Intimate Partner Violence and Perinatal Mental Health Disorders

Introduction

Intimate partner violence refers to any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship.¹ Intimate partner abuse against women is a serious global problem due to its negative consequences on the woman’s physical and mental health.² In a study done by the World Health Organisation (WHO) in 2005, revealed that the incidence of physically abused pregnant women was more than 5 in 11 of the 15 countries studied.³ The lowest figure was 1% in Japan, and the highest was 28% in Peru. Moreover, it was found that in over 90% of women, the reported abuse was carried out by the biological father of the child. The majority of those who reported being beaten during pregnancy had experienced physical abuse by the same partner before being pregnant.³ A Maltese study conducted in 2015 at the general obstetric wards amongst women after giving birth found that 22% of all mothers were exposed to one or more acts of domestic abuse.⁴ This implied that 1 to 2 out of every 5 women had experienced partner abuse during pregnancy.

A meta-analysis conducted by Taillieu & Brownridge in 2010, found that intimate partner abuse during pregnancy is more common than many of the medical conditions pregnant women were routinely screened for. Moreover, this study concluded that although pregnancy was found to be a protective period for some women, it was clearly a period of increased risk of abuse for a significant proportion of pregnant women.⁵

The antenatal period provides a good opportunity for identifying women suffering from intimate partner abuse, because in this period, pregnant women may be more open to discuss partner abuse and may be more ready to make changes in order to protect their unborn baby.⁶ For many women, their pregnancy period, may be their only point of contact and follow up with healthcare professionals.⁷

The mental health consequences of intimate partner abuse are extensive. Several studies, conducted across multiple countries, suggested there is a high prevalence rate of intimate partner abuse amongst women suffering from a mental disorder.^8,9 Moreover, Golding in 1999, found out that the severity and duration of physical partner abuse was related to the frequency and severity of depression.⁸ A review which examined post-traumatic stress disorder (PTSD) among victims of domestic abuse, similarly, reported that the intensity of symptoms was associated with the extent, severity and type of abuse.¹⁰ Limitations highlighted in these studies included; focusing only on perinatal depressive disorder and not on the full range of perinatal mental health disorders; not specifying the time period partner abuse was experienced and for including studies that did not use validated mental health screening tools.

Materials and methods

The research aim of this study was to assess the prevalence of intimate partner abuse amongst pregnant women attending the Perinatal Mental Health Clinic and diagnosed with an antenatal or postnatal depression and/or anxiety disorder. Moreover, the socio-demographic variables associated with intimate partner abuse were also to be investigated. Another objective of this study was to compare the data generated with the data documented as per a previous study done in Malta by Debono.⁴

Study design and participants

In this study, a survey research design using self-reported questionnaires was used after getting the necessary approvals. The questionnaire used in this study, was an adapted version of the WHO “Violence Against Women Structured Interview”, which was modified and translated to Maltese by Debono.⁴ using the WHO translation protocol.¹¹ Although, the WHO tool was already tested for reliability and validity in local¹² and international studies¹³, the questionnaire used in the study by Debono⁴, was re-tested using Test-Retest Reliability and Face and Content Validity methods.

The survey was divided into two sections. Section 1 consisted of seven questions which cover the emotional, physical and intimate health in a relationship. The purpose of this section was to identify those mothers who are experiencing intimate partner abuse during the pregnancy. Participants were considered to be victims of intimate partner abuse if they responded “Yes” to one (or more) of the questions listed in this section. Section 2 contained nine demographic questions about the participant and her partner.

Eligible criteria for participants included women aged 18 years of over, have the mental capacity to consent for participation and who can read and write in English and/or Maltese.

Data collection

All women attending for their visit with the Perinatal Psychiatrist at the Perinatal Mental Health Clinic, between February 2021 and May 2021, were invited to participate if they met the inclusion criteria. Eligibility was determined by the Perinatal Psychiatrist leading the clinic as mental capacity to participate in the study was performed for every mother attending for a consultation at the clinic. Once consent was obtained the women completed the self-administered questionnaire.

Ethical considerations

Permission was obtained from the Director of the Department of Psychiatry, Consultant Perinatal Psychiatrist. Maltese Health Ethics Committee (HEC) and from Sheffield Hallam University Research Ethics Committee. The ethical considerations in this study were based on the Nuremberg Code ¹⁴, the Helsinki Declaration¹⁵ and the WHO ethical guidelines on researching violence against women.¹⁵

To ensure autonomy, all participants were given detailed and comprehensive verbal and written information required to make an informed decision regarding their involvement in the research. A written consent form was not required as filling out the questionnaire signified consent. Moreover, all participants were informed that their contribution was on a voluntary basis and that they were free to accept, refuse or withdraw from the study at any time during the research process. To ensure confidentiality, participants were assured that no one except for the investigator would have access to the data gathered from each survey. Anonymity was also ensured since all forms were coded numerically, so that only the investigator could trace the patients’ details, in case the participant disclosed that she or someone else was at risk of injury. Furthermore, privacy was safeguarded by providing participants, a private room to fill out the survey. Due to COVID-19 pandemic restrictions, partners were not allowed to accompany the mothers for the appointments, hence this was an added precaution. Due to sensitive nature of the questionnaire, all the participants were asked by the midwife if they felt the need to discuss any personal issues, after filling out the survey. In addition, they were encouraged to take with them a leaflet produced by the local Commission on Domestic Violence, with local helplines should they feel the need to seek help later. To ensure safety for the participants, COVID-19 hospital protocols were followed at all times. In cases, were the questionnaire indicated a risk to the mother and/or children, the researcher discussed with the Consultant Psychiatrist and appropriate mitigation was taken.

Data analysis

The data gathered from the surveys was inputted manually and analysed using the International Business Machines Corporation (IBM) Statistical Package for Social Sciences (SPSS) version 22 and Microsoft Office Excel (2019). The Pearson’s chi-square test was used to assess the association between two categorical variables.

Results

In total, 100 mothers were eligible to participate in the study. Out of these, 85 mothers completed and handed in the questionnaire. Therefore, this yielded a response rate of 85%.

Demographic characteristics of women and their partner

Digital Supplementary File 1 and 2 present the sociodemographic details of female and male participants, respectively. Most of the participants were between 31 and 35 years old. Most of the participants and their intimate partners were both Maltese. However, when comparing non-Maltese cohorts, the female to male ratio was 1:3. More than half of the participants (51%) were found to be married to their intimate partner, 26% claimed to be cohabitating with their intimate partner and 23% were single. 60% of all the women had obtained post-secondary and tertiary education when compared to their partners (48%). With regards to employment status, 61% of the women and 87% of their partners were in a fixed employment. When assessing smoking habits, the majority of the women were non-smokers (52%) and only 15% smoked on a daily basis. On the other hand, 40% of their partners were non-smokers and 38% smoked daily. With regards to alcohol use, 41% of the women reported that they did not drink any alcohol during pregnancy, 36% drank only occasionally and 2% reported to drink alcohol daily. When asked about their partner drinking habits, 40% reported that their partner does not drink any alcohol, 38% reported that their partner drinks alcohol daily and 13% reported that their partner only drinks occasionally. Regarding drug use, 92% of the women did not use any illicit drugs and only 2% of participants reported to use drugs occasionally. When asked about their partners’ habits, 85% reported that their partner never used any drugs, 2% reported the usage of drugs daily and 5% reported the usage of drugs occasionally.

Frequency and severity of intimate partner abuse during pregnancy

Frequency of intimate partner abuse during pregnancy defined by types of abuse

40 out of 85 women (47%) reported one or more acts of psychological, verbal, physical or sexual abuse by their intimate partner during pregnancy. This implies that amongst the mothers attending the Perinatal Mental Health clinic, almost half of the mothers will experience some form of intimate partner abuse during their pregnancy. Out of the 40 abused women, 13 women (23%) reported one type of abuse, while 33 women (78%) reported more than one type of abuse. Amongst the 85 participants, verbal abuse (n=36, 42%) and psychological (n=33, 39%) were the most common reported types of abuse during pregnancy. Both physical (n=11, 13%) and sexual (n=10, 12%) abuse were experienced at lower frequencies.

Frequency of psychological intimate partner abuse during pregnancy

The most common reported act of psychological abuse was that partners insisted on knowing where the women were at all times (n=19, 22%), that their partner got angry if they spoke to other men (n=20, 24%) and the restriction of finances (n=17, 20%). In contrast, a fewer number of women claimed that their partner restricted their contact with family (n=11, 13%), restricted their contact with friends (n=11, 13%) and that their partner expected their permission before seeking health care (n=10, 12%).

Frequency and severity of verbal intimate partner abuse during pregnancy

The most common type of verbal abuse reported was that of partners making women feel bad about themselves during pregnancy (n=30, 35%). Additionally, women reported they were humiliated by their partner in front of other people (n=20, 24%) and that their partner did things to intimidate or scare them on purpose (n=21, 25%). Moreover, 9 of the participants, reported that their partner had threatened to hurt either them or someone they care about (11%). 6 out of these 9 women, reported that this abuse occurred on many occasions.

Frequency and severity of physical intimate partner abuse during pregnancy

The most reported physical abuse included being pushed, shoved, or having their hair pulled (n=8, 12%) and that of being slapped or having things thrown at (n=10, 9%). Five mothers reported that they were kicked, dragged or beaten; 4 mothers reported that they were punched during pregnancy, 2 mothers reported being choked or burnt; 2 mothers reported being punched specifically in the abdomen and 1 mother was even threatened with a weapon. Most of the physical abuse reported was experienced on many occasions.

Frequency and severity of sexual intimate partner violence during pregnancy

The most common sexual abuse reported by participants was that women participated in sexual intercourse because they were afraid of their partner’s actions in case of refusal (n=9, 11%). Moreover, 5 women reported they were forced to have sexual intercourse and 6 women reported they were forced to degrading activities against their will. The majority of the sexual abuse reported was experienced on many occasions.

Reported fear of partner

Sixty-two participants (73%) were never afraid of their intimate partner, while 15 mothers (18%) reported that sometimes they fear their partner. Four mothers (5%) reported feeling almost constantly scared and 4 mothers (5%) reported they didn’t want to answer.

Cross tabulations

Association between demographic variables and intimate partner abuse during pregnancy

Thirty-three out of 85 women (39%) experienced some form of psychological abuse by their intimate partners. There was a larger percentage of females aged 25 years or less who were abused (30%) compared to not abused (10%); and a smaller percentage of females aged 31 years or more who were abused (42%) compared to not abused (64%). These percentage differences were significant (p=0.017). Moreover, 11 out of 85 women (13%) experienced physical abuse by their intimate partner during pregnancy. A large percentage of females who were abused were within the 20-25 years age group (45%). These percentage differences were significant as well (p=0.030). Hence, it can be summarized that psychological and physical abuse by intimate partners was more prevalent in the younger females than in the older ones. Mothers who experienced psychological (67%, p=0.023) and sexual abuse (60%, p=0.021) were found to be associated with a partner of age between 26 and 35 years whilst mothers who experienced physical abuse (73%, p=0.001) were more likely to have a partner of age between 20 and 30 years old.

Women’s level of education was found to be significantly associated with psychological abuse. Women who had a primary, secondary or postsecondary level of education (85%) were found to be significantly more at risk of physiological abuse then compared to women with tertiary education (p=0.014). Women without a fixed job were found to be more associated with psychological partner abuse (55%, p=0.032). No fixed partner employment was found to be related to a higher risk of psychological (18%, p=0.001), verbal (11%, p=0.035) and physical abuse (27%, p=<0.0001).

Women who reported physical abuse were more at risk of daily alcohol misuse during pregnancy (9%, p=0.027). Daily smoking habits in men were found to be significantly related to higher rates of psychological abuse (60%, p=0.006) and sexual abuse (80%, p=0.018). Partner’s daily use of drugs was found to increase the risk of psychological abuse (6%, p=0.008), verbal abuse (6%, p=0.001), physical abuse (18%, p=<0.0001) and sexual abuse (20%, p=<0.0001).

With regards to marital status, being single and living with partner out of wedlock were found to increase the risk of psychological abuse (p=0.006) and physical abuse (45%, p=0.036). Fear of their partner was found to be more prominent in women who suffered physical abuse (73%, p=<0.0001) and sexual abuse (90%, p=<0.0001) when compared to women who suffered from psychological (42%, p=<0.0001) and verbal abuse (50%, p=<0.0001).

Association between the prevalence of intimate partner abuse in the general pregnant population when compared to pregnant women diagnosed with a perinatal mental health disorder

Pregnant women suffering from an antenatal or postpartum depression and/or anxiety disorder were found to be at a significant higher risk for all types of intimate partner abuse when compared to the general population of pregnant women (Table 1).

Conclusions

Intimate partner abuse during pregnancy is a worldwide problem. This study confirms that mothers suffering from an antenatal or postpartum depression and/or anxiety disorder are at a higher risk of experiencing intimate partner abuse during pregnancy. Moreover, young women with lower educational levels who are economically dependent on their partner and who are not married are at the highest risk of suffering from verbal, physical, psychological or sexual abuse. More needs to be done to identify pregnant mothers at risk of abuse at an early stage and offer the necessary interventions.

Knowing the prevalence and socio-demographic variables of intimate partner abuse are only the first step in developing and implementing new interventions to identify and respond early to such abuse. In fact, guidelines published by the WHO in 2013¹⁷ and the National Institute for Health and Care Excellence (NICE) in 2014¹⁸, recommend that mental health professionals should screen for partner abuse as part of a comprehensive psychiatric clinical assessments and that they should be able to provide support and ensure safety when partner abuse is disclosed.

Due to the COVID-19 pandemic, the prevalence of intimate abuse reported in this study might have been more than predicted. Worldwide records from helplines, police forces and other service providers indicate an increase in reported cases of domestic abuse, mostly child maltreatment and partner abuse against women during the COVID-19 pandemic. ¹⁹

References

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