The unique needs of pregnant, violence-exposed women: A systematic review of current interventions and directions for translational research
Introduction
Intimate partner violence (IPV), which involves emotional, physical, and/or sexual abuse committed by a romantic partner, affects millions of women in the United States each year (Black, 2011). It is estimated that approximately 23.6% of American women experience IPV during their lifetime (Black, 2011, Coker et al., 2002, Rivara et al., 2007, Sarkar, 2008, Silverman et al., 2006). Women may experience IPV at any time, but multiple studies indicate that the risk for exposure rises during pregnancy (Campbell and Lewandowski, 1997, Shah and Shah, 2010, Silverman et al., 2006). Given that violence during pregnancy affects not only a woman's well-being, but also the well-being of her unborn child, it is especially crucial to examine the effects of, and to develop effective interventions for, IPV during pregnancy. Pregnancy may present a window of opportunity during which women are highly motivated to make changes in their lives—a compelling argument for targeting intervention efforts to this population (Campbell & Lewandowski, 1997). The objectives of the current review are to: (1) present representative literature on the effects of IPV in pregnancy, (2) conduct a systematic review of existing interventions for IPV-exposed pregnant women and (3) provide recommendations for future translational research in this area.
As the frequency and severity of IPV intensifies, women's risk for detrimental physical health outcomes rises (Black, 2011). Clearly, IPV puts women at risk for experiencing injuries, ranging in severity from cuts and bruises to broken bones to life-threatening wounds (Black, 2011, Bonomi et al., 2009, Campbell and Lewandowski, 1997). Beyond direct injuries, physical health consequences of IPV include somatic symptoms, gastrointestinal problems, neurologic problems, compromised cardiovascular health, immune/endocrine system dysfunction, and poor sexual or reproductive health (Black, 2011, Bonomi et al., 2009, Campbell and Lewandowski, 1997, Coker et al., 2000, Ellsberg et al., 2008, Rivara et al., 2007, Silverman et al., 2006). While IPV poses serious health risks to all women, pregnant women may be at risk for additional adverse health-related outcomes. IPV-exposed pregnant women are at increased risk for high blood pressure, edema, vaginal bleeding, severe nausea, vomiting and dehydration, and increased hospital visits during pregnancy (Campbell and Lewandowski, 1997, Silverman et al., 2006). Silverman et al. (2006) found that pregnant women who endorsed IPV during the past year reported more adverse health outcomes throughout their pregnancy than women who had not experienced IPV. Factors specific to pregnant women that may exacerbate physical health consequences include inadequate prenatal care, unintended pregnancy, and suboptimal weight gain during pregnancy (Campbell and Lewandowski, 1997, Shah and Shah, 2010).
Exposure to IPV not only confers risk for poor physical health outcomes, but also negatively influences women's psychological functioning (Bogat et al., 2003, Campbell and Lewandowski, 1997, Goldstein and Martin, 2004).Women endorsing IPV exposure are at increased risk for depressive symptoms and diagnosis (Black, 2011, Bonomi et al., 2009, Pico-Alfonso et al., 2006, Rivara et al., 2007, Silverman et al., 2006), heightened anxiety (Afifi et al., 2008, Black, 2011, Bogat et al., 2003, Pico-Alfonso et al., 2006, Rivara et al., 2007), and posttraumatic stress symptoms (Black, 2011, Bogat et al., 2003, Campbell and Lewandowski, 1997, Pico-Alfonso et al., 2006). Similarly, IPV-exposed pregnant women report poorer mental health (Tiwari et al., 2008) and lower life satisfaction than do pregnant women with no IPV history (Varma, Chandra, Thomas, & Carey, 2007). Specifically, pregnant women with IPV histories are more likely to be hospitalized due to substance abuse or mental health-related diagnoses than those with no IPV history (Lipsky, Holt, Easterling, & Critchlow, 2004). Hospitalizations aside, alcohol and illicit drug abuse are more prevalent among pregnant women experiencing IPV than those with no IPV exposure (Campbell & Lewandowski, 1997). Additionally, among pregnant women endorsing proximal or distal IPV exposure, researchers have noted increased risk for elevated depressive symptoms, both during pregnancy and postpartum (Beydoun et al., 2012, Garabedian et al., 2011, Ogbonnaya et al., 2013, Ross and Dennis, 2009, Tiwari et al., 2008, Varma et al., 2007). Furthermore, Jackson et al. (2015) found that IPV history predicted more severe postpartum depressive symptoms, beyond the influence of prenatal depression. In addition to associations with depression, IPV-exposed pregnant women are at increased risk for self-harming thoughts (Tiwari et al., 2008), suicidal ideation (Alhusen, Frohman, & Purcell, 2015), higher stress levels (Jackson et al., 2015), PTSD symptoms (Rodriguez et al., 2008, Varma et al., 2007), somatic complaints (Varma et al., 2007), and alterations in self-perception (Rose et al., 2010).
IPV exposure during pregnancy is unique in that it may influence the course of a child's development, even before birth. For example, victimized pregnant women are less likely to receive adequate prenatal care and are more likely to engage in behaviors that could compromise fetal health, including smoking, substance use, and unhealthy diet (Black, 2011, Campbell and Lewandowski, 1997, Shah and Shah, 2010). In addition to these risk factors, IPV-related stress and trauma have been linked to physical health issues during pregnancy, such as suboptimal maternal weight gain, pre-term delivery, premature labor, ruptured membranes and organs, fetomaternal hemorrhaging, placental abruption, gynecological problems, and preeclampsia, all of which may contribute to adverse fetal outcomes (Black, 2011, Campbell and Lewandowski, 1997, Dutton et al., 2006, Lipsky et al., 2003, Shah and Shah, 2010, Silverman et al., 2006). Lastly, maternal depression, which is more prevalent among victimized pregnant women, can compromise healthy fetal development, resulting in an increased risk for elevated prenatal activity, delayed prenatal growth, prematurity, low birth weight, and compromised physical health indices among newborns (Field et al., 2006, Marcus, 2008, Silverman et al., 2006). Prenatal maternal stress may influence newborn health via maternal HPA axis activity, which has been associated with abnormal fetal brain development and impaired HPA function in infants (Marcus, 2008). These findings suggest multiple pathways through which maternal health following IPV exposure may negatively impact fetal development.
Consistent with findings that IPV exposure is associated with a number of risk factors for adverse pregnancy outcomes, IPV proximal to or during pregnancy confers a higher risk of fetal/infant mortality as a result of miscarriage, spontaneous abortion, perinatal death, and neonatal death (Black, 2011, Campbell and Lewandowski, 1997, Coker et al., 2004, Lipsky et al., 2003, Shah and Shah, 2010, Silverman et al., 2006). Additionally, children of IPV-exposed mothers are more likely to have lower gestational weight gain and be classified as low birth weight (LBW) or very low birth weight (VLBW) infants (Campbell and Lewandowski, 1997, Coker et al., 2004, Dutton et al., 2006, Lipsky et al., 2003, Shah and Shah, 2010, Silverman et al., 2006). LBW may be a result of physical consequences of IPV, such as abdominal trauma, infections, and chronic illnesses. It is also possible that the stress of IPV confers risk for LBW among infants of victimized mothers or that the suboptimal health behaviors observed among women with IPV increase risk for LBW (Campbell & Lewandowski, 1997).This association represents a serious concern, as LBW/VLBW/preterm infants are at increased risk for demonstrating deficits in cognition, executive function, academic performance, intelligence, motor skills, neurosensory functioning, developmentally appropriate behavior, and adaptive functioning, with developmental lags that often extend into adulthood (Anderson et al., 2003, Aarnoudse-Moens et al., 2009, Hack et al., 2002, Short et al., 2003).
IPV exposure during pregnancy may result in consequences that persist throughout the child's development, especially as the adverse mental health, physical health, and functional outcomes associated with IPV undermine women's ability to parent warmly, effectively, and consistently. Indeed, when interviewed during pregnancy, victims of IPV had more negative representations of themselves as mothers, reflecting under- or over-confidence in parenting competence and self-efficacy (Huth-Bocks, Levendosky, Theran, & Bogat, 2004). Further, IPV-exposed mothers tend to have more negative representations of their infants during pregnancy, which leads to less positive parenting, increased hostility towards the child, and insecure infant attachment after the child is born (Cox et al., 2000, Dayton et al., 2010, Huth-Bocks et al., 2004, Levendosky et al., 2011, Zeanah et al., 1999). The disruption of healthy attachment relationships between abused women and their children may have serious implications throughout the child's lifespan, as attachment security is a critical milestone that fosters healthy developmental pathways, while attachment insecurity confers risk for an array of adverse cognitive, behavioral, and emotional consequences (e.g., Carpenter and Stacks, 2009, Belsky and Fearon, 2002, Belsky et al., 2010, Sroufe, 2005). IPV exposure may also influence decisions regarding early infant care. More specifically, while breastfeeding has known benefits for both mothers and children, women reporting IPV are less likely to breastfeed (Lau and Chan, 2007, Silverman et al., 2006). Furthermore, women endorsing IPV exposure proximal to pregnancy who initiate breastfeeding are more likely to cease breastfeeding after just four weeks (Silverman et al., 2006).
These challenges to infant care and attachment may contribute to some of the long-term consequences of IPV exposure that persist throughout the childhood years. For instance, IPV-exposed youth are more likely to experience adjustment and emotional difficulties, including depressive symptoms, posttraumatic stress disorder, anxiety, worry, anger, and low self-esteem (Campbell and Lewandowski, 1997, Koverola et al., 2005, Levendosky and Graham-Bermann, 2001). These children are also more likely to demonstrate cognitive, academic, and social struggles, as well as internalizing and externalizing behavior problems (Campbell and Lewandowski, 1997, Koverola et al., 2005, Levendosky et al., 2006). It is therefore critical to address IPV as early as possible in order to potentially protect children from the severe consequences stemming from exposure to violence in the home.
Given the devastating short- and long-term ramifications of IPV exposure on mothers and children, there is a clear need for interventions serving pregnant women who experience IPV. Despite the prevalence and consequences of IPV during pregnancy, few interventions targeting pregnant women are available, and those that do exist often lack substantial empirical support. The following section systematically reviews available interventions for this population with the primary goal of determining the extent to which existing services adequately address this significant public health concern. Intervening during the prenatal period with women who experience IPV may offer a unique window of opportunity during which women are especially motivated to improve circumstances for themselves and their unborn child.
Section snippets
Materials and methods
A search for interventions for IPV-exposed pregnant women was conducted in PsycINFO, an extensive research database managed by the American Psychological Association. The search was limited to work published in scholarly, peer-reviewed journals from 1806 to present time. A second search was conducted in PubMed, an extensive database of biomedical literature managed by the National Center for Biotechnology Information, and a final search was conducted in Google Scholar, a database estimated to
Types of intervention
We grouped the 17 identified interventions according to their program content, resulting in four primary categories of care: (1) interventions targeted at reducing women's IPV victimization (n = 7), (2) interventions addressing the mental health effects of IPV (n = 1), (3) integrated care programs addressing both mental health and victimization (n = 6), and (4) programs addressing intergenerational risk (e.g., birth outcomes; n = 3, see Table 1).
Discussion
Despite significant practical challenges to conducting research with IPV-exposed pregnant women, researchers have made great strides that have contributed to the field's understanding of the effects of IPV on pregnant women and their children. Furthermore, prior work has provided some promising preliminary evidence about the types of intervention efforts that may improve outcomes among this highly vulnerable population. The group of researchers who have contributed to this body of literature
References (83)
- et al.
Intimate partner violence against adult women and its association with major depressive disorder, depressive symptoms and postpartum depression: A systematic review and meta-analysis
Social Science & Medicine
(2012) - et al.
Cueing prenatal providers: Effects on discussions of intimate partner violence
American Journal of Preventive Medicine
(2008) - et al.
Mental and physical health effects of intimate partner violence on women and children
Psychiatric Clinics of North America
(1997) - et al.
Developmental effects of exposure to intimate partner violence in early childhood: A review of the literature
Children and Youth Services Review
(2009) - et al.
Physical and mental health effects of intimate partner violence for men and women
American Journal of Preventive Medicine
(2002) - et al.
Nurse case management for pregnant women experiencing or at risk for abuse
Journal of Obstetric, Gynecologic, &Neonatal Nursing
(2006) - et al.
Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: An observational study
The Lancet
(2008) - et al.
Prenatal depression effects on the fetus and newborn: A review
Infant Behavior and Development
(2006) - et al.
Increasing discussions of intimate partner violence in prenatal care using video doctor plus provider cueing: Arandomized, controlled trial
Women's Health Issues
(2011) - et al.
Impact of police-reported intimate partner violence during pregnancy on birth outcomes
Obstetrics & Gynecology
(2003)
Healthcare utilization and costs for women with a history of intimate partner violence
American Journal of Preventive Medicine
Intimate partner violence victimization prior to and during pregnancy among women residing in 26 US states: Associations with maternal and neonatal health
American Journal of Obstetrics and Gynecology
Intimate partner violence and sexual coercion among pregnant women in India: Relationship with depression and post-traumatic stress disorder
Journal of Affective Disorders
Meta-analysis of neurobehavioral outcomes in very preterm and/or very low birthweight children
Pediatrics
Mental health correlates of intimate partner violence in marital relationships in a nationally representative sample of males and females
Journal of Interpersonal Violence
Intimate partner violence and suicidal ideation in pregnant women
Archives of Women's Mental Health
Neurobehavioral outcomes of school-age children born extremely low birth weight or very preterm in the 1990s
JAMA
A qualitative exploration of the nature of domestic violence in pregnancy
Violence Against Women
Cognitive trauma therapy for battered women: Replication and extension
Psychology of Violence
Early attachment security, subsequent maternal sensitivity, and later child development: Does continuity in development depend upon continuity of caregiving?
Attachment & Human Development
Infant attachment security and the timing of puberty testing an evolutionary hypothesis
Psychological Science
Intimate partner violence and adverse health consequences: Implications for clinicians
American Journal of Lifestyle Medicine
Predicting the psychosocial effects of interpersonal partner violence (IPV): How much does a woman's history of IPV matter?
Journal of Interpersonal Violence
Medical and psychosocial diagnoses in women with a history of intimate partner violence
Archives of Internal Medicine
Partner violence during pregnancy and risk of adverse pregnancy outcomes
Paediatric and Perinatal Epidemiology
Physical health consequences of physical and psychological intimate partner violence
Archives of Family Medicine
Attachment in preterm infants and their mothers: Neonatal risk status and maternal representations
Infant Mental Health Journal
Intimate partner violence during pregnancy: A pilot intervention program in Lima, Peru
Journal of Interpersonal Violence
The child as held in the mind of the mother: The influence of prenatal maternal representations on parenting behaviors
Infant Mental Health Journal
Intimate partner violence, PTSD, and adverse health outcomes
Journal of Interpersonal Violence
Preventing child abuse and neglect with a program of nurse home visitation: The limiting effects of domestic violence
JAMA
Very preterm birth is reduced in women receiving an integrated behavioral intervention: A randomized controlled trial
Maternal and Child Health Journal
An integrated intervention in pregnant African Americans reduces postpartum risk: A randomized trial
Obstetrics and Gynecology
Impact of current and past intimate partner violence on maternal mental health and behaviour at 2 years after childbirth: Evidence from the Pacific Islands Families Study
Australian and New Zealand Journal of Psychiatry
Violence against women and postpartum depression
Journal of Women's Health
Intimate partner physical assault before and during pregnancy: How does it relate to women's psychological vulnerability?
Violence and Victims
Intervention to reduce traumatic stress following intimate partner violence: An efficacy trial of the Moms' Empowerment Program (MEP)
Psychodynamic Psychiatry
Outcomes in young adulthood for very-low-birth-weight infants
New England Journal of Medicine
The impact of domestic violence on mothers' prenatal representations of their infants
Infant Mental Health Journal
Cognitive–behavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors
Journal of Consulting and Clinical Psychology
Adaptation and implementation of the nurse-family partnership in Canada
Canadian Journal of Public Health
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2021, Child Abuse and NeglectCitation Excerpt :Women experiencing violence during pregnancy are also more likely than their counterparts who do not to use tobacco, alcohol, and drugs during pregnancy (Audi et al., 2012; Covington et al., 2001; Huth-Bocks et al., 2002; Janssen et al., 2003; Meuleners et al., 2011; Silverman et al., 2006; Taillieu et al., 2020). All of these factors likely contribute to the increased incidence of adverse pregnancy outcomes among women experiencing violence during pregnancy (Alhusen et al., 2015; Howell et al., 2017). However, because most research focuses on more immediate outcomes (e.g., pregnancy outcomes), and the same sample of women and children is rarely followed into the post-partum period, relatively little is known about the longer-term impact of prenatal violence on maternal and child developmental health.
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