The unique needs of pregnant, violence-exposed women: A systematic review of current interventions and directions for translational research

https://doi.org/10.1016/j.avb.2017.01.021Get rights and content

Highlights

  • Prenatal IPV exposure increases risk for numerous physical/mental health problems.

  • Perinatal IPV exposure heightens risk for adverse pregnancy/developmental outcomes.

  • Few effective interventions exist for IPV-exposed pregnant women.

  • Existing interventions for IPV-exposed pregnant women are limited in scope/duration.

  • Interventions must be theory driven & address IPV-exposed pregnant women's needs.

Abstract

Intimate partner violence (IPV) is, unfortunately, a common lifetime experience for women, with heightened risk of exposure during pregnancy. IPV exposure in pregnancy is associated with serious physical and mental health problems in the perinatal period, as well as detrimental effects on the health and well-being of the developing infant. 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. The review indicated that despite the broad range of negative effects associated with IPV exposure during pregnancy, interventions are scarce and largely limited to crisis intervention approaches. Available interventions seeking to address broader or intergenerational effects of violence are limited in scope, and effectiveness data are preliminary in nature. As such, there is a great need for theory-based interventions that address women's complex needs, including specific developmental necessities of both the pregnant woman and her child (e.g., breastfeeding, early parenting, infant care). Incorporating these elements within a strengths-based paradigm may also decrease stigma related to IPV and facilitate empowerment and self-efficacy for this at-risk group.

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

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