and the risk of IPV as violence is normalized. The web constricts through the partner's control as violence emerges or worsens with pregnancy. Young mothers become increasingly isolated, and live with the physical and psychological consequences of IPV. Trauma-informed nursing practice is needed to support teen mothers in violent intimate relationships to spin a new web.

A feasibility study to assess the effectiveness of safe dates for teen mothers

OBJECTIVE

To determine the effectiveness of the adapted Safe Dates curriculum as an intervention for pregnant and/or parenting teens to prevent teen dating violence (TDV).

DESIGN

This pre-/posttest, single-sample study provided a means to assess the effectiveness of an adapted Safe Dates curriculum for teen mothers.

SETTING

The adapted Safe Dates curriculum was implemented in three schools designed for the unique needs of teens who are pregnant and/or parenting.

PARTICIPANTS

The final sample of 41 teen participants, with a mean age of 16.27, completed 80% of the curriculum and two of the three assessments. Most of the teens were pregnant during participation in the curriculum, and six had infants between age 1 and 3 months.

METHODS

The teen mothers completed the pretest, participated in the 10-session adapted Safe Dates curriculum, and completed the posttest at the end of the program and 1 month after program completion. The pre/posttest was adapted from the Safe Dates curriculum-specific evaluation instrument. Senior, undergraduate nursing students were trained in and implemented the curriculum.

RESULTS

Participation in the adapted Safe Dates program yielded significant differences in the areas of responses to anger, gender stereotyping, awareness of resources for perpetrators and victims, and psychological violence perpetration.

CONCLUSIONS

This adapted program may be effective in changing selected outcomes. The implementation of a larger scale, experimental/control group study may demonstrate the program's efficacy at reducing the incidence of TDV among teen mothers.

Multi-perpetrator domestic violence

A significant proportion of reports of domestic violence against women involve multiple perpetrators. Although the number of perpetrators has been consistently identified as a measure of abuse severity, only a minority of studies of domestic violence examine the role of multiple offenders. Data on multi-perpetrator domestic violence (MDV) is frequently removed from analysis in domestic violence studies, or multi-perpetrator incidents are treated as single-perpetrator incidents. However, the available research links MDV to negative mental and physical health outcomes, intimate partner homicide, homelessness among women, and severe mental illness and suicidality. This article reviews the available prevalence data on MDV and draws together research on the contexts in which MDV takes place. It highlights two groups that are particularly vulnerable to MDV: (1) girls and women partnered to members of gangs and organized crime groups and (2) girls and women in some ethnic minority communities. While discussions of honor in relation to domestic violence are often racialized in Western media, this article highlights the cross-cultural role of masculine honor in collective violence against women in the working class and impoverished communities of majority cultures as well as in migrant and ethnic minority communities. It is clear that such complex forms of violence present a range of challenges for intervention and treatment and the article emphasizes the need for specialized and coordinated modes of investigation, support, and care.

Associations between intimate partner violence and termination of pregnancy: a systematic review and meta-analysis

BACKGROUND

Intimate partner violence (IPV) and termination of pregnancy (TOP) are global health concerns, but their interaction is undetermined. The aim of this study was to determine whether there is an association between IPV and TOP.

METHODS AND FINDINGS

A systematic review based on a search of Medline, Embase, PsycINFO, and Ovid Maternity and Infant Care from each database's inception to 21 September 2013 for peer-reviewed articles of any design and language found 74 studies regarding women who had undergone TOP and had experienced at least one domain (physical, sexual, or emotional) of IPV. Prevalence of IPV and association between IPV and TOP were meta-analysed. Sample sizes ranged from eight to 33,385 participants. Worldwide, rates of IPV in the preceding year in women undergoing TOP ranged from 2.5% to 30%. Lifetime prevalence by meta-analysis was shown to be 24.9% (95% CI 19.9% to 30.6%); heterogeneity was high (I (2)>90%), and variation was not explained by study design, quality, or size, or country gross national income per capita. IPV, including history of rape, sexual assault, contraceptive sabotage, and coerced decision-making, was associated with TOP, and with repeat TOPs. By meta-analysis, partner not knowing about the TOP was shown to be significantly associated with IPV (pooled odds ratio 2.97, 95% CI 2.39 to 3.69). Women in violent relationships were more likely to have concealed the TOP from their partner than those who were not. Demographic factors including age, ethnicity, education, marital status, income, employment, and drug and alcohol use showed no strong or consistent mediating effect. Few long-term outcomes were studied. Women welcomed the opportunity to disclose IPV and be offered help. Limitations include study heterogeneity, potential underreporting of both IPV and TOP in primary data sources, and inherent difficulties in validation.

CONCLUSIONS

IPV is associated with TOP. Novel public health approaches are required to prevent IPV. TOP services provide an opportune health-based setting to design and test interventions.

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.

Women's stories of birth: a suitable form of research evidence?

In the past one to two decades, midwifery care has taken a new direction, which encompasses a valuing of women's birth experiences. This move has been contingent upon, and congruent with the adoption of 'woman centred' care and a renewed emphasis on normal birth. In line with these developments, women's stories and anecdotes of birth and midwives stories of experience increasingly form the basis of presentations at midwifery conferences and forums. Overall, this philosophical realignment, which commenced in Australia in the early 1990s, has been applauded by many midwives in terms of a greater valuing of the wishes and experiences of childbearing women and as being consistent with a greater promotion of normal birth. Nonetheless, it also gives rise to several questions, regarding the suitability of this form of research evidence. In a bid to answer some of those questions, this paper aims to evaluate the use of stories and anecdotal evidence within midwifery. First, an overview is presented of the way in which stories of pregnancy and birth appear in the literature. Secondly, the value of stories as evidence is critiqued and, finally, the ratio of story based publications, compared to traditional research methodologies, is reviewed. This review aims to address an area poorly attended in the literature and asks specifically: Are women's birth stories a suitable form of research evidence in midwifery?

Perinatal violence assessment: teenagers' rationale for denying violence when asked

OBJECTIVE

To describe teenagers' experiences with perinatal violence assessment.

DESIGN

A descriptive design utilizing qualitative content analysis.

SETTING

Participants were recruited from gynecologic clinics of two level III maternity units and interviewed offsite.

PARTICIPANTS

Twenty nonpregnant teenagers between the ages of 18 and 20 years who had experienced physical or sexual abuse in the year before or during (or both) a pregnancy occurring within the last 3 years were recruited for this study, regardless of past pregnancy outcome.

METHODS

Data were analyzed using categorical content analysis.

RESULTS

Participants reported a range of violence experiences from their parents, current and past intimate partners, and gangs (groups). Four categories emerged that addressed their reasons for not disclosing violence to their health care providers: Power/Powerlessness, Fear/Hope, Trust/Mistrust, and Action/Inertia.

CONCLUSIONS

Abused teenagers have unique needs and concerns that should be addressed when providing pregnancy care.

Prenatal diagnostic decision-making in adolescents

STUDY OBJECTIVE

We sought to evaluate the prenatal decision-making of pregnant adolescents identified at increased risk for identifiable fetal genetic abnormalities.

DESIGN

A retrospective review of records of gravid women 19 years old or younger undergoing genetic counseling from 2001-2003 (inclusive) was undertaken.

SETTING

Hospital-based academic center.

PARTICIPANTS

Thirty-seven women were identified; four cases did not meet inclusion criteria.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Decision to undergo or forgo invasive prenatal testing.

RESULTS

Of the 33 women included in this study, the average age was 17.6 years (range: 15-19). Eighteen were Latinas, eight were African-Americans, and seven were Caucasians. Sixteen women had positive maternal serum screening outcomes; nine women sought counseling because of personal/family histories of genetic abnormalities, seven sought counseling after fetal structural anomalies were detected by ultrasound, and one woman sought counseling because she and her partner were positive for Mendelian disorder screening (sickle cell disease). Sixteen of the women (48.5%) chose to undergo invasive testing (15 amniocenteses, one chorionic villus sampling) whereas 17 (51.5%) chose to forgo invasive testing.

CONCLUSIONS

Adolescents offered invasive prenatal diagnosis will chose to undergo or forgo such testing based on diagnostic and personal criteria as do adult women. Nonetheless, unique adolescent issues may make the process by which information is obtained and communicated during counseling to be different from counseling provided to adults. The development of new genetic screening and diagnostic protocols has and will increase the number of pregnant adolescent women who will be offered genetic counseling during their pregnancies. Such an increase in numbers will place considerably more pressure on an already taxed genetic counseling system; accordingly, new counseling paradigms will need to be developed to provide service to an expanded patient population seeking information for an increasing number of genetic issues.