The association between experiences of Intimate Partner Violence and Post Partum Depression
– a study within the BASIC cohort
Erik Blomqvist, projektarbete
Table of contents
Abstract………3
Introduction………..4
Post partum depression………..4
Violence against women………..5
Intimate partner violence………5
Aim………7
Material and method………..8
Result………..10
Discussion……….12
References………...16
Abstract
Purpose To investigate the association between Intimate Partner Violence (IPV) and symptoms of post partum depression (PPD) within the BASIC cohort. Post partum depression is a common
complication after childbirth. Several risk factors have been identified among them intimate partner violence.
Methods This study was part of the BASIC study at Uppsala University Hospital. Mothers attending their routine Ultrasound in week 17‐18 were invited to participate. Web based questionnaires and assessment scales were sent out to the participants at weeks 17 and 32 of gestation as well as 6 weeks and 6 months postpartum. Experience of IPV was assessed with two questions in the first questionnaire. Participation rate was 25% (1919 women. Symptoms of PPD were assessed using the EPDS.
Result 9.2% reported having any lifetime experience of IPV. At 6 weeks postpartum the prevalence of post partum depression was 12.3%. After adjusting for confounders the prevalence of PPD symptoms were found to be significantly higher among those with an experience of IPV with an adjusted OR of 2.07 with (p‐value <0.05).
Conclusion any lifetime Intimate Partner violence is positively associated with symptoms of PPD among women in the BASIC study cohort
Introduction
1.1 Post partum depression
Post partum depression (PPD) is a major health concern and considered one of the most common complications of childbirth. The prevalence of PPD varies between settings and study populations. In western populations the prevalence is usually stated to be in the range of 10-20% (Beck 2001) (Miller 2002), (Gavin, Gaynes et al. 2005). The prevalence of PPD in Sweden is also within this range, at around 12% (Josefsson, Berg et al. 2001) (Rubertsson, Wickberg et al. 2005)
Post partum depression is defined as a major depressive episode beginning within the first four weeks of childbirth (DSM IV). However, this period is usually extended to the first year post-partum in order not to miss those with a later onset of depressive symptoms (Woolhouse, Gartland et al. 2012). If untreated PPD poses a serious threat to the health and well-being of both mother and child.
Symptoms of PPD are similar to those of a major depression and include depressed mood, diminished pleasure in activities, insomnia, fatigue, anorexia, concentration inability, feelings of worthlessness and excessive guilt, anxiety and suicidal thoughts (Gale and Harlow 2003).
Despite being a potentially very harmful condition and with possible treatment available, PPD is an under diagnosed and inadequately treated condition. (Bågedahl-Strindlund and Monsen Börjesson 1998). Several screening tools have been constructed and validated for detecting PPD; the most commonly used being the Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden et al. 1987) . Treatments including different forms psychotherapy (such as Cognitive behavioral Therapy CBT, Intrapersonal therapy IPT or group therapy) might be sufficient in milder cases (Dennis and Hodnett 2007) (Goodman and Santangelo 2011), SSRI or SNRI medication can be used in more severe cases (Ng, Hirata et al. 2010), which might also
require hospitalization. In such severe cases, ECT treatment have shown to be effective (Berle 1999).
Several factors have been associated with an increased risk of developing post partum
depression. These include psychological, sociological, biological factors and obstetric factors.
Factors shown to be strongly associated with PPD include a history of psychiatric illness,
antenatal depression, a history of depression and a low level of partner support. (Robertson, Grace et al. 2004) (Milgrom, Gemmill et al. 2008)
The relative importance of various socio-demographical factors as potential risk factors of PPD has been somewhat disputed. However several studies have found associations between factors such as lower socioeconomic status, low level of education, unemployment and PPD.
(Rich-Edwards, Kleinman et al. 2006) (Robertson, Grace et al. 2004) (Milgrom, Gemmill et al. 2008) (Goyal, Gay et al. 2010).
1.2 Violence against women
Violence against women is affecting millions of women worldwide and there is mounting evidence of the detrimental effect violence has on women’s health, thus making violence against women not only a legal issue but also a major health concern.
The concept of violence against women is not only restricted to physical violence but implies any act of gender based violence that results in, or is likely to result in, physical sexual and psychological harm or suffering as defined by the United Nations. The American National Institute of Justice recommends that violence should be categorized into five components including physical abuse, sexual violence, threats of physical or sexual violence, stalking, and psychological/emotional abuse. (Saltzman LE, Fanslow JL, McMahon PM, Shelley GA.
Intimate partner violence surveillance: uniform definitions and recommended data elements, version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2002.)
Intimate partner violence (IPV) refers to acts of violence perpetrated against someone by a current or former intimate partner. IPV includes all violence in intimate relationships and is not limited to male violence against a female partner but also female to male, male to male and female to female violence.
The prevalence of intimate partner violence against women shows a great variation between study locations and study populations. The problem when comparing prevalence rates between different settings is a variation between studies in population sampling, how IPV is defined and data collection methods which makes comparison difficult. A study from Canada revealed a current or recent rate of any IPV of 15% in a group of female family practise patients (Ahmad, Hogg-Johnson et al. 2007). A study from Spain found a 32% lifetime
prevalence of any type of IPV (Ruiz-Pérez, Plazaola-Castaño et al. 2007). In Nicaragua a study found a 52% rate of lifetime experience of IPV (Ellsberg, Peña et al. 1999).
In a recent Swedish study 15.9% of the women had sometime in their life experienced physical IPV. (Lövestad and Krantz 2012). A multicenter study by the WHO with data collected using a standardized instrument found the lifetime prevalence of physical or sexual violence or both to be between 15% and 71%. The highest reported was from a rural setting in Ethiopia and the lowest from a Japanese city. (Garcia-Moreno, Jansen et al. 2006)
Based on the WHO study, a number protective factors and risk factors were identified and found to be similar across different settings. Secondary education, high SES, and formal marriage were found to be protective, while alcohol abuse, cohabitation, young age, attitudes supportive of wife beating, having outside sexual partners, experiencing childhood sexual abuse, growing up with domestic violence, and experiencing or perpetrating other forms of violence in adulthood where found to increase the risk of IPV. (Abramsky, Watts et al. 2011) Poverty or low SES seems to be an important factor showing a consistency between different settings (Jewkes 2002) (Bohn, Tebben et al. 2004, Jeyaseelan, Sadowski et al. 2004)
(Ellsberg, Peña et al. 1999). IPV is however not restricted to specific socio/economic groups.
Lack of social support is also reported as a risk factor (Lövestad and Krantz 2012).
Negative health consequences of IPV is not limited to physical health issues. Intimate partner violence is shown to increase the risk of mental health disorders such as depressive and anxiety symptoms, posttraumatic stress syndrome, suicide and substance use. (Jacqueline M.
Golding 1999) (Pico-Alfonso, Garcia-Linares et al. 2006) (Coker, Davis et al. 2002) (Mechanic, Weaver et al. 2008)
Violence and pregnancy related health
Intimate partner violence during pregnancy show a similar variation in prevalence and is often quoted as to be in the range between 0.9% and 20.1% based on a review of literature from United States, the variation was in part depending both on the population studied and the way IPV were assessed (Gazmararian, Lazorick et al. 1996).
In a Swedish study 1.3% of the women had experienced physical violence by a relative or close acquaintance during pregnancy or shortly thereafter. (Stenson, Heimer et al. 2001). A previous study found a significantly higher prevalence rate with a total of 24.5% reporting any form of IPV during the last year (before and during pregnancy) of and as many as 4.3%
reporting acts of serious violence during the pregnancy. (Hedin, Grimstad et al. 1999) Intimate partner violence during pregnancy has been associated with negative pregnancy outcomes, such as an increased risk of perinatal death, preterm low birth weight and term low birth weight (Coker, Sanderson et al. 2004) (Sarkar 2008). However in the population based large study in Canada and another in Hong Kong failed to see a statistically significant correlation between intimate partner violence and negative pregnancy outcomes. (Urquia, O'Campo et al. 2011) (Tiwari, Chan et al. 2008)
The correlation between IPV, especially during pregnancy, and an increased risk of depressive symptoms in the mother during the post partum period is well established and shown in a number of studies (Appendix A).
Aim
The aim of this study was to investigate the association between any lifetime experience of Intimate Partner Violence (IPV) and the risk of developing symptoms of Post-Partum Depression (PPD), after adjusting for possible confounding factors.
2. Methods
2.1 Study population
This study was carried out as part of the BASIC project, a population based cohort study in the county of Uppsala, Sweden, investigating multiple correlates of post partum depression.
The study was conducted at the department of Obstetrics and Gynecology at Uppsala
University Hospital with a catchment area of approximately 325000 people and around 4000 deliveries per year.
All pregnant women in Uppsala, when invited to the routine ultrasound in gestational week 18 received information about this study and were asked by their midwives if they wanted to participate.
The mothers received both oral and written information about the objectives of the study and a written consent was obtained. Thereafter an e-mail was sent to them after the routine ultrasound examination, containing a link to the web based questionnaires that are the basis for the BASIC study. Additional questionnaires were sent to the women at gestational weeks 32, as well as 6 weeks and 6 months post partum. The Questionnaires contain the EPDS as well as more extensive scales designed to evaluate psychiatric illness, personality traits, anxiety traits, posttraumatic stress, stressfull life events and sleep disturbances. In addition the questionnaires contained multiple questions on social parameters such as level of education, employment status, habits, expectations concerning the delivery and the relationship to the partner and the baby.
The women were also asked if they wanted to provide a number of different biologic samples during delivery ranging from saliva to uterus biopsies
2.2 Study variables and outcome measures
Experience of IPV was assessed by two questions in week 17 “Have you experienced partner violence in any previous relationship?” and “Have you experienced violence in your present relationship?” Possible answers were “Yes” and “No”. Recipients were also given the opportunity to give a written comment to their answers.
Those who answered the questions were divided into two groups, based on their answers;
group 1 with no experience of IPV and group 2, with some experience of IPV (in previous relationship, present relationship or both).
After analyzing the written comments it became clear that some of the women who answered
“yes” to “Have you ever experienced violence in a relationship?” had not experienced intimate partner violence themselves but had, for instance, witnessed abusiveness in the relationship between parents, or that they themselves had been abused during childhood by a parent or close relative. For the reasons of this study, those were classified under the group
“no experience of IPV”.
Symptoms of post partum depression were assessed at 6 weeks and at 6 months post partum by using the EPDS. The EPDS have been validated in Sweden with a cut-off score at 11.5 points. Above, a mother is screened positive for depressive symptoms in the post-partum period (Rubertsson, Wickberg et al. 2005). During pregnancy a cut-off score of 12.5 has been validated (Rubertsson, Börjesson et al. 2011).
2.3 Statistical analyses
Possible correlates of IPV such as age, employment status, level of education, history of depression, chronic physical illness, tobacco use, alcohol abuse and history of psychiatric illness, were cross-tabulated with experience of IPV. These factors were then separately cross- tabulated with self-reported PPD at six weeks and at six months postpartum. Factors associated with both at a p-value of less than 0.2 were then treated as possible confounders.
The data were then modeled through multivariate logistic regression with self reported PPD at six weeks as the outcome variable and IPV and possible confounders as the predictor
variables.
SPSS 20 was used for the analyses. Statistical significance was set at p-value of 0.05.
3. Results
The participation rate in the BASIC study is around 25% of all women attending routine ultrasound examination. A total number of 1919 women were included in this sub-study. A total number of 1611 women (83.9%) did answer questions about partner violence. Of those, 138 (8.6%) reported that they had experienced violence in a previous relationship, 10 (0.6%) reported experience of IPV in their current relationship and 1 (0.1%) had experience of partner violence in both her current and in former relationships, giving a total prevalence of IPV experience of 9.2%.
The level of education was high in this group of women, with 75.8% with a university education and only 1.5 % with primary school as their highest level of education.
Employment rate was high with only 3.5% reporting to be unemployed and the rest working full or part time, on maternity leave or on sick leave or conducting studies. Twenty seven percent reported a history of major or minor depression. At 6 weeks post partum, 167 out of 1361 (12.3%) had an EPDS score of 12 or above.
In the univariate analyses presented in Table 1, factors associated with IPV experience were low level of education, being unemployed or on sick leave, a history of depression and/or other psychiatric illness, having a chronic illness (including psychiatric illness), being of younger age (under 23 years old at the time of study), having had previous abortions and using tobacco. A greater number of those having an experience of IPV reported that their pregnancy was unplanned. Mothers with an experience of IPV are significantly less likely to breastfeed at 6 weeks post-partum and are significantly more likely to experience a lack of partner support in 6 weeks and 6 months post-partum (Table 1).
In an univariate model, the increased risk, expressed as odds ratio, of having depressive symptoms in the post-partum period of those exposed to IPV was 2.54, with 95 % CIs 1.58- 4.08 at 6 weeks postpartum and 2.74, with 95% CIs 1.59-4.74 at six months postpartum (Table 2). Women exposed to any lifetime IPV were also more likely to report depressive symptoms at 17 and 32 weeks respectively (Table 2).
Results of the multivariate analysis with depressive symptoms at six weeks as the outcome and IPV as well as possible confounders as the predictor variables are presented in Table 3.
In the first model, results are adjusted for all possible confounders, as described earlier. In Model 2, for previous psychiatric contact, unemployment and previous abortions and in Model 3 for previous psychiatric contact, the factor which remained statistically significant in Model 2. Experience of IPV remains an independent risk factor for depressive symptoms postpartum in all three models.
4. Discussion
The main finding of this study is the substantial association between any lifetime experience of IPV and the subsequent risk for development of PPD symptoms, even after adjustment for possible confounders, in agreement with previous studies.
In a meta-analysis published in 2012 including 6 studies, the respective OR was found to be 3.47, with 95% CIs 2.13-5.64 (Wu, Chen et al. 2012). Other studies present similar results.
Our study has also confirmed several socio-economic and psychosocial factors as correlates of IPV. Factors associated with a low socio-economic status such as low level of education and unemployment have been identified as risk factors of violence. Young age has also been associated with an increased risk of IPV. Depression, other psychiatric illness and chronic physical illness have been associated with violence as potential negative health consequences of violence.
Unplanned pregnancy and previous abortions are found to be associated to IPV in other studies (Laanpere, Ringmets et al. 2012) (Stöckl, Hertlein et al. 2012) (Roth, Sheeder et al.
2011) (Fanslow, Silva et al. 2008) (Pallitto, García-Moreno et al. 2013)
Studies have shown that IPV during pregnancy is associated with mothers not initiating or sustaining breastfeeding (Silverman, Decker et al. 2006) and that mothers with no experience of IPV are more likely to initiate breastfeeding than mothers experiencing IPV during
pregnancy (Lau and Chan 2007). To our knowledge this is the first study to present a strong association between any lifetime experience of IPV and not breastfeeding at 6 weeks post partum with mothers either failing to initiate or sustaining breastfeeding. The result was however not adjusted for other factors associated with breastfeeding.
The non-statistically significant effect of alcohol consumption in our study can be explained by the selective group of patients in this study, with participants not reporting hazardous drinking habits or alcohol consumption at any great extent.
The prevalence of current or recent experience of partner violence (violence in the current relationship) was significantly lower at 0.6% when compared to a recent study of IPV prevalence in the Swedish population with 8.1% of the women exposed to acts of physical
reported PPD is in accordance with what is reported in the literature for Swedish populations.
The lack of representivity does not, however, compromise the possibility of assessing a possible association between experience of IPV and development of PPD.
The majority of studies on the relationship between violence and PPD focus on violence in a perinatal period (some time before, during pregnancy and in the postpartum period). Because of the very low number of study participants reporting current experience of IPV (N= 11), such sub-analyses were unfortunately not feasible. On the other side, and most importantly, this study shows a possible long-term negative effect of experience of IPV in increasing the risk for self reported PPD even if there is no reported violence in the present relationship.
These findings have significant clinical implications, as health care workers might be advised to screen for any experience of IPV, not only IPV in the present relationship.
Among the strengths of this study are size, its population-based prospective design, and the availability of information on various possible confounding factors at an individual level.
Among the limitations of this study is the low participation rate, which results in a sample not representative of the population. Therefore, no conclusions on prevalence rates of either IPV or PPD can be drawn. On the other hand, we do not expect any bias in assessing a possible association between two variables.
The lack of a validated instrument to assess experience of IPV, but rather asking the open question “Have you ever experienced Violence in a relationship?” is problematic. There is an obvious risk that “violence” (våld in Swedish) is interpreted as physical violence only not including acts of psychological and/or sexual violence. The risk then being that those with no experience of physical violence but with an experience of emotional/psychological violence or sexual violence would answer “no”, increasing misclassification of the subjects in the study. Such a misclassification problem, would, on the other hand, only attenuate the strength of a possible association between experience of IPV and PPD.
On an international basis there are several instruments constructed to assess experience of IPV these are however not validated for a Swedish population.
From the open comments fields, we can also discern a tendency to interpret the question as experience of violence in any relationship, and not only their own relationship with an
intimate partner. With a more strictly defined question such as ”have you ever been abused by an intimate partner?” this could have been avoided. There is at least a theoretical possibility that some of the women answering “Yes” were the perpetrator of violence, rather than the victim of violence.
Ethnicity was not included as a factor in this study even though it is reported that the prevalence of IPV could be higher among immigrants in Sweden (Fernbrant, Essén et al.
2011). The questions were not translated to other languages, which results in a poor representation of immigrant groups not fully fluent in written Swedish.
This study provides further support to the already known association between IPV and depressive symptoms in the post-partum period. It furthermore establishes an association between any lifetime experience of violence and the risk of developing post-partum
depression. Because of the known negative effects of violence on pregnancy related health, it is essential to screen for IPV experience of among pregnant women. Previous studies from Sweden have shown that midwives are aware of the importance of, and positive towards asking every pregnant woman about violence but that they because of different reasons fail to do so. (Edin and Högberg 2002) (Stenson, Sidenvall et al. 2005)
Concerns have been expressed about implementing a routine screening by midwives for detecting victims of IPV among pregnant women. The potential risk of women with or without an experience of violence being stigmatized or feeling uneasy when asked about previous experience of violence is pointed out as being problematic.
(http://www.lakartidningen.se/engine.php?articleId=8994)
However a Swedish study concerning women’s attitudes towards midwives asking questions about IPV found that only 3% of the women in the study found it unacceptable to be asked questions about IPV. (Stenson, Saarinen et al. 2001)
The use of a standardized and validated tool among all women would probably minimize this risk and would furthermore increase the quality of documentation and the likelihood of finding those being abused. The clinical implementation of this would be of paramount importance, considering the possibly detrimental effects of violence on women´s health
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Wu, Q., H. L. Chen and X. J. Xu (2012). "Violence as a risk factor for postpartum depression in mothers: a meta‐analysis." Arch Womens Ment Health 15(2): 107‐114.
Table 1.
Binary logistic derived Odss Ratios (OR) and 95% confidence intervals (95% CIs) for experience of intimate partner violence (IPV) in relation to various variables.
Experience of IPV
No (n=1462) Yes (n=149) OR 95% CIs
Variable N (%) N (%)
Level of education > Secondary school
Primary school
1434(91.3)
14(51.9)
136(8.7)
13(48.1)
1.00
9.79 Ref
4.51-21.26
Unemployement No
Yes
1360(91.0) 46(82.1)
135(9.0) 10(17.9)
1.00 2.19
Ref 1.08-4.44
Year of birth 1962-1986 1987-1994
1396(91.2) 64(81.0)
134(8.8) 15(19.0)
1.00 2.44
Ref 1.35-4.40
BMI <25
>25
488(90.7) 235(89.7)
50(9.3) 27(10.3)
1.00 1.12
Ref 0.69-1.84
Planned pregnancy Yes No
1221(91.3) 222(87.4)
117(8.7) 32(12.6)
1.00 1.50
Ref 0.99-2.28
Previous miscarriage No Yes
580(91.5) 157(86.7)
54(8.5) 24(13.3)
1.00 1.64
Ref 0.98-2.74
Previous abortions No Yes
640(92.6) 97(78.2)
51(7.4) 27(21.8)
1.00 3.49
Ref 2.09-5.84
Previous contact with psychologist/psychiatrist
No Yes
585(94.2) 142(78.0)
36(5.8) 40(22.0)
1.00 4.58
Ref 2.82-7.44
Self reported history of No 1089(94.4) 65(5.6) 1.00 Ref
depression Yes 356(81.5) 81(18.5) 3.81 2.69-5.40
Alcohol consumption, Yes 267(92.4) 22(7.6) 1.00 Ref
3 months prior No 425(89.1) 52(10.9) 1.49 0.88-2.50
Tobacco use, No 650(92.6) 52(7.4) 1.00 Ref
3 months prior Yes 80(75.5) 26(24.5) 4.06 2.40-6.87
Chronic illness (incl. No 472(93.3) 34(6.7) 1.00 Ref psychiatric illness) Yes 321(86.5) 50(13.5) 2.16 1.37-3.42
Partner support, Yes 1044(91.4) 98(8.6) 1.00 Ref
6 weeks postpartum No 27(75.0) 9(25.0) 3.55 1.62-7.76
Partner support, Yes 824(92.1) 71(7.9) 1.00 Ref
6 months postpartum No 25(65.0) 14(35.0) 6.25 3.12-12.50
Breastfeeding, Yes 1015(91.4) 95(8.6) 1.00 Ref
6 weeks postpartum No 65(82.3) 14(17.7) 2.30 1.25-4.26
Breastfeeding, Yes 638(91.3) 61(8.7) 1.00 Ref
6 months postpartum No 214(88.8) 27(11.2) 1.32 0.82-2.13
Table 2
Binary logistic derived Odss Ratios (OR) and 95% confidence intervals (95% CIs) for
experience of intimate partner violence (IPV) in relation to depressive symptoms postpartum.
Experience of IPV
No (n=1462) Yes (n=149) OR 95% CI
Variable N (%) N (%)
EPDS score at gestational week 17
<13
>13
1350(92.1) 103(76.9)
116(7.9) 31(23.1)
1.00 3.50
Ref 2.25-5.46
EPDS score at gestational week 32
<13
>13
1181(92.0) 99(80.5)
102(8.0) 24(19.5)
1.00 2.81
Ref 1.72-4.58
EPDS score 6 weeks postpartum
<12
>12
964(92.0) 122(81.4)
84(8.0) 27(18.1)
1.00 2.54
Ref 1.58-4.08
EPDS score 6 months postpartum
<12
>12
775(91.8) 82(80.4)
69(8.2) 20(19.6)
1.00 2.74
Ref 1.59-4.74
Table 3
Multiple logistic regression- derived odds ratios (ORs) for significant depressive symptoms (EPDS>12) at six weeks postpartum
Variables Model 1
OR
Model 2 OR
Model 3 OR
Experience of IPV No
Yes
- 2.07**
- 2.06**
- 2.33**
Previous psychiatric contact No
Yes
- 1.90**
- 2.08**
- 2.29**
Previous abortion(s) No
Yes
- 1.67*
- 1.65*
Employment No
Yes
- 2.20
- 2.36*
Education Higher
Lower
- 1.09
Age 26 and older
Younger than 26
- 1.20
Self-reported depression No
Yes
- 1.14
**p<0.05, * p< 0.10
APPENDIX A.
Study Location Result
adjusted OR 95 % CI
Time of violence
Type of violence
Certain et al.
(cross sectional survey)
USA 4,21 (2,19‐
8,09)
Previous year
All types
Ludemir et al.
(prospective cohort)
Brazil 2.12 (23.2‐
28.6)
During pregnancy
All types
Savarimuthu et al.
(Qualitative methodology)
India (rural) 3.33(1.09‐
9.61)
Pregnancy and post partum.
Physical
Gao et al, (Prospective cohort)
New Zealand 2.34,(1.52‐
3.60)
Past 12 months
All types
Valentine et al.
(Prospective observational study)
USA (among Latinas)
5,38, (2,21‐
13.08)
Recent year All types
Tiwari et al.
(Survey)
Hong‐Kong 1,84 (1.12‐
3,02
Pregnancy Psychological
Beydoun et al.
(Cross‐
sectional survey)
Canada 1,61 (1,06‐
2,45
Past 2 years Physical/sexual
Woolhouse et al.
(Prospective cohort)
Australia 2,72 (1,72‐
4.13) 3,94 (2.44‐
6.36)
Within 12 months after birth
Physical/psychological
