Violence against women and the perinatal period: the impact of lifetime violence and abuse on pregnancy, postpartum, and breastfeeding

Pivots and Partnerships: Successes, Challenges, and Lessons Learned From Conducting Research During a Global Pandemic

While the importance of including vulnerable populations in research is widely acknowledged, the differential effects of COVID-19 on vulnerable populations necessitated thoughtful participant recruitment. This research note describes one team's attempt at conducting a longitudinal, mixed-methods study during the COVID-19 pandemic with women in the perinatal period who had experienced intimate partner violence. Initial recruitment strategies are provided, as well as the ways in which those initial efforts necessitated revision and redesign. Lessons learned are offered, including ways these strategies may be adapted for other similarly vulnerable populations in the context of a community-level trauma.

Prevalence of postpartum depression & anxiety among women in rural India: Risk factors & psychosocial correlates

BACKGROUND OBJECTIVES

Postpartum depression and anxiety (PPD/A) impact a woman's physical and psychological wellbeing. In the absence of corroboratory evidence from the community setting in India, the present study was undertaken to examine the prevalence, psychosocial correlates and risk factors for PPD/A in the rural community of India.

METHODS

This cross-sectional study included 680 women during the postpartum period from a rural community in northern India. Screening for PPD/A was done using Edinburg Postnatal Depression Scale and State and Trait Anxiety Inventory. Diagnostic assessment of screened-positive women was done using Mini-International Neuropsychiatric Interview (MINI). The psychosocial evaluation was done on parameters including women's social support, bonding with the child, functionality, parental stress, interpersonal violence and marital satisfaction.

RESULTS

The overall prevalence of PPD/A/both in community women was 5.6 per cent, with a specific prevalence of 2.2 per cent for PPD, 0.74 per cent for PPA and 2.8 per cent for both disorders. Comparative analysis indicated that women with PPD/A/both experienced significantly higher levels of parenting stress, poor lifestyle (prior two weeks), less support from their partner, parents-in-law and parents, less marital satisfaction, high intimate partner violence, poor bonding with infants and higher infant-focussed anxiety. On multivariable logistic regression analysis, higher education, marital satisfaction, support from partners and in-laws were associated with reducing the risk of PPD/A/both.

INTERPRETATION CONCLUSIONS

Rural Indian women experience PPD/A/both which causes stress and impacts their functionality, bonding with the infant and relationship with their spouse and parents. Higher education, marital satisfaction and higher support from partners and in-laws reduce the risk of developing PPD/A/both.

Examining the Role of Interpersonal Violence in Racial Disparities in Breastfeeding in North Dakota (ND PRAMS 2017-2019)

BACKGROUND

The 2019 overall breastfeeding initiation rate in the US was 84.1%, yet only 76.6% of American Indian (AI) women initiated breastfeeding. In North Dakota (ND), AI women have greater exposure to interpersonal violence than other racial/ethnic groups. Stress associated with interpersonal violence may interfere with processes important to breastfeeding. We explored whether interpersonal violence partially explains racial/ethnic disparities in breastfeeding in ND.

METHODS

Data for 2161 women were drawn from the 2017-2019 ND Pregnancy Risk Assessment Monitoring System. Breastfeeding questions in PRAMS have been tested among diverse populations. Breastfeeding initiation was self-report to "Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period?" (yes/no). Breastfeeding duration (2 months; 6 months) was self-reported how many weeks or months of breastmilk feeding. Interpersonal violence for both 12 months before and during pregnancy based on self-report (yes/no) of violence from a husband/partner, family member, someone else, or ex-husband/partner. An "Any violence" variable was created if participants reported "yes" to any violence. Logistic regression models estimated crude and adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for breastfeeding outcomes among AI and Other Race women compared to White women. Sequential models were adjusted for interpersonal violence (husband/partner, family member, someone else, ex-husband/partner, or any).

RESULTS

AI women had 45% reduced odds of initiating breastfeeding (OR: 0.55, 95% CI: 0.36, 0.82) compared to white women. Including interpersonal violence during pregnancy did not change results. Similar patterns were observed for all breastfeeding outcomes and all interpersonal violence exposures.

DISCUSSION

Interpersonal violence does not explain the disparity in breastfeeding in ND. Considering cultural ties to the tradition of breastfeeding and the role of colonization may provide a better understanding of breastfeeding among AI populations.

[Child and adolescent psychiatric and therapeutic treatment needs in care settings in the Lower Austrian industrial district. A survey of the demand situation]

An increasing need for child and adolescent psychiatric care is clearly observed in recent years. The present study deals with 20 child and youth care facilities taking care of 439 children and adolescents, in the industrial district, in Lower Austria. The aim of the study is to evaluate treatment needs of this special group of patients. The care facilities reported that 270 children and adolescents (62%) show psychiatric problems. Of these, 220 (50.1%) are diagnosed with one or more psychiatric diagnoses, and 200 children and adolescents are receiving child and adolescent psychiatric treatment. Eleven care facilities reported the necessity for treatment in 80-100% of their accommodated children and adolescents. This results in highly stressful working conditions for professional psychosocial helpers and high treatment needs within their fosterlings. It is evident that more intensive networking and cooperation between institutions and helpers involved is necessary. Further, the development of new, low-threshold child and adolescent psychiatric services would be desirable to adequately meet the increasing need for psychiatric treatment in children and adolescents.

The influence of childhood abuse and prenatal intimate partner violence on childbirth experiences and breastfeeding outcomes

BACKGROUND

Despite the detrimental effects and life-course health consequences of violence exposure, relatively few studies have adequate capacity to investigate the evolution of violence from childhood to motherhood.

OBJECTIVE

This study aims to examine the cyclical nature of childhood abuse and prenatal inter-partner violent victimization (p-IPV) and its adverse impact on childbirth trauma and exclusive breastfeeding (EBF) practice in Vietnam.

METHOD

Using a prospective birth cohort, 150 pregnant women were recruited in the third trimester of pregnancy in Hue city in central Vietnam (Wave 1-Baseline) and re-interviewed approximately three months after delivery (Wave 2-Follow-up). The direct and indirect effects of violent victimization on subsequent childbirth experience (measured by Birth Memories and Recall Questionnaire) and EBF practice were estimated by using augmented-inverse-probability-weighted models, sensitivity analysis, and structural equation model.

RESULTS

Detrimental and prolonged effects of the inter-generational cycle of violence transverse childhood to motherhood. Women who experienced either childhood abuse or p-IPV violence were more likely to experience negative emotional childbirth memories [ARR 1.21, 95 % CI (1.04, 1.39)]. Evidence also suggested that not continuing to exclusively breastfeed at 3 months post-partum was strongly associated with prenatal depression, young age, and perceived low social status during pregnancy. Perceived strong connectedness among extended family members and social networks (i.e. nexus among family, friends, and neighborhood) provided a buffering effect by preventing EBF termination.

CONCLUSION

This research provides insights into the protective role of social connectedness in improving breastfeeding practice. It is vital to establish wholistic antenatal care and social service system to offer specialized support and response for victims of violence and mitigate the long-term sequelae of traumatic events.

Lifetime prevalence and correlates of perinatal depression in a case-cohort study of depression

OBJECTIVES

This study sought to evaluate the prevalence, timing of onset and duration of symptoms of depression in the perinatal period (PND) in women with depression, according to whether they had a history of depression prior to their first perinatal period. We further sought to identify biopsychosocial correlates of perinatal symptoms in women with depression.

DESIGN AND SETTING

The Australian Genetics of Depression Study is an online case cohort study of the aetiology of depression. For a range of variables, women with depression who report significant perinatal depressive symptoms were compared with women with lifetime depression who did not experience perinatal symptoms.

PARTICIPANTS

In a large sample of parous women with major depressive disorder (n=7182), we identified two subgroups of PND cases with and without prior depression history (n=2261; n=878, respectively).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was a positive screen for PND on the lifetime version of the Edinburgh Postnatal Depression Scale. Descriptive measures reported lifetime prevalence, timing of onset and duration of PND symptoms. There were no secondary outcome measures.

RESULTS

The prevalence of PND among parous women was 70%. The majority of women reported at least one perinatal episode with symptoms both antenatally and postnatally. Of women who experienced depression prior to first pregnancy, PND cases were significantly more likely to report more episodes of depression (OR=1.15 per additional depression episode, 95% CI 1.13 to 1.17, p<0.001), non-European ancestry (OR 1.5, 95% CI 1.0 to 2.1, p=0.03), severe nausea during pregnancy (OR 1.3, 95% CI 1.1 to 1.6, p=0.006) and emotional abuse (OR 1.4, 95% CI 1.1 to 1.7, p=0.005).

CONCLUSIONS

The majority of parous women with lifetime depression in this study experienced PND, associated with more complex, severe depression. Results highlight the importance of perinatal assessments of depressive symptoms, particularly for women with a history of depression or childhood adverse experiences.

Intimate Partner Violence and Breastfeeding Behaviors: Does the Source of Breastfeeding Information Affect the Associations Between Prepregnancy or Prenatal IPV and Breastfeeding Behaviors of Women in the United States? A PRAMS 2018 Study

Background: Most countries do not meet World Health Organization's breastfeeding recommendations, and exposure to intimate partner violence (IPV) hinders positive breastfeeding behaviors. One in four U.S. women (43.6 million women) experiences IPV. This study aims to assess relationships between IPV, and breastfeeding initiation, duration, and early cessation among women in 42 U.S. states; and to evaluate possible modifying effect(s) of different breastfeeding information sources. Methods: Centers for Disease Control and Prevention's 2016-2018 Pregnancy Risk Assessment Monitoring System data (n = 105,230) were used to assess relationships between prepregnancy/prenatal IPV and breastfeeding initiation, duration, and early cessation; and modify effects of various breastfeeding information sources on study associations using multilogistic regression models. Results: About 1.4% of women experienced prenatal IPV with reduced odds of breastfeeding for 6 months or more (odds ratio [OR] = 0.74; 95% confidence interval = 0.58-0.94). Receiving breastfeeding information from baby's doctor modified early cessation (0.37 [0.18-0.78]) (p for interaction = 0.009) with prenatal IPV exposure. Among women exposed to prenatal IPV, breastfeeding initiation was stronger in women who received breastfeeding information from family/friends (2.46, [1.24-4.88]) (p for interaction = 0.010) or from breastfeeding support groups (3.03 [1.17-7.88]) (p for interaction = 0.023) compared to those who did not. Breastfeeding information from family/friends modified association between prepregnancy IPV and breastfeeding duration (0.67 [0.45-0.99]) (p for interaction = 0.042). Conclusions: Prenatal IPV is a risk factor for short-duration breastfeeding. Receiving information from doctors, nurses, support groups, and family/friends may improve breastfeeding behavior among IPV-exposed women. Interventions promoting breastfeeding information dissemination by family/friends, support groups, and doctors/nurses during hospital visits are encouraged.

Physical violence against women by their intimate partner during pregnancy and its relationship with breastfeeding

Abstract Objectives: to estimate the association between physical violence against women by their intimate partner during pregnancy and breastfeeding. Methods: the data source is the 2010 National Demographic and Health Survey (DHS) conducted in Colombia, and 11,416 mother-child dyads were analysed. The relationship between physical violence against women by their partner during pregnancy and breastfeeding indicators was carried out using the weighted propensity score from the Inverse Probability of Treatment Weighting (IPTW). Variables for adjustment were selected through the Directed Acyclic Diagram (DAG) and performed a sensitivity analysis to identify the strength of hidden bias. Results: according to the data, 6.4% (730) of the women suffered physical violence by their partner during their pregnancy. The median time of exclusive breastfeeding was 1.0 month. No statistically significant relationship was observed with any of the breastfeeding indicators analysed: exclusive breastfeeding (OR=1.17; CI95%=0.82-1.67); breastfeeding at any time (OR=1.61; CI95%=0.58-2.60); and initiation of breastfeeding (OR=1.07; CI95%=0.74-1.2) Conclusion: although the association between violence against women committed during pregnancy and breastfeeding indicators was not found, the suboptimal breastfeeding practices and high prevalence of violence against women by the partner are two major public health issues in Colombia. Prenatal care professionals can change this scenario by identifying women exposed to intimate partner violence and offering tailored support for breastfeeding practices.

MOSAIC (MOthers’ AdvocateS In the Community) for pregnant women and mothers of children under 5 with experience of intimate partner violence: A pilot randomized trial study protocol

Background

Pregnancy and motherhood increase the risk for long-term exposure to physical, psychological and sexual intimate partner violence (IPV; sexual or physical violence by current or former partners). Pregnant women and mothers with children under 5 who have experienced IPV exhibit poor physical and mental health and obstetric outcomes. Depression and posttraumatic stress disorder (PTSD) are the two most common mental health consequences of IPV. There is good evidence that women with good social support have better mental health and IPV outcomes.

Methods

This study will develop MOthers’ AdvocateS In the Community (MOSAIC) Plus intervention for pregnant women and mothers with children under the age of 5. MOSAIC uses trained mentor mothers and has been found to reduce subsequent IPV. This study will blend the original MOSAIC intervention with principles of interpersonal psychotherapy (IPT) to address symptoms of depression, PTSD, and prevent subsequent risk of IPV. We will conduct a pilot randomized trial of the MOSAIC Plus intervention compared to the traditional MOSAIC intervention to determine its feasibility and acceptability. Study samples include focus groups (n = 36), open trial (n = 15), and a randomized pilot trial including 40 pregnant women and mothers with children under 5 who report current/recent of IPV and elevated symptoms of maternal depression and/or PTSD. The study’s primary outcome will be changes in maternal depressive and PTSD symptoms. Secondary outcomes will include reduction in subsequent IPV, improvement in functioning, changes in social support and effectiveness in obtaining resources.

Discussion

This is a formative study evaluating the feasibility and acceptability of a mentor mother intervention for pregnant women and mothers with children under 5. Promising results of this study will be used for a larger, fully-powered randomized trial evaluating the effectiveness of a mentor mother intervention in preventing subsequent IPV and reducing depressive and PTSD symptoms in this population.

Association between exposure to intimate partner violence and the nutritional status of women and children in Nigeria

Background

Globally, intimate partner violence (IPV) epitomizes a greater proportion of the violence experienced by women, with more than a third of women (41.3%) in sub-Saharan Africa reporting IPV during their lifetime. This study examined the association between exposure to IPV and the nutritional status of women and their children in Nigeria.

Methods

The study analyzed secondary data obtained from the 2018 Nigeria Demographic and Health Survey. Data on women’s lifetime experience of psychological, physical, and sexual IPV, as well as demographic and socioeconomic characteristics, were collected. We used regression models to determine the association between exposure to IPV and women and child nutrition indicators. A weighted sample of 4,391 women aged 15–49 years and 2,145 children 6–59 months were analyzed.

Results

The lifetime experience of IPV in the study was 35.31% (95% CI: 33.35, 37.33), 30.43% (95% CI: 28.54, 32.38) experienced psychological IPV, 19.43% (95% CI: 17.79, 21.19) experienced physical IPV, and 6.03% (95% CI: 5.12, 7.09) experienced sexual IPV. After adjusting for a range of characteristics, maternal lifetime exposure to IPV was associated with underweight (ARRR = 0.63; 95% CI: 0.44, 0.91) and overweight/obesity (ARRR = 1.28; 95% CI: 1.04, 1.58). We also found that, children whose mothers experienced IPV were less likely to be underweight compared to their counterparts (ARRR = 0.69; 95% CI: 0.50, 0.96).

Conclusions

Overall, IPV against women, particularly psychological, physical, and sexual IPV, is common in Nigeria and has an association with the nutritional status of affected women and their children. According to the study, women with a lifetime experience of IPV were more likely to be overweight. On the other hand, affected women’s children were less likely to be underweight. A far-reaching effort is required to curb IPV against women, particularly policies, programs, and laws are needed to protect women and children from the unfavourable effects of IPV to reduce the prevalence and impact of such violence.

Pathways Linking Intimate Partner Violence and Postpartum Depression Among Jewish and Arab Women in Israel

Intimate partner violence (IPV) is a major risk factor for postpartum depression (PPD), with 9% to 28% of PPD cases reporting IPV at some point in their lives. Yet little is known about how these phenomena are associated. We asked, "What direct and indirect pathways link IPV to PPD in women belonging to different ethnic-national groups in Israel?" We recruited a stratified sample of Jewish and Arab women, 18 to 48 years old and 6 months postpartum, during their visits to maternal and child health clinics. We computed path analyses to identify both direct and indirect predictors linking IPV frequency and PPD in a stratified sample of Jewish (n = 807) and Arab (n = 248) women. The overall rate of PPD was estimated at 10.3%, whereas the rate of IPV for the total sample was 36%. We identified a direct link between IPV and PPD. IPV also appeared to have an equivalent, indirect effect on PPD via greater chronic stress and reduced social support. IPV was greater and social support was lower for Arab women, who also reported higher PPD, independent of sociodemographic differences between ethnic groups (i.e., education, occupation). Of note, an unplanned pregnancy appeared to increase the risk of both IPV and PPD. Our findings suggest that complex pathways link IPV to PPD and that indirect effects of IPV are equivalent to its direct effects on postpartum women. These findings contribute to a growing international body of research showing the significant effects of IPV on health and well-being. The factors we identified as directly and indirectly associated with PPD might inform interventions to identify and treat PPD.

Design and Evaluation of a Postpartum Depression Ontology

OBJECTIVE

Postpartum depression (PPD) remains an understudied research area despite its high prevalence. The goal of this study is to develop an ontology to aid in the identification of patients with PPD and to enable future analyses with electronic health record (EHR) data.

METHODS

We used Protégé-OWL to construct a postpartum depression ontology (PDO) of relevant comorbidities, symptoms, treatments, and other items pertinent to the study and treatment of PPD.

RESULTS

The PDO identifies and visualizes the risk factor status of variables for PPD, including comorbidities, confounders, symptoms, and treatments. The PDO includes 734 classes, 13 object properties, and 4,844 individuals. We also linked known and potential risk factors to their respective codes in the International Classification of Diseases versions 9 and 10 that would be useful in structured EHR data analyses. The representation and usefulness of the PDO was assessed using a task-based patient case study approach, involving 10 PPD case studies. Final evaluation of the ontology yielded 86.4% coverage of PPD symptoms, treatments, and risk factors. This demonstrates strong coverage of the PDO for the PPD domain.

CONCLUSION

The PDO will enable future researchers to study PPD using EHR data as it contains important information with regard to structured (e.g., billing codes) and unstructured data (e.g., synonyms of symptoms not coded in EHRs). The PDO is publicly available through the National Center for Biomedical Ontology (NCBO) BioPortal ( https://bioportal.bioontology.org/ontologies/PARTUMDO ) which will enable other informaticists to utilize the PDO to study PPD in other populations.

Perception, Prevalence, and Determinants of Intimate Partner Violence During Pregnancy in Urban Slums of Pune, Maharashtra, India

There is limited evidence on the prevalence and determinants of violence against pregnant women in India. Previous studies were entirely restricted to the violence against women in the reproductive age group. There is lack of evidence about the factors affecting violence against women during pregnancy. Understanding such factors, women's perception regarding violence during pregnancy and their justification of such violence could manifest an important aspect of violence. Women living in slum communities particularly are victims of violence. In this context, this study intended to examine women's perception, prevalence of, and factors affecting the violence against women during pregnancy in the slum communities of Pune. A community-based cross-sectional study of 1-year duration was undertaken in urban slums of Pune city, Maharashtra, India. The study participants were women who have delivered 2 years preceding the survey. Using simple random sampling, 500 women were selected from 10 purposively selected slums. House-to-house visits were made and face-to-face interviews conducted using a pretested structured questionnaire. Univariate, bivariate, and logistic regression analyses were applied. The study results show that 15.3% of women have experienced violence during their recent pregnancy. Furthermore, 9.2% of women experienced physical violence, 1.8% sexual violence, and 11.2% psychological violence. Education level of women, husband's education and alcohol consumption, history of violence in the family, and provision of spurious justification for violence have emerged as some of the leading factors associated with the violence inflicted during pregnancy. Effective interventions at both community and health care settings are needed urgently to reduce the violence inflicted during pregnancy.

Prenatal Stress Exposure and Post-traumatic Stress Disorder Associated With Risk of Postpartum Alcohol Misuse Among Women Veterans

OBJECTIVES

Maternal alcohol misuse during the postpartum period is associated with negative maternal and infant outcomes. This study examined whether greater stress exposure in the year before the baby's birth and maternal post-traumatic stress disorder (PTSD) were associated with postpartum alcohol misuse among a sample of women veterans. Maternal PTSD was also examined as a moderator of the association between stress exposure and postpartum alcohol misuse.

METHODS

Data were drawn from the Center for Maternal and Infant Outcomes Research in Translation study, a multisite prospective cohort study of pregnant and postpartum women veterans. Interviews were conducted within 12 weeks after birth. At this post-birth interview, women reported whether they experienced stressful events (e.g., loss of job, military deployment, separation/divorce) in the year before birth. PTSD diagnosis and postpartum scores on the Alcohol Use Disorders Identification Test (AUDIT-C) were derived from the Department of Veterans Affairs medical records.

RESULTS

Models testing main and interaction effects showed a statistically significant association of both PTSD (p = .02) and stress exposure (p = .04), as well as significant interaction of PTSD and stress exposure (p = .03) with AUDIT-C scores postpartum, after controlling for marital status, age, and race. Specifically, compared with women without PTSD, those with PTSD had higher overall AUDIT-C scores postpartum, regardless of stress exposure. For women without PTSD, more stress exposure before birth was associated with higher AUDIT-C scores during the postpartum phase.

CONCLUSIONS

PTSD diagnosis and life stressors before infant birth predicted maternal alcohol misuse during the postpartum period. Identifying such risk factors is an initial step in preventing alcohol misuse, with the goal of enhancing postpartum health for the birthing parent and infant.

Exposure to domestic violence and the risk of developing depression within 6 months postpartum in Bangladesh

PURPOSE

Domestic violence (DV) by husbands or in-laws is a recognized problem in many countries and is associated with a wide range of adverse mental health outcomes. However, detailed knowledge on the relationship between DV experience and postpartum depression (PPD) is essential to design appropriate interventions. Therefore, this study assesses the relationship between maternal experience of DV perpetrated by husbands or in-laws and PPD in Bangladesh.

METHODS

A cross-sectional survey was conducted from October to December 2019 among 497 mothers within the first 6 months postpartum who attended a health center in Rajshahi City Corporation, Bangladesh. Multivariable logistic regressions were performed to identify the associations after controlling for potential confounders.

RESULTS

The prevalence of PPD in this sample was 34% within the first 6 months after birth; 58.6% of mothers reported having experienced any form of DV in their lifetime. Maternal experience of any form of DV (Adjusted Odds Ratio [AOR] = 1.87; 95% confidence interval [CI] = 1.19-2.93) was associated with PPD, as were experiences of any physical DV (AOR = 2.25; 95% CI = 1.40-3.59), emotional DV (AOR = 2.07; 95% CI = 1.34-3.19), and controlling behavior (AOR = 1.69; 95% CI = 1.08-2.66). Additionally, the likelihood of PPD significantly increased among women who experienced more forms of DV.

CONCLUSION

DV perpetrated by husband and/or in-laws is highly prevalent and significantly associated with PPD in Bangladesh. Strategies in developing interventions for improving maternal mental health should consider DV perpetrated by either husband or in-laws.

Psychological Intervention and Treatment for Posttraumatic Stress Disorder During Pregnancy: A Systematic Review and Call to Action

Posttraumatic stress disorder (PTSD) during pregnancy is a significant global mental health concern that affects up to 1 in 5 trauma-exposed pregnant women and is associated with an increased risk of adverse maternal and infant complications and health outcomes. This systematic literature review, conducted in accordance with PRISMA guidelines, examined findings from studies of psychological interventions and treatments for prenatal PTSD to inform recommendations for future research. Relevant evidence was identified from reference reviews and electronic databases (i.e., PubMed, Google Scholar, PsychInfo, and Scopus). Included studies reported on the effect of nonpharmacological intervention or treatment of PTSD symptomatology delivered during pregnancy, with at least one postintervention follow-up collected during pregnancy to assess prenatal treatment outcomes. The systematic review was augmented with a discussion of lower-level evidence. Of the 954 articles screened, six peer-reviewed, quantitative reports met the inclusion criteria and featured three empirically based interventions, including two randomized controlled trials: Two psychoeducation interventions for PTSD and one treatment study of interpersonal psychotherapy in trauma-exposed pregnant women. Effect sizes for PTSD symptom change ranged from small to large, Cohen's d/η_p ² = 0.16-0.78. No studies examined evidence-based PTSD treatments (e.g., exposure therapy, cognitive processing therapy). A risk of bias assessment indicated variability in study quality. This review demonstrates that research on prenatal PTSD symptoms, diagnosis, and treatment is extremely limited despite a clear link between prenatal PTSD and perinatal complications. Early evidence supports further scientific inquiry into psychoeducation, psychotherapy treatments (e.g., exposure therapy), integrated prenatal care approaches, and community-based approaches.

Early exclusive breastfeeding cessation and postpartum depression: Assessing the mediating and moderating role of maternal stress and social support

Background

Early termination of exclusive breastfeeding (EBF) and postpartum depression (PPD) are both recognized as global health problems. Recent literature reviews demonstrate a notable link between PPD and breastfeeding outcomes, however, the underlying mechanisms linking the two remain unclear.

Objectives

The aim of the study is to: 1) explore the comparative risk for PPD among new mothers who terminated EBF before the 6-month mark, compared to those who did not; and 2) test whether maternal stress and social support operate to mediate and/or moderate the relationship between EBF and PPD.

Methods

Between October 2015 and January 2016, a cross-sectional study was carried out among 426 new mothers of Bangladesh who were six months postpartum.

Results

Based on the multivariate logistic regression model, non-exclusively breastfeeding mothers were 7.58-fold more likely to experience PPD (95% CI [3.94, 14.59]) than exclusively breastfeeding mothers. Additionally, maternal stress and social support not only partially mediate the relationship between EBF and PPD but also substantially moderate this relationship. Specifically, the odds of PPD are significantly higher among mothers who had early EBF interruption in conjunction with increased stress levels and limited social support.

Conclusions

Current evidence suggests that concurrent screening for EBF difficulties and maternal stress are important red flags that might hint at complications even before mother’s screen positive for PPD. Support and care from family members can provide assistance in overcoming this issue.

The effects of Intimate Partner Violence and a history of Childhood Abuse on Mental Health and Stress during Pregnancy

PURPOSE

Maternal adverse childhood experiences (ACEs) and intimate partner violence (IPV) are temporally distinct risk factors that negatively impact mothers and their offspring. Risk associated with ACEs and IPV begin during pregnancy, a period of increased physical and psychological demands. The current study examined a person-centered method to empirically identify profiles of pregnant women based on type and severity of ACEs and past-year IPV. Profiles were then differentiated on psychosocial functioning indicators.

METHODS

A primarily Latinx, low socioeconomic sample of women (n = 225) completed measures assessing ACEs and past-year IPV, perceived and experienced stress, emotion regulation, and trauma-related symptoms during their third trimester. Latent profile analysis (LPA) was used to identify unique profiles of women based on seven dimensional indicators reflecting threat- and deprivation-based ACEs and IPV.

RESULTS

A 4-class solution best fit the data: (1) low probability of ACEs or IPV (64.9%), (2) childhood neglect-only (20.4%), (3) childhood abuse/neglect (10.2%), and (4) polytrauma characterized by a combination of childhood abuse, neglect, and IPV (4.4%). Women with the "childhood abuse/neglect" or "polytrauma" profiles reported more stress and symptoms than women with the "low exposure" profile. Women in the "childhood neglect-only" profile were generally similar to women in the "low exposure" profile, but did report greater difficulties in emotion regulation.

CONCLUSIONS

These results suggest that childhood abuse and IPV, exposure types involving threat, are potent correlates of stress, emotion regulation, and mental health difficulties during pregnancy. However, exposure characterized by deprivation alone generally did not increase difficulties.

Lactose-free infant formula does not change outcomes of neonatal abstinence syndrome (NAS): a randomized clinical trial

OBJECTIVE

To determine if lactose-free formula, compared to lactose-containing formula, decreases the cumulative morphine dose required to treat neonatal abstinence syndrome (NAS).

STUDY DESIGN

In a double-blind clinical trial, we randomized 74 infants (36-42 weeks gestation) at risk for developing NAS due to in-utero exposure to opioids to receive either lactose-free (Similac Sensitive®) or lactose-containing (Similac Advance®) infant formula. The primary outcome measure was the cumulative dose of morphine used for the treatment of NAS during the first 14 days of life.

RESULTS

Data on 69 (4 withdrew consent and 1 ineligible)/74 randomized infants were analyzed. Patient characteristics between the infant groups fed lactose-free (n = 34) vs. lactose-containing (n = 35) infant formula were similar except more common maternal heroin abuse in the latter group (p = 0.013). Cumulative morphine dose (20.7 ± 19.8 vs. 23 ± 23.5 mg, p = 0.61) between the two groups were similar.

CONCLUSION

Lactose-free vs. lactose-containing infant formula did not change the outcomes of infants with NAS.

Maternal experience of intimate partner violence is associated with suboptimal breastfeeding practices in Malawi, Tanzania, and Zambia: insights from a DHS analysis

BACKGROUND

Despite widespread suboptimal breastfeeding practices and maternal experiences of intimate partner violence (IPV), the association of IPV and breastfeeding practices remains unclear. This study investigated the associations between maternal experience of physical, sexual, emotional violence, and controlling behaviors with suboptimal breastfeeding practices in Malawi, Tanzania, and Zambia.

METHODS

Data included mother-infant dyads from the most recent Demographic and Health Surveys for Malawi (n = 1878), Tanzania (n = 3184), and Zambia (n = 3879). Intimate partner violence (physical, sexual, and emotional) was measured using the Revised Conflict Tactics Scale. Breastfeeding practices were early initiation of breastfeeding (within 1 h of birth), exclusive breastfeeding (in previous 24 h), and continued breastfeeding. Associations between experience of physical, sexual, or emotional violence or controlling behaviors and breastfeeding practices, as well as associations between the frequency of IPV and breastfeeding practices were assessed.

RESULTS

Many Malawian (77.6%) and Zambian (67.7%) and just over half (53.6%) of Tanzanian mothers, initiated breastfeeding within 1 h of birth. Exclusive breastfeeding was 70.6% in Zambia and 60.1% in Malawi, while 55.0% of Tanzanian mothers breastfed exclusively. Continued breastfeeding to at least 1 year was high in Malawi 92.2%, Tanzania 93.4%, and Zambia 95.0%. Most mothers reported experiences of IPV in Tanzania 79.1%, Zambia 78.9%, and Malawi 73.9%. Mothers who experienced sexual IPV were significantly more likely to delay breastfeeding (Malawi [AOR 1.55 (1.14, 2.10)]; Tanzania [AOR 1.30 (1.04, 1.62)]; and Zambia [AOR 1.28 (1.06, 1.54)]). Sexual IPV in Malawi and Zambia was associated with greater odds of not exclusively breastfeeding (Malawi [AOR 1.90 (1.05, 3.45)]; Zambia [AOR 1.75 (1.15, 2.67)]). Tanzanian mothers who experienced IPV often or sometimes were two times more likely not to breastfeed at one-year post-delivery [AOR 2.23 (1.09,4.57)].

CONCLUSIONS

In the three countries investigated maternal experience of IPV was associated with suboptimal breastfeeding practices. Policies and programs targeting improved breastfeeding practices should consider screening during antenatal and postnatal care for experience of violence and support initiatives to reduce IPV.

Intimate partner violence and exclusive breastfeeding of infants: analysis of the 2013 Nigeria demographic and health survey

BACKGROUND

Existing knowledge on the relationship between intimate partner violence (IPV) and exclusive breastfeeding (EBF) in the context of Nigeria is minimal and limited to a lifelong measure of IPV experience. An abuse experienced a long time ago may not have as much negative effect as that encountered at a more proximal time to the breastfeeding phase. To this effect, we examined this relationship with maternal IPV experienced around the time of pregnancy and postpartum.

METHOD

We analyzed data from the 2013 Nigeria Demographic and Health Survey. The sample includes 2668 breastfeeding mothers having a child aged under 6 months. The outcome variable was EBF or mixed-feeding (24 h recall). The exposure variables were: the maternal experience of psychological, physical, and sexual intimate partner violence. Also, there was an experience of any form of IPV and frequency score of intimate partner violence. Analysis includes chi-square and t-test bivariates, complete case and imputed logistic regressions for binary outcome.

RESULTS

In the imputed analysis, compared to mothers who experienced no IPV, those who experienced IPV had a 26% reduced likelihood of EBF practice (AOR 0.74; 95% CI 0.55, 1.00). Also, a unit dose of maternal IPV experience was associated with a 5% reduced likelihood of EBF practice (AOR 0.69; 95% CI 0.49, 0.98). Among the three forms of IPV, physical IPV had the highest effect size. Physical IPV was associated with a 37% reduced likelihood of EBF practice (AOR 0.63; 95% CI 0.44, 0.90), while psychological IPV was associated with a 34% reduced likelihood of EBF practice (AOR 0.66; 95% CI 0.47, 0.92), when compared to the respective reference groups. On the other hand, those who reported sexual IPV were just as likely to breastfeed as those who did not (AOR 0.94; 95% CI 0.62, 1.41).

CONCLUSIONS

In this study, maternal IPV is associated with EBF practice. Policies aimed at promoting EBF should also be framed to combat IPV against pregnant women and nursing mothers.

A Systematic Review and Meta-Analysis of Risk Factors for Postpartum Depression Among Latinas

OBJECTIVES

The purpose of this article was to describe the findings from a systematic review, quality review, and meta-analysis of risk factors for postpartum depression among adult Latinas in the United States.

METHODS

Databases were searched from inception to May 2020 for studies published in English related to Latina/Hispanic mothers and risk factors of postpartum depression. Of 115 abstracts screened, 10 met the inclusion criteria for the review and meta-analysis. Eleven risk factors from these studies were included: acculturation, age, economic stress, education, marital status, number of children, prenatal depression, recent and remote intimate partner violence (IPV), general social support, and partner/father's social support.

RESULTS

Partner/father's social support had a large effect size. Prenatal depression and recent IPV had medium effect sizes, while education, economic stress, general social support and remote IPV had small effect sizes. Negligible effect sizes were found for age, marital status, number of children, and acculturation.

CONCLUSIONS

Prenatal depression, IPV, social support (general and from partner/father), economic stress and education are risk factors that should be screened for when working with perinatal Latinas. Future directions for clinical practice and research are discussed.

Predictors of Prenatal Depression: A Cross-Sectional Study in Rural Pakistan

Objective: To determine the prevalence and association of prenatal depression with socioeconomic, demographic and personal factors among pregnant women living in Kallar Syedan, Rawalpindi, Pakistan. Methods: Five hundred women in the second and third trimester of pregnancy, living in Kallar Syedan, a rural area of district Rawalpindi Pakistan, were included in the study. Depression was assessed using "Patient health questionnaire" (PHQ9) in Urdu, with a cut-off score of 10. Multi-dimensional scale of perceived social support (MSPSS) was used to assess perceived social support. Life Events and Difficulties Schedule (LEDS) were used to measure stressful life events in past 1 year. Tool to assess intimate partner violence (IPV) was based on WHO Multi Country Study on "Women's Health and Domestic Violence against Women." Results: Prevalence of prenatal depression was found to be 27%. Number of pregnancies was significantly associated with prenatal depression (p < 0.01). Women living in a joint family and those who perceived themselves as moderately satisfied or not satisfied with their life in the next 4 years were found to be depressed (p < 0.01, OR 6.9, CI 1.77-26.73). Depressive symptomatology in women who experienced more than five stressful life events in last 1 year was three times higher (p < 0.001, OR 3.2, CI 1.68-5.98) than in women with 1-2 stressful events. Women who were supported by their significant others or their family members had 0.9 times (p < 0.01, OR 0.9, CI 0.85-0.96) less chance of getting depressed. Pregnant women who were psychologically abused by their partners were 1.5 times more depressed (p < 0.05 CI 1.12-2.51). Odds of having depression was also high in women who had less mean score of MSSI (p < 0.05, OR 1.1, CI 1.01-1.09). Women who had suitable accommodation had 0.5 times less chance of having depression than others (p < 0.05, OR 0.5, CI 0.27-0.92). Conclusion: Over a quarter of the women in the study population reported prenatal depression, which were predicted predominantly by psychosocial variables.

Risk and resilience: a mixed methods investigation of Aboriginal Australian women's perinatal mental health screening assessments

PURPOSE

To describe the psychosocial protective and risk factors for perinatal mental health identified in a sample of Aboriginal women's Kimberley Mum's Mood Scale (KMMS) assessments and explore the role of these factors in their screening assessment and diagnostic outcome.

METHODS

We used a mixed methods approach to retrospectively analyse a cross-sectional study dataset of 91 completed KMMS assessments. This included: categorising the clinical notes from the KMMS psychosocial yarn into 'risk' and 'protective' factors and describing these categories, describing the number and type of risk and protective factors associated with different KMMS risk assessment categories (no, low, medium, high), and exploring relationships between these risk and protective factors and diagnosis of perinatal depression and/or anxiety.

RESULTS

Protective factors were recorded for the vast majority of the women; the most prominent was positive family relationships. When protective and risk factors were stratified by KMMS risk category, women in the higher risk group less commonly had specific protective factors (11-33% high vs 61-100% no risk) and more commonly had risk factors (22-67% high vs 6-28% no risk) than women with lower KMMS assessed risk. The average number of protective factors decreased with increasing KMMS risk category (4.9 ± 1.1 to 1.6 ± 1.3), with the inverse pattern for risk factors (1.1 ± 1.1 to 3.8 ± 1.0). Having protective factors also appeared to reduce the risk of developing clinical depression or anxiety.

CONCLUSION

Assessing protective factors in mental health screening for perinatal Aboriginal women increases the effectiveness of screening and provides a foundation for the delivery of local structured psychosocial care.

The Price of Pre-adolescent Abuse: Effects of Sexual Abuse on Perinatal Depression and Anxiety

INTRODUCTION

Childhood abuse is a major public health concern and a risk factor for subsequent poor maternal mental health. This study of 176 racially diverse women explored the associations between the histories of childhood sexual abuse and depression and anxiety during pregnancy, at six weeks postpartum, and 12 weeks postpartum.

METHODS

Data on depressive and anxiety symptoms were gathered during pregnancy, at six weeks postpartum, and 12 weeks postpartum. Sociodemographic data were collected during pregnancy, while data on childhood sexual abuse were gathered during the 12-week postpartum period. Bivariate analyses and repeated mixed-effects linear regression with bootstrapping were used to assess the association between childhood sexual abuse and perinatal depressive and anxiety symptoms.

RESULTS

Childhood sexual abuse was significantly associated with depressive symptoms (β = 2.52, 95% CI 1.72, 3.32, p < .001) and anxiety symptoms (β = 4.44, 95% CI 3.70, 5.81, p < .001) over time, while controlling for demographic characteristics and lifetime major depression and anxiety. Depressive and anxiety symptoms decreased over the perinatal period and were highest during pregnancy. Black women were more likely to report higher depressive symptoms (β = 1.35, 95% CI 0.51, 2.19, p = .002) and anxiety symptoms (β = 3.29 95% CI 1.72, 4.87, p < .001) over time compared to White women.

DISCUSSION

The results highlight the importance of assessing the long-term effects of childhood sexual abuse on perinatal depressive and anxiety symptoms to help inform the development of interventions for women, particularly Black women.

Recurrent Violence, Violence with Complications, and Intimate Partner Violence Against Pregnant Women and Breastfeeding Duration

Background: Few studies have investigated the association between violence against pregnant women in terms of recurrence, complications, and perpetrators of violence, and breastfeeding duration. This study verifies whether recurrent violence, violence with pregnancy complications, and intimate partner violence (IPV) against pregnant women are associated with shorter exclusive breastfeeding up to the infant's 6th month and breastfeeding up to the 12th month of life. Materials and Methods: A cohort study with a convenience sample of 1,146 pregnant women was performed. Follow-up assessments were conducted at birth, and at 12-36 months. Survival analysis was used to verify whether recurrent violence, violence with pregnancy complications, and IPV were associated with reduced duration of exclusive breastfeeding and breastfeeding. Results: The adjusted Cox regression revealed no difference regarding exclusive breastfeeding duration among mothers exposed or not exposed to violence and according to who perpetrated the violence. The risk of an infant not being breastfed within the first 12 months of life increased in cases of violence before/during pregnancy (95% confidence interval [CI] = 1.03-1.88), recurrent psychological/physical/sexual violence during pregnancy (95% CI = 1.11-1.92), recurrent psychological violence (95% CI = 1.05-1.96), and recurrent physical/sexual violence (95% CI = 1.01-2.39). Violence with pregnancy complications (95% CI = 0.94-2.22) was not associated with breastfeeding interruption. Similar risks of breastfeeding interruption were observed for IPV (95% CI = 0.96-1.87) and violence perpetrated by other family members (95% CI = 0.83-1.89). Conclusions: We observed a shorter breastfeeding duration up to 12 months of life in cases of recurrent violence.

Patterns of healthcare services utilization associated with intimate partner violence (IPV): Effects of IPV screening and receiving information on support services in a cohort of perinatal women

Background

While women experiencing intimate partner violence (IPV) face significant health consequences, their patterns of healthcare services (HCS) utilization are unclear, as are the effects of IPV screening and receiving information on these patterns.

Objectives

1. Compare utilization patterns of five HCS (visits to family physician, gynecologist, specialist and emergency room, and hospitalization) in a cohort of perinatal women who reported experiencing versus not experiencing any IPV and IPV types (physical and/or sexual; emotional and/or verbal; social and economic); 2. Examine whether IPV screening, receiving information on support services, or both, affect patterns; and 3. Compare these associations between ethnic groups (Arab and Jewish women).

Methods

We conducted a prospective study using registry data on HCS utilization obtained from Israel’s largest Health Fund (Clalit) in the year following a 2014–2015 survey of a cohort of 868 perinatal women in Israel (327 Arab minority, 542 Jewish) on their reports of experiencing IPV, IPV screening, and receiving information. Using multivariate analysis, we calculated adjusted odds ratios (AOR) and 95% confidence intervals (CI) for the five HCS utilizations in association with reports of any IPV and IPV types. We adjusted for IPV screening, receiving information about services, and both, in the total sample, and separately among ethnic groups.

Results

Any IPV and IPV types had significant associations with some HCS utilization variables, with different directions and patterns for the ethnic groups. Experiencing IPV was associated with higher HCS utilization among Arab women, lower utilization in Jewish women. Arab women experiencing IPV were twice as likely to visit a gynecologist than women not experiencing IPV (AOR (95% CI) was 2.00, 1.14–3.51 for any IPV; 2.17, 1.23–3.81 for emotional and/or verbal IPV, and 1.83, 1.04–3.22, for social and economic IPV). Among Jewish women, experiencing any IPV was associated with lower likelihood of emergency-room visits (0.62, 0.41–0.93); and experiencing physical and/or sexual IPV was associated with lower likelihood of family physician visits (OR = 0.20, 0.05–0.82). Both IPV screening and receiving information were associated with lower HCS utilization among Arab women only.

Conclusions

Different HCS utilization patterns among women who reported experiencing versus not experiencing IPV in different ethnic groups suggest complex relationships that hinge on how HCS address women’s needs, starting with IPV screening and providing information. This might inform tailored programs to tackle IPV at the HCS, particularly for minority women.

Determinants of Exclusive Breastfeeding Cessation in the Early Postnatal Period among Culturally and Linguistically Diverse (CALD) Australian Mothers

There are limited epidemiological data on exclusive breastfeeding (EBF) among culturally and linguistically diverse (CALD) Australian mothers to advocate for targeted and/or culturally-appropriate interventions. This study investigated the determinants of EBF cessation in the early postnatal period among CALD Australian mothers in Sydney, Australia. The study used linked maternal and child health data from two local health districts in Australia (N = 25,407). Prevalence of maternal breastfeeding intention, skin-to-skin contact, EBF at birth, discharge, and the early postnatal period (1-4 weeks postnatal), were estimated. Multivariate logistic regression models were used to investigate determinants of EBF cessation in the early postnatal period. Most CALD Australian mothers had the intention to breastfeed (94.7%). Skin-to-skin contact (81.0%), EBF at delivery (91.0%), and at discharge (93.0%) were high. EBF remained high in the early postnatal period (91.4%). A lack of prenatal breastfeeding intention was the strongest determinant of EBF cessation (adjusted odds ratio [aOR] = 23.76, 95% CI: 18.63-30.30, for mothers with no prenatal breastfeeding intention and aOR = 6.15, 95% CI: 4.74-7.98, for those undecided). Other significant determinants of EBF cessation included a lack of partner support, antenatal and postnatal depression, intimate partner violence, low socioeconomic status, caesarean birth, and young maternal age (<20 years). Efforts to improve breastfeeding among women of CALD backgrounds in Australia should focus on women with vulnerabilities to maximise the benefits of EBF.

Intimate partner violence and subsequent premature termination of exclusive breastfeeding: A cohort study

Objective

The objective of this study was to examine whether exposure to Intimate Partner Violence (IPV) is associated with premature termination of Exclusive Breastfeeding (EB). Per WHO recommendations, this was defined as ceasing breastfeeding or supplementing with other foods or liquids before the child was 6 months old.

Method

It is a prospective cohort study set in Moshi, Tanzania consisting of 1128 pregnant women with live singleton births. Women were enrolled during pregnancy and followed up with interviews during pregnancy, after birth and 2–3 years postpartum, using structured questionnaires. Emotional, physical and sexual IPV exerted by the current partner was assessed at 34 weeks gestational age with WHO questionnaires. Months of EB was assessed 2–3 years postpartum. Premature termination of EB was defined as less than 6 months of EB. Analyses were made using a logistic regression model adjusted for maternal age, education, HIV-status, alcohol use during pregnancy and parity. Confounding variables were determined using a theoretical framework approach, i.e. a Directed Acyclic Graph model to minimize bias.

Results

Women who were exposed to IPV had more than 50% higher odds of terminating EB before the child was 6 months old compared to women who were not exposed (aOR = 1.62, 95%CI: 1.27–2.06).

Women exposed to all three types of IPV had twice the odds of early termination of EB (aOR = 1.95, 1.12; 3.37). Furthermore, the odds were tripled if exposure happened specifically during the index pregnancy (aOR = 2.93 95%CI: 1.3; 6.6). Stratified analyses showed the most severely affected groups were the mothers older than 30 and those who gave birth to girls.

Conclusions

The results indicated that exposure to IPV is associated with increased risk of premature termination of EB. The odds increase with multiple types of the IPV, especially when exposed during the index pregnancy.

Mapping a Syndemic of Psychosocial Risks During Pregnancy Using Network Analysis

BACKGROUND

Psychosocial risks during pregnancy impact maternal health in resource-limited settings, and HIV-positive women often bear a heavy burden of these factors. This study sought to use network modeling to characterize co-occurring psychosocial risks to maternal and child health among at-risk pregnant women.

METHODS

Two hundred pregnant HIV-positive women attending antenatal care in South Africa were enrolled. Measured risk factors included younger age, low income, low education, unemployment, unintended pregnancy, distress about pregnancy, antenatal depression, internalized HIV stigma, violence exposure, and lack of social support. Network analysis between risk factors was conducted in R using mixed graphical modeling. Centrality statistics were examined for each risk node in the network.

RESULTS

In the resulting network, unintended pregnancy was strongly tied to distress about pregnancy. Distress about pregnancy was most central in the network and was connected to antenatal depression and HIV stigma. Unintended pregnancy was also associated with lack of social support, which was itself linked to antenatal depression, HIV stigma, and low income. Finally, antenatal depression was connected to violence exposure.

CONCLUSIONS

Our results characterize a network of psychosocial risks among pregnant HIV-positive women. Distress about pregnancy emerged as central to this network, suggesting that unintended pregnancy is particularly distressing in this population and may contribute to further risks to maternal health, such as depression. Prevention of unintended pregnancies and interventions for coping with unplanned pregnancies may be particularly useful where multiple risks intersect. Efforts addressing single risk factors should consider an integrated, multilevel approach to support women during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03069417.

Does the type of maltreatment matter? Assessing the individual and combined effects of multiple forms of childhood maltreatment on exclusive breastfeeding behavior

BACKGROUND

Childhood maltreatment (CM) has been associated with a range of adult health outcomes; however, extant research has focused more on exposure to a single form of abuse rather than multiple forms. Moreover, very few studies have specifically investigated the impact of CM on exclusive breastfeeding (EBF) outcomes.

OBJECTIVES

This study aims to examine: (1) the individual and combined effects of multiple forms of CM on EBF outcomes; and (2) whether postpartum depression and maternal stress act to mediate or moderate the association between CM and EBF.

METHOD

Cross-sectional survey data were collected between October 2015 and January 2016 from 426 women of Bangladesh who were six months postpartum.

RESULTS

Based on the adjusted multivariate logistic regression model, women who experienced childhood sexual abuse (CSA) were significantly less likely to exclusively breastfeed babies than their non-abused counterparts (AOR: 0.38, 95% CI [0.15, 0.92]). When a composite measure was created to examine the additive effects of adverse childhood experiences, a dose-response association was observed between the reported number of different types of CM and early termination of EBF. Though experiencing postpartum depression and maternal stress do not mediate the effect of CSA on EBF, they do moderate them such that the odds of early termination of EBF are notably higher among women who experienced CSA in combination with postpartum depression or high levels of stress.

CONCLUSIONS

Findings from this study offer some insight into the intergenerational effects associated with CM experiences, and underpin the need for effective policies and programs to prevent or reduce its occurrence and improve the EBF outcomes.

Improving Maternal Representations in High-Risk Mothers: A Randomized, Controlled Trial of the Mom Power Parenting Intervention

A key mechanism of risk transmission between maternal risk and child outcomes are the mother's representations. The current study examined the effects of an attachment-based, trauma-informed parenting intervention, the Mom Power (MP) program, in optimizing maternal representations of high-risk mothers utilizing a randomized, controlled trial design (NCT01554215). High-risk mothers were recruited from low-income community locations and randomized to either the MP Intervention (n = 42) or a control condition (n = 33) in a parallel design. Maternal representations were assessed before and after the intervention using the Working Model of the Child Interview. The proportion of women with balanced (secure) representations increased in the MP group but not in the control group. Parenting Reflectivity for mothers in the treatment group significantly increased, with no change in the control condition. Participation in the MP program was associated with improvements in a key indicator of the security of the parent-child relationship: mothers' representations of their children.

Postpartum outcomes of a pilot prenatal care-based psychosocial intervention for PTSD during pregnancy

This study examines postpartum posttraumatic stress disorder (PTSD) symptoms and secondary outcomes including postpartum depression and birth outcomes for pregnant women who screened positive for PTSD and received a psychosocial education intervention compared to women with PTSD in the usual prenatal care setting. All women entering prenatal care at two federally qualified health centers were screened for symptoms of current PTSD; one site was selected randomly to have prenatal care advocates deliver eight Seeking Safety topics for women with clinical or subclinical PTSD. Women were not blind to condition. Baseline and postpartum interviews, including demographic characteristics and assessment of mental health, social support, and coping skills, were conducted. Medical record data was collected to document preterm delivery and low birth weight. Of the 149 participants at baseline, 128 (86%) participated in the postpartum interview. Intervention women, compared to controls, significantly decreased PTSD symptoms, and showed a non-significant trend for improved social support. However, depression, coping, and birth outcomes did not differ. This study suggests some initial support for the Seeking Safety intervention in prenatal care settings and requires further research to determine the best approaches to its implementation.

Postpartum psychiatric disorders

Pregnancy is a complex and vulnerable period that presents a number of challenges to women, including the development of postpartum psychiatric disorders (PPDs). These disorders can include postpartum depression and anxiety, which are relatively common, and the rare but more severe postpartum psychosis. In addition, other PPDs can include obsessive-compulsive disorder, post-traumatic stress disorder and eating disorders. The aetiology of PPDs is a complex interaction of psychological, social and biological factors, in addition to genetic and environmental factors. The goals of treating postpartum mental illness are reducing maternal symptoms and supporting maternal-child and family functioning. Women and their families should receive psychoeducation about the illness, including evidence-based discussions about the risks and benefits of each treatment option. Developing effective strategies in global settings that allow the delivery of targeted therapies to women with different clinical phenotypes and severities of PPDs is essential.

Adverse childhood experiences and intimate partner violence during pregnancy and their association to postpartum depression

BACKGROUND

Adverse childhood experiences (ACEs) and intimate partner violence (IPV) are recognized global health problems. Both ACEs and IPV have been linked to adverse physical and mental health problems for both mothers and infants. The aim of this study was to determine the prevalence of physical and/or sexual ACEs and IPV and their association to symptoms of postpartum depression among postpartum women in sub-Saharan Africa.

METHODS

A cross-sectional survey was conducted in three health centers in the three districts of Dar es Salaam, comprising Ilala, Kinondoni and Temeke. A total of 500 women were interviewed by two trained midwife nurses during their routine postnatal care. The women were asked about their experiences of adverse childhood experiences, intimate partner violence and symptoms of postpartum depression.

RESULTS

Of the 500 women who were interviewed, 39.4% (n = 197) reported to have experienced physical and/or sexual ACE and 18.8% (n = 94) experienced physical and/or sexual IPV during their index pregnancy. Physical ACE (AOR 2.6, 95% CI: 1.50-4.57), sexual ACE (AOR 2.7, 95% CI: 1.35-5.41), physical IPV (AOR 5.8, 95% CI: 2.98-11.43) and Sexual IPV (AOR 5.5, 95%CI: 2.51, 12.09) were significantly associated with symptoms of postpartum depression.

CONCLUSION

Four out of ten women reported to have experienced ACEs and two out of ten women reported IPV in the index pregnancy which was significantly associated with symptoms of postpartum depression. These results are alarming and call upon the attention of health workers and the community at large in prevention, screening and early intervention of ACEs, IPV and symptoms of postpartum depression.

Adverse life events increase risk for postpartum psychiatric episodes: A population-based epidemiologic study

BACKGROUND

Trauma histories may increase risk of perinatal psychiatric episodes. We designed an epidemiological population-based cohort study to explore if adverse childhood experiences (ACE) in girls increases risk of later postpartum psychiatric episodes.

METHODS

Using Danish registers, we identified women born in Denmark between January 1980 and December 1998 (129,439 childbirths). Exposure variables were ACE between ages 0 and 15 including: (1) family disruption, (2) parental somatic illness, (3) parental labor market exclusion, (4) parental criminality, (5) parental death, (6) placement in out-of-home care, (7) parental psychopathology excluding substance use, and (8) parental substance use disorder. Primary outcome was first occurrence of in- or outpatient contact 0-6 months postpartum at a psychiatric treatment facility with any psychiatric diagnoses, ICD-10, F00-F99 (N = 651). We conducted survival analyses using Cox proportional hazard regressions of postpartum psychiatric episodes.

RESULTS

Approximately 52% of the sample experienced ACE, significantly increasing risk of any postpartum psychiatric diagnosis. Highest risks were observed among women who experienced out-of-home placement, hazard ratio (HR) 2.57 (95% CI: 1.90-3.48). Women experiencing two adverse life events had higher risks of postpartum psychiatric diagnosis HR: 1.88 (95% CI: 1.51-2.36), compared to those with one ACE, HR: 1.24 (95% CI: 1.03-49) and no ACE, HR: 1.00 (reference group).

CONCLUSIONS

ACE primarily due to parental psychopathology and disability contributes to increased risk of postpartum psychiatric episodes; and greater numbers of ACE increases risk for postpartum psychiatric illness with an observed dose-response effect. Future work should explore genetic and environmental factors that increase risk and/or confer resilience.

Intimate Partner Violence Against HIV-Positive Women is Associated with Sub-Optimal Infant Feeding Practices in Lusaka, Zambia

Objectives The aim of this study is to determine how intimate partner violence against HIV-positive women affects safe infant feeding practices in Lusaka, Zambia. Methods A cross-sectional face-to-face survey was conducted with 320 married postpartum women at a large public health center in Lusaka, Zambia, in 2014. Variables were measured using previously validated instruments from the Demographic and Health Survey. Data were analyzed using simple and multivariate logistic regression in Stata 12. Results Thirty-seven percent of women report early mixed infant feeding prior to six months. Women who experienced intimate partner violence have 2.8 higher adjusted odds of early mixed infant feeding (p < 0.001). Women who experienced emotional violence, specifically, have 1.9 higher adjusted odds of early mixed infant feeding (p < 0.05), while women who experienced sexual violence have 2.3 higher adjusted odds (p < 0.01). There is also a dose-response relationship between IPV and early mixed infant feeding (p < 0.05). Lastly, disclosing one's HIV-positive status to the husband is associated with at least 67 % lower adjusted odds of early mixed feeding (p < 0.05). Conclusions Intimate partner violence against HIV-positive women, in particular emotional and sexual violence, increases the likelihood of early mixed infant feeding, putting infants at greater risk for both mother-to-child transmission of HIV and other infant morbidities. Intimate partner violence should thus be given increased attention within the context of infant feeding and HIV in sub-Saharan Africa.

Breastfeeding and Exposure to Past, Current, and Neighborhood Violence

Objectives Breastfeeding has short- and long-term health benefits for children and mothers, but US breastfeeding rates are suboptimal. Exposure to violence may contribute to these low rates, which vary by race/ethnicity. We studied: (1) whether patterns of violence exposure differ by race/ethnicity and (2) whether these patterns are associated with breastfeeding outcomes. Methods We conducted a secondary analysis of data drawn from self-report surveys completed by a convenience sample of low-income postpartum women (n = 760) in upstate New York. Latent class analysis was used to identify groups of women with similar responses to seven violence measures, including childhood physical and/or sexual violence, experience of partner violence during or just after pregnancy (physical, emotional, verbal), and neighborhood violence (perceived or by ZIP code). Logistic regression and survival analysis were utilized to determine if classes were associated with breastfeeding initiation, duration, and exclusivity, controlling for demographics. Results Exposure to at least one form of violence was high in this sample (87%). We identified 4 classes defined by violence exposure (combining current and historical exposures). Violence exposure patterns differed between racial/ethnic groups, but patterns were inconsistently associated with breastfeeding plans or outcomes. For White women, history of violence exposure increased the likelihood of earlier breastfeeding cessation. By contrast, among Black women, history of violence exposure increased the likelihood of having a breastfeeding plan and initiating breastfeeding. Conclusions for Practice Some differences between violence exposure classes are likely due to the correlation between race/ethnicity and socioeconomic status in the community studied. Additional studies are warranted to better understand how exposure to violence is related to breastfeeding and how best to support women making decisions about intention, initiation, and duration of breastfeeding.

Intimate Partner Violence Associated with Postpartum Depression, Regardless of Socioeconomic Status

Objective This study examined whether socioeconomic status moderated the association between intimate partner violence (IPV) and postpartum depression among a community-based sample of women. Defining the role of poverty in the risk of postpartum depression for IPV victims enables prioritization of health promotion efforts to maximize the effectiveness of existing maternal-infant resources. Methods This cross-sectional telephone-survey study interviewed 301 postpartum women 2 months after delivery, screening them for IPV and depression [using Edinburgh Postnatal Depression Scale (EPDS)]. Socioeconomic status was defined by insurance (Medicaid-paid-delivery or not). This analysis controlled for the following covariates, collected through interview and medical-record review: demographics, obstetric history, prenatal health and additional psychosocial risk factors. After adjusting for significant covariates, multiple linear regression was conducted to test whether socioeconomic status confounded or moderated IPV's relationship with EPDS-score. Results Ten percent of participants screened positive for postpartum depression, 21.3 % screened positive for current or previous adult emotional or physical abuse by a partner, and 32.2 % met poverty criteria. IPV and poverty were positively associated with each other (χ(2) (1) = 11.76, p < .001) and with EPDS score (IPV: beta 3.2 (CI 2.0, 4.5) p < .001, poverty: beta 1.3 (CI 0.2, 2.4) p = .017). In the multiple linear regression, IPV remained significantly associated, but poverty did not (IPV: adjusted beta 3.1 (CI 1.8, 4.3) p < .001, poverty: adjusted beta 0.8 (CI -0.3, 1.9) p = .141), and no statistically significant interaction between IPV and poverty was found. Conclusions Study findings illustrated that IPV was strongly associated with postpartum depression, outweighing the influence of socioeconomic status upon depression for postpartum women.

Prevalence of physical intimate partner violence in the first six months after childbirth in the city of Rio de Janeiro, Brazil

The aim of the study was to estimate the prevalence of physical intimate partner violence in the first six months after childbirth among women attending primary care clinics (UBS) for the infant's follow-up in Rio de Janeiro, Brazil. This is the first study on the theme using a representative sample of primary care clinics in the city of Rio de Janeiro. The study used a cross-sectional design from June to September 2007 and included 927 mothers/infants seen at 27 UBS, selected by complex sampling, geographically representative of the city. The information was collected in face-to-face interviews by a previously trained team, using a structured questionnaire. History of physical intimate partner violence from the child's birth to the date of the interview was obtained with the Brazilian version of the Revised Conflict Tactics Scales (CTS2). Thirty percent (95%CI: 26.2-33.8) of mothers reported having experienced some form of physical intimate partner violence in the postpartum and 14% (95%CI: 11.0-17.0) reported severe physical violence. The physical abuse occurred especially among black teenage mothres, in unfavorable socioeconomic situation, that did not live with the partner and that had received inadequate or no prenatal care and reported difficulties in breastfeeding and use of healthcare services. The widespread occurrence of physical intimate partner violence emphasizes the urgent need to deal with the problem. Primary healthcare services must be linked to other support networks and health professionals need to be prepared to deal with the problem.

Pregnant plurisexual women's sexual and relationship histories across the lifespan: A qualitative study

Plurisexual women (that is, those with the potential for attraction to more than one gender) experience unique issues associated with forming and maintaining intimate relationships. In particular, plurisexual women, unlike monosexual women, navigate choices and decisions related to the gender of their partners throughout their lifetime, and may experience a variety of social pressures and constraints that influence these decisions. However, previous research on women's sexual and relationship trajectories has largely focused on adolescence and young adulthood, and therefore we know little about the experiences of plurisexual women at other life stages. The aim of this study was to profile the lifetime sexual and relationship trajectories of 29 plurisexual, different-gender partnered women as described during pregnancy. We identified three primary types of trajectories: women who predominantly partnered with men, women who partnered with men and women about equally, and women who predominantly partnered with women, and found that various contextual factors, including heterosexism and monosexism, constrained women's opportunities for partnering with women. Implications for social and clinical interventions are discussed.

Intimate partner violence around the time of pregnancy and postpartum depression: The experience of women of Bangladesh

BACKGROUND AND OBJECTIVES

Intimate partner violence (IPV) around the time of pregnancy is a serious public health concern and is known to have an adverse effect on perinatal mental health. In order to craft appropriate and effective interventions, it is important to understand how the association between IPV and postpartum depression (PPD) may differ as a function of the type and timing of IPV victimization. Here we evaluate the influence of physical, sexual and psychological IPV before, during and after pregnancy on PPD.

METHODS

Cross-sectional survey data was collected between October 2015 and January 2016 in the Chandpur District of Bangladesh from 426 new mothers, aged 15-49 years, who were in the first six months postpartum. Multivariate logistic regression models were used to estimate the association between IPV and PPD, adjusted for socio-demographic, reproductive and psychosocial confounding factors.

RESULTS

Approximately 35.2% of women experienced PPD within the first six months following childbirth. Controlling for confounders, the odds of PPD was significantly greater among women who reported exposure to physical (AOR: 1.79, 95% CI [1.25, 3.43]), sexual (AOR: 2.25, 95% CI [1.14, 4.45]) or psychological (AOR: 6.92, 95% CI [1.71, 28.04]) IPV during pregnancy as opposed to those who did not. However, both before and after pregnancy, only physical IPV evidences a direct effect on PPD. Results highlight the mental health consequences of IPV for women of Bangladesh, as well as the influence of timing and type of IPV on PPD outcomes.

CONCLUSIONS AND IMPLICATIONS

The findings confirm that exposure to IPV significantly increases the odds of PPD. The association is particularly strong for physical IPV during all periods and psychological IPV during pregnancy. Results reinforce the need to conduct routine screening during pregnancy to identify women with a history of IPV who may at risk for PPD and to offer them necessary support.

"I Felt Like I Was Being Abused All Over Again": How Survivors of Child Sexual Abuse Make Sense of the Perinatal Period Through Their Narratives

Sequelae following child sexual abuse pervade the lives of adult survivors, significantly impacting on pregnancy and childbirth. Symptoms of this distress are recognized, but meanings for women are less understood. This research aimed to examine the meaning for women themselves of the impact of child sexual abuse on experiences of pregnancy, childbirth, and the postnatal period. Taking a critical feminist perspective, three open-ended interviews with three survivors enabled women's narratives of pregnancy and childbirth to be heard, explored the structure of these narratives, including how experiences were connected, and identified key themes and how selves and others were positioned. Women themselves contributed to the analysis of their own narratives. The different struggles of each woman occurred within three domains of experience: identity, embodiment, and parenting. They were underpinned by a fluctuation between empowerment and disempowerment. These findings, although based on detailed analysis of the experiences of only three women, dovetail with, integrate, and extend the existent literature, offering a framework for understanding the complexity of meaning making for women. Further research might develop this. The framework may facilitate clinicians' understandings of what it is like for some women having children who have experienced child sexual abuse.

New insights into early-life stress and behavioral outcomes

Adverse early-life experiences, including various forms of early-life stress, have consistently been linked with vulnerability to cognitive and emotional disorders later in life. Understanding the mechanisms underlying the enduring consequences of early-life stress is an active area of research, because this knowledge is critical for developing potential interventions. Animal models of early-life stress typically rely on manipulating maternal/parental presence and care, because these are the major source of early-life experiences in humans. Diverse models have been created, and have resulted in a wealth of behavioral outcomes. Here we focus on recent findings highlighting early-life stress-induced behavioral disturbances, ranging from hippocampus-dependent memory deficits to problems with experiencing pleasure (anhedonia). The use of naturalistic animal models of chronic early-life stress provides insight into the spectrum of cognitive and emotional outcomes and enables probing the underlying mechanisms using molecular-, cellular-, and network-level approaches.

Exploring the associations between intimate partner violence victimization during pregnancy and delayed entry into prenatal care: Evidence from a population-based study in Bangladesh

OBJECTIVE

Intimate partner violence (IPV) during pregnancy can have serious health consequences for mothers and newborns. The aim of the study is to explore: 1) the influence of experiencing IPV during pregnancy on delayed entry into prenatal care; and 2) whether women's decision-making autonomy and the support for traditional gender roles act to mediate or moderate the relationship between IPV and delayed entry into prenatal care.

DESIGN

cross-sectional survey. Multivariate logistic regression models were estimated that control for various socio-demographic and pregnancy related factors to assess whether women who experienced IPV during pregnancy were more likely to delay entry into prenatal care compared with women who had not experienced IPV. The influence of traditional gender roles acceptance and decision-making autonomy were examined both as independent variables and in interaction with IPV, to assess their role as potential mediators or moderators.

SETTING

Chandpur district, Bangladesh.

PARTICIPANTS

the sample comprised of 426 Bangladeshi women, aged 15-49 years. Postpartum mothers who visited vaccinations centres to receive their children's vaccinations constitute the sampling frame.

RESULTS

almost 70% of the women surveyed reported patterns consistent with delayed entry into prenatal care. Accounting for the influence of other covariates, women who experienced physical IPV during pregnancy were 2.61 times more likely (95% CI [1.33, 5.09]) to have delayed entry into prenatal care than their counterparts who did not report physical IPV. Neither sexual nor psychological IPV victimization during pregnancy was linked with late entry into prenatal care. Both gender role attitudes and levels of autonomy mediate the effect of IPV on prenatal care.

KEY CONCLUSIONS

the results suggest that the high rates of IPV in Bangladesh have effects that can compromise women's health seeking behaviour during pregnancy, putting them and their developing fetus at risk. Specifically, Bangladeshi women who experience physical IPV during pregnancy are more likely to delay or forgo prenatal care, an effect that is further magnified by cultural ideals that emphasize women's traditional roles and limit their autonomy.

IMPLICATIONS FOR PRACTICE

this study reinforces the need to detect and assist women suffering IPV, not only to offer them help and support but also to increase entry into prenatal care. Healthcare professionals involved in obstetrics and midwifery need to be aware of the risk factors of IPV during pregnancy and be able to identify women who are at risk for delayed entry into prenatal care.