Abuse of women is a global epidemic.1 Frequently, the abuse begins during pregnancy and is associated with late entry into prenatal care,2,3 spontaneous abortions,4 lower-weight newborns,5 preterm births,6 and stillbirths.7 Women abused during pregnancy report more anxiety,8,9 posttraumatic stress disorder (PTSD),10 and depression in the postnatal period11 compared with nonabused women.
Women abused when pregnant are at nearly three times the risk for serious injury and homicide,12 with homicide being the leading cause of death during pregnancy,13 occurring at a rate of 2.9 deaths per 100,000 live births,14. Most homicides are committed by intimate partners.15
Children who witness the abuse of their mothers experience mental health,16 behavioral,17 functional,18 and academic problems.19 Children who witness domestic violence show more psychological problems than children who do not witness,20 and young children disproportionately exposed to domestic violence21 have increased risk of behavioral problems.22,23
Therefore, the following questions must be addressed:
1. Do abused women who report abuse during pregnancy also report significantly more abuse, danger for murder, and adverse mental health conditions compared with abused women only reporting abuse outside of pregnancy?
2. At 24 months after delivery, do levels of abuse, danger for murder, and adverse mental health conditions differ significantly by whether an abused woman reports abuse during pregnancy?
3. Over the course of 24 months after delivery, do abused women's level of abuse, danger for murder, and mental health differ significantly by whether an abused woman reports abuse during pregnancy?
4. Does behavioral functioning of children differ significantly by whether the abused woman reports abuse during her pregnancy?
MATERIALS AND METHODS
This study is a prospective cohort-control design followed by repeated measures every 4 months for 24 months.24 The study occurred in a large urban metropolis in the United States with a population exceeding four million. Five shelters designated for abused women with a collective bed capacity of 500 for women and their children serve the population, along with a central District Attorney's office for processing of protection orders. The shelters offer safe refuge, counseling, and advocacy services. Services of the District Attorney's Office are legal processing for a 2-year protection order as well as safety and resource information.
Our eligible population comprises English-speaking or Spanish-speaking abused women seeking a shelter for abused women or justice services, specifically a protection order, for the first time who had never used shelter services or applied for a protection order in the past and who also had at least one child between the ages of 18 months and 15 years who live with the mother at least 50% of the time. Only one child was selected at random because of time burden for the participant and study costs. Considering two independent samples (ie, sheltered women and protection order applicants) with a conservative effect size of 0.40, a power of 0.90, and alpha of 0.05, 135 women were needed in each group. Allowing for attrition, we set the sample at 150 women and 150 children in each group for a total of 300 women and 300 children. If the woman had more than one child between the ages of 18 months and 15 years, each child was given a number according to birth order and a die was rolled to select one child at random to be followed-up in the study.
After receiving approval from the Texas Woman's University Institutional Review Board, recruitment began at five local shelters for abused women and the District Attorney's office. Trained, bilingual (English and Spanish) researchers approached all women entering the shelter or applying for a protection order and established eligibility criteria. If the women were eligible, they were taken to a private room and invited to participate in the study. After signing informed consent, which included an incremental compensation schedule and completion of the 60-minute interview, all 300 women were offered $30 cash. Two native Spanish and English speakers completed standard forward and backward translation of all questionnaires from English to Spanish and back to English. The interview could be completed in 60 minutes in both languages. The researchers recorded the responses of the women. Recruitment, eligibility screening, and entry into the study continued daily for 13 months at the five shelters and Monday through Friday at the District Attorney's office. Over the course of 13 months, 330 women met eligibility criteria. A total of 19 eligible women refused to participate, mainly because of a lack of time, and 11 women were missed (ie, left the shelter or District Attorney's office before the study could be explained). A total of 300 women (eg, 150 at the shelters and 150 at the District Attorney's office) met eligibility criteria and agreed to participate in this study.
As part of the interview schedule, all 300 women were asked if they had been pregnant during the past 4 months. Among the 300 abused women, 46 women (15%) reported that they had been pregnant during the preceding 4 months. Ages for the 46 women ranged from 19 to 37 years (mean, 26.8; standard deviation [SD], 5.20), with almost half of the women (41%) self-identifying as being Spanish or Hispanic, followed by 33% self-identifying as African American, 17% self-identifying as white, and 9% self-identifying as multiracial. The majority of the women (65.2%) reported birth in the United States, and the majority (73.9%) identified English as their primary language. Regarding the randomly chosen child, 48% were male and 52% were female. Ages at of these children ranged from 18 months to 13 years, with a mean age of 5.4 years (SD, 3.4 years). The number of children per participant ranged from one to six (mean, 1.85; SD, 1.07).
To establish temporal sequencing, the measures were asked at entry into the study prefaced by, “During the last 4 months” and repeated every 4 months for 24 months prefaced by, “Since we talked on (date of last visit).” A 4-month interval was selected for maximum stability of the child functioning instruments and to minimize recall bias. All initial measures were completed within 48 hours of entry into the shelter or application for a protection order.
Severity of Violence Against Women Scale25 is a 47-item instrument designed to measure threats of abuse (19 items) and physical abuse (28 items). Examples of behaviors that represent threats and physical abuse, respectively, are “How often has (name of abuser) threatened to hurt you?” and “How often has (name of abuser) kicked you?” Included are the following nine factors or subscales that have been demonstrated valid through factor analytic techniques: symbolic violence and mild, moderate, and serious threats (threats of violence dimension) and mild, minor, moderate, serious, and sexual violence (actual violence dimension). For each item, the woman responded using a 4-point scale to indicate how often the behavior occurred (1=never, 2=once, 3=2 or 3 times, 4=4 or more times). The possible range of scores is 19 to 76 for the threats of abuse and 28 to 112 for physical assault. Initial internal consistency reliability estimates ranged from 0.92 to 0.96 for a sample of 707 female college students and from 0.89 to 0.96 for a scale of 208 women in the community.25 Subsequent reliability rates for abused women have ranged from 0.89 to 0.91 for threats of abuse and from 0.91 to 0.94 for assault, respectively.26,27 For this study, Coefficient alpha was 0.95 for the total scale, 0.90 for threats of abuse subscale, 0.93 for physical abuse subscale, and 0.84 for sexual abuse subscale.
The Danger Assessment Scale28 is 19-item questionnaire with a yes-or-no response format was designed to assist women in determining their potential risk for becoming a homicide victim. All items refer to risk factors that have been associated with murder in situations involving abuse, such as “Has the physical violence increased in severity or frequency?“ Convergent construct validity of the instrument has been supported by correlations in the moderately strong range, with instruments measuring severity or frequency of abuse.29 Validity in terms of differentiating groups is supported by the different means in seven groups of abused women studied that accurately reflect the differing degrees of severity of abuse one would expect in different populations. For example, the lowest scores were in the nonabused sample, with the highest scores in the hospital emergency room group. Samples of abused women from the community had scores in the intermediate range.29 Initial reliability of the instrument was 0.7128 and ranged from 0.60 to 0.86 in five subsequent studies.29 Weighted scoring, based on risk for murder, resulted in four ranges of danger: score less than 8 indicates variable danger; score 8–13 indicates increased danger; score 14–17 indicates severe danger; and score 18 or more indicates extreme danger. For this study, coefficient alpha was 0.66.
The Brief Symptom Inventory-1830 is an abbreviated version of the 53-item Brief Symptom Inventory,31 which is a shortened form of the 90-item Symptom Checklist-90 revised.32 The Brief Symptom Inventory-18 is an 18-item self-report scale that measures three global indices of psychological distress: depression, anxiety, and somatization. Internal consistency reliability ranged from 0.74 to 0.89 on the subscales. Test–retest reliability over the course of 2 weeks ranged from 0.68 to 0.91. A principal components analysis has been performed to determine dimensional analysis. Factors identified in the analysis include depression, somatization, and anxiety. Scores for each measure are converted to t scores, corresponding percentiles, and normative and clinical ranges based on a community sample of 1,122 individuals (605 male and 517 female).
The short screening scale for the Diagnostic Statistical Manual of Mental Disorders (Fourth Edition) PTSD33 is a subset of seven items from the National Institute of Mental Health Diagnostic Interview Schedule for Diagnostic Statistical Manual of Mental Disorders (Fourth Edition). A score of 4 or more defines a positive case of PTSD with a sensitivity of 80%, specificity of 97%, positive predictive value of 71%, and negative predictive value of 98%.34
The Achenback Child Behavior Checklist provides a standardized parental report of child behavioral problems35,36 with a form for children aged 18 months to 5 years and a form for those aged 6 years to 18 years. The Child Behavior Checklist is orally administered to a parent who rates the presence and frequency of certain behaviors on a 3-point scale (0=not true; 1=somewhat or sometimes true; and 2=very true or often true). Examples of behaviors for younger children include “physically attacks people” and “does not want to sleep alone.” Behaviors of older children are “bully behavior,” “vandalism,” and “prefers being with older children.” The Child Behavior Checklist consists of two broadband factors of behavioral problems, internalizing and externalizing, with mean scale scores for national normative samples as well as clinically referred, borderline clinical, and nonreferred samples of children.
Before conducting primary data analyses, preliminary analyses were conducted to test for differences in outcome measures by key demographics (ie, ethnicity, immigrant status, language) to test whether demographics needed to be controlled for in primary analyses. Baseline data for the outcomes of interest (ie, threats of abuse, physical abuse, sexual abuse, danger, PTSD, anxiety, depression, somatization) meet the assumptions of normality, homoscedasticity, and independence, indicating that parametric analysis was appropriate given the obtained data. Follow-up data from 24 months for the outcomes of interest did slightly violate the assumptions of normality, as evidenced by SD more than half the mean, kurtosis more than ±4.0, and skewness to standard error ratio of ±2.0. As such, parametric analyses (ie, repeated-measures analysis of variance [ANOVA]) were confirmed with nonparametric equivalencies (ie, Wilcoxon sign rank) because these tests are not constrained by the assumption of normality.
To test research question one, a series of one-way ANOVA tests were conducted to test for differences in baseline scores for severity of abuse (threats, physical, and sexual), danger for murder, and mental health outcomes (PTSD, somatization, depression, anxiety) as a function of whether a woman reported abuse during her pregnancy. Next, a series of two (time [baseline compared with 24 months later]) by two (abuse during pregnancy compared with no abuse during pregnancy) repeated-measures ANOVAs were conducted. When conducting the repeated measures ANOVA, we were able to test for main effects of time and whether a woman had reported abuse during pregnancy as well as the interaction effect of time by whether a woman was abused during pregnancy. In the event of significant interaction effects of time by abuse during pregnancy, further univariate analyses were conducted to further determine where significant differences could be detected. With ANOVA, the reported effect size is partial eta-squared (η2) and can be interpreted as ∼0.01 as a small effect, ∼0.059 as a moderate effect, and ∼0.138 and greater as a large effect. In addition to tests of significance and measures of effect size, observed power for all analyses were calculated to determine the relative risk of a type II error. Significance levels for all analyses were set at 0.05.
As shown in Table 1, there were statistically significant differences across measures whether a woman reported abuse during pregnancy for the outcome measures of threats of abuse severity, physical abuse severity, sexual abuse severity, danger for murder, and PTSD symptoms, all with significant levels less than 0.05 and effect sizes (η2) ranging from 0.095 to 0.92. Furthermore, across all of these measures, women who reported abuse during pregnancy had significantly higher scores, indicating that women who experienced abuse during pregnancy experienced much greater severity of abuse (threats, physical abuse, and sexual abuse), were at greater risk of murder, and had higher levels of PTSD symptoms. As also shown in Table 1, there were no significant differences in somatization, anxiety, or depression as a function of abuse during pregnancy (all significant levels more than 0.05); however, levels of observed power ranged from 0.06 to 0.13, indicating that there was insufficient statistical power to conclusively determine whether women's Brief Symptom Inventory subscale scores significantly varied as a function of reported abuse during pregnancy.
An overview of the repeated-measures ANOVA examining interaction effect of time by abuse status are outlined in Table 2. As shown, there were significant interactions of time and abuse during pregnancy for threats of abuse, physical abuse, danger for murder, and somatization scores, with significance levels ranging from less than 0.001 to 0.008 and η2 ranging from 0.230 to 0.363. Furthermore, there was a significant main effect of time across all measures (all significance levels less than 0.001 and η2 ranging from 0.267 to 0.822), indicating that there was a significant and large decrease in all measures for women regardless of whether they reported abuse during pregnancy. Furthermore, there were significant main effects of abuse during pregnancy on threats of abuse, physical abuse, danger for murder, and PTSD symptoms (all significance levels less than 0.05 and η2 ranging from 0.110 to 0.400). There were no significant main effects of abuse during pregnancy detectible for somatization, depression, or anxiety (all significance levels more than 0.05); however, similar to baseline findings, investigation of observed power (range 0.07–0.37) indicated that there may be insufficient statistical power to detect a difference in these scores if, in fact, significance exists.
At baseline, women who reported abuse during pregnancy during the preceding 4 months had higher levels of threats, physical abuse, sexual abuse, danger for murder, and PTSD. For threats, physical abuse, and sexual abuse scores stabilized at 4 months and remained steadily and statistically the same across abuse and no abuse groups during pregnancy. For danger for murder, scores did not even out until after 8 months. For PTSD, women who were abused during pregnancy had higher scores at baseline and scores evened out at 4 and 8 months, but women who experienced abuse during pregnancy had worsening scores at 16 and 20 months, which evened out again at 24 months. Regarding depression, women who were abused during pregnancy did not differ from those without abuse during pregnancy at baseline; however, women who experienced abuse had more depression at 4, 16, 20, and 24 months. There was no difference across any time points for somatization scores.
Table 3 shows the Child Behavior Checklist clinical ranges for children living with a mother abused during pregnancy compared with mothers not reporting abuse at intake at shelter, 12 months, and 24 months. Children of mothers abused during pregnancy demonstrate significantly more internalizing problems (ie, depression, anxiety) compared with those living with a mother not abused during pregnancy. Examination of observed proportions over the course of 24 months of children living with mothers abused during pregnancy showed consistently more behavioral problems in the borderline and clinical ranges compared with children of mothers not abused and significantly (as determined by Fisher exact test, P<.05) more internalizing problems (ie, depression, anxiety) at 24 months.
Abuse during pregnancy places a woman at risk for development of postpartum depression and PTSD that, for abused women in this study who reported abuse during and outside of pregnancy, extends for 24 months after delivery. Recent studies have found that traumatic childbirth experiences alone can lead to PTSD in women who have not experienced any type of intimate partner violence.37–39 However, McDonald et al40 found that only 17% of women experiencing PTSD as a result of a birthing experience continued to report any type of clinically significant PTSD symptoms 24 months after birth. A traumatic birth, especially when compounded with a history of childhood abuse,41 a family history of major depression,42 and PTSD diagnosed before pregnancy,43 yields a situation in which the woman is at extremely high risk for long-lasting mental and physical health impairment.44 Adding abuse during pregnancy to this list may account for the sustained 24 months distress of PTSD reported in our study.
Pregnancy-associated homicide affects 2.90 women per 100,000 live births,45,46 with approximately one-third of these deaths occurring within the first year postpartum and accounting for more deaths than most obstetric complications traditionally associated with maternal mortality.14 This research documents the increased risk for murder that remains for 8 months after delivery for women reporting abuse during pregnancy.
The negative effect on child behavior for children of mothers abused during pregnancy continues for 24 months, at which time internalizing problems (ie, depression) have worsened significantly. This finding concurs with those of Spillar et al47 and may help to explain the differential growth, developmental, functional, behavioral, and academic problems experienced by children who witness abuse of their mothers. Our research supports a greater effect of domestic violence on children who witness the abuse of their pregnant mother and greater potential increased risk for long-term dysfunction compared with children who do not witness abuse of their pregnant mothers.
The sample was a convenience sample. There was insufficient statistical power to conclusively determine whether women's mental health measures of somatization, depression, and anxiety differed significantly as a function of abuse during pregnancy. We relied on the woman's reports of pregnancy, abuse, and functioning status for herself and her randomly chosen child. Recall bias was operant in all responses. We only sampled from shelters designated for abused women; therefore, abused women who access a shelter for homeless persons would have been missed, as would have been abused women applying for a protection order from a private lawyer or legal service other than the county District Attorney's office. Our participants were limited to English or Spanish speakers. Despite the limitations, the researchers feel this study provides comprehensive data for mothers reporting abuse during pregnancy and the subsequent levels of abuse, danger for murder, and functioning of mother and child for 24 months.
Our findings indicate abuse during pregnancy has more implications than previously thought, with both mother and children experiencing negative outcomes 24 months after delivery. Identifying pregnant women who are abused is a priority for health care professionals. In the 2013 Clinical and Policy Guidelines, the World Health Organization48 recommended antenatal screening for intimate partner violence. Abuse screening is covered by the Affordable Care Act and is available to a woman free of charge if she is insured. This coverage began in August of 2012 and includes both women and adolescent girls.49
In January 2013, the U.S. Preventive Services Task Force issued a recommendation for health care providers to begin routine screening of women patients for partner violence.50 The U.S. Preventive Services Task Force's recommendation aligns with the 2011 recommendation by the Institute of Medicine that all women of childbearing age should be routinely screened by health care providers for partner violence.51 The American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women52 recommends screening during obstetric care should take place at the initial visit and at least once per trimester to increase the opportunity for disclosure.
Interventions for pregnant abused women, which should take place after safety and referral information by the provider, have included mentor support, counseling, and nursing case management.53 Some promising results have been noted in recent studies.54–56 There is also evidence that telling a health care provider that violence is occurring may decrease future violence in pregnant women.57
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