Mental Health of Women Who Suffer Intimate Partner Violence During Pregnancy

Original article Mental health of women who suffer intimate partner violence during pregnancy

Mariana de Oliveira Fonseca-Machado1 Lisiane Camargo Alves2 Patrícia Scotini Freitas3 Juliana Cristina dos Santos Monteiro4 Flávia Gomes-Sponholz5 12

Mental health of women who suffer intimate partner violence during pregnancy

Objective. To identify the relationship between intimate partner violence (IPV) during pregnancy and mental disorders in women in the pregnancy-puerperal cycle. Method. A review was conducted of papers published in Portuguese, English and Spanish regarding the study theme. The databases explored were PubMed, CINAHL, LILACS and PsycINFO. Results. The 17 included papers studied the relationship between IPV and: pre- and postpartum depression (41%); pregnancy anxiety (23%) and pregnancy posttraumatic 1 RN, Ph.D. student. University of São stress disorder (12%). None of the studies investigated the Paulo at Ribeirão Preto College of association between IPV and suicidal ideation. Conclusion. IPV Nursing – EERP-USP-, Brazil. email: [email protected] against women during the pregnancy-puerperal cycle causes 2 RN. Ph.D. student. EERP-USP, Brazil. negative impacts on mental health. Concrete actions shall be email: [email protected] proposed regarding the prevention, identification and treatment of 3 RN. Ph.D. student. Professor at women exposed to IPV during their pregnancy period. Faculdade Pitágoras in Poços de Caldas, Brazil. email: [email protected] Key words: spouse abuse; pregnancy; postpartum period; mental 4 RN, PhD. Professor at EERP-USP, Brazil. health; nursing. email: [email protected] 5 RN, PhD. Professor at EERP-USP, Brazil. email: [email protected] Salud mental de la mujer víctima de violencia por parte Article related to research: Violence during compañero íntimo durante la gestación pregnancy and mental health of women who are made victim by their partners. Objetivo. Identificar la relacción entre violencia por compañero íntimo (VCI) en la gravidez y los trastornos mentales en mujeres Subventions: São Paulo Research Foundation en el ciclo grávido-puerperal. Metodologia. Se hizo revisión (Fundação de Amparo à Pesquisa do Estado de los artículos publicados en portugués, inglés y español de São Paulo – FAPESP). Ph.D. student scholarship. que trataran este tema. Las bases de datos exploradas fueron PubMed, CINAHL, LILACS y PsycINFO. Resultados. De los 17 Conflicts of interests: none. artículos incluídos, estudiaron la relación de VCI con: depresión pre y posparto (41%); ansiedad gestacional (23%) y transtorno Receipt date: Jun 21, 2013. de estrés postraumático gestacional (12%). Ningún estudio investigó la asociación entre VCI e ideación suicida. Conclusión. Date of Approval: Jun 3, 2014. La VCI contra las mujeres en el ciclo grávido-puerperal tiene repercusiones negativas para la salud mental. Deben desarrollarse How to cite this article: Fonseca-Machado MO, Alves LC, Freitas PS, Monteiro JCS, acciones concretas de prevención, identificación y tratamento de Gomes-Sponholz F. Mental health of las mujeres en situación de VCI durante el período gestacional. women who suffer intimate partner violence during pregnancy. Invest Educ Enferm. Palabras clave: maltrato conyugal; embarazo; período de 2014;32(2): 291-305. postparto; salud mental; enfermeira.Invest Educ Enferm. 2013;31(3) • 291 Mariana de Oliveira Fonseca-Machado • Lisiane Camargo Alves • Patrícia Scotini Freitas • Juliana Cristina dos Santos Monteiro • Flávia Gomes-Sponholz

Saúde mental da mulher vítima de violência por colega íntimo durante a gestação

Objetivo. Identificar a relação entre violência por colega íntimo (VCI) na gravidez e os transtornos mentais em mulheres no ciclo grávido-puerperal. Metodologia. Fez-se revisão dos artigos publicados em português, inglês e espanhol que tratassem o tema de estudo. As bases de dados exploradas foram PubMed, CINAHL, LILACS e PsycINFO. Resultados. Dos 17 artigos incluídos estudaram a relação de VCI com: depressão pré e pós-parto (41%); ansiedade gestacional (23%) e transtorno de estresse pós-traumático gestacional (12%). Nenhum estudo pesquisou a associação entre VCI e ideação suicida. Conclusão. A VCI contra as mulheres no ciclo grávido-puerperal tem repercussões negativas para a saúde mental. Devem desenvolver-se ações concretas de prevenção, identificação e tratamento das mulheres em situação de VCI durante o período gestacional.

Palavras chave: maus-tratos conjugais; gravidez; período pós-parto; saúde mental; enfermagem.

Introduction

Violence is defined by the World Health mental disorders during pregnancy,7 defined as a Organization as “the intentional use of physical clinically significant behavioral or psychological force or power, threatened or actual, against pattern or syndrome occurring in a subject oneself, another person, or against a group or and is associated with discomforts, functional community, that either results in or has a high incapacities or with a significantly increased risk likelihood of resulting in injury, death, psychological of death, pain, disability or freedom deprivation.9 harm, maldevelopment, or deprivation”.1 While Among the principal mental disorders occurring domestic violence is referred as a series of violent in women during pregnancy, depressive actions occurring in the domestic environment, disorders, suicidal ideation, posttraumatic stress intimate partner violence (IPV) describes violence disorder (PTSD) and anxiety disorders were in the intimate relation context.2 It is defined as highlighted.6,10-12 violence perpetrated by a partner or ex-partner which involves physical and sexual threats and Although it is known that during the pregnancy- aggressions, psychological/emotional abuse, and/ puerperal cycle women become sensitive, both or forced sexual intercourse.3 The IPV situation is physically and emotionally, and for that reason more prevalent among women in their childbearing they may be in a more vulnerable condition, there period,4 and it may occur during the pregnancy are evidences that this is the right moment to period, which makes it of particular concern due investigate violence, based on the fact that, for to the adverse events incurring to the mother’s, many women, the pregnancy-puerperal cycle is fetus’ and, posteriorly, child’s health.5,6 the only opportunity to establish contact and bond with the health facility.13 Therefore, incorporation Pregnancy, frequently seen as a period of emotional of mental health and IPV coping actions to well-being, may also represent a moment of stress prenatal care by health professionals is needed in and changes. Stressful situations are considered order to improve women’s health and well-being, to be mental disorder triggers,7 and such disorders as well as their children’s.10,11 are the most common health problems associated to pregnancy.8 In this context, IPV is considered In view of this reality, although most human to be an stressing factor to many women9 and and financial resources are intended for significantly contributes to the occurrence of the immediate approach and/or long-term

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consequences of violence, the issue goes by about a specific theme and contributes to the health facilities unnoticed and voiceless, generally development of future studies. The comprehensive due to victims’ personal reasons and/or unskillful review summarizes research conducted professionals.14,15 Such situation is justified as IPV separately, but investigating identical or similar is surrounded by gender-based issues and cultural issues regarding a specific topic, and draws a traditions and conventions which make it a matter conclusion. The studies have been systematically of family privacy, individual choice or an inevitable analyzed with regard to their objectives, materials, 20 fact of life, and should therefore be veiled behind methods and results. closed doors.16,17 Thus, health professionals’ The development of this comprehensive review awareness with regard to the existence of IPV followed the following stages: i) identification during pregnancy becomes crucial, given its of the theme and selection of the hypothesis potential consequences to the mental health of or research issue; ii) sampling or search in the 5 women in the pregnancy-puerperal cycle. In this literature of the primary studies; iii) definition of context, greater visibility of this public health the information to be extracted from the selected issue may be achieved through evidence-based primary studies; iv) assessment of the primary practice, defined as a search and assessment studies included in the comprehensive review; process, and by applying the scientific evidences v. result interpretation; and vi) presentation of to health treatment and management, which the knowledge review/synthesis.21 The guideline permits improving the quality of the care provided question for such comprehensive review was: to the population and motivates the health which are the evidences available in the literature professional to search for scientific knowledge by related to the relationship between IPV during developing research or applying literature results pregnancy and mental disorders in women in the in their daily practice. With this approach, for the pregnancy-puerperal cycle? decision making process regarding health care, the professional’s clinical competence and the The primary studies have been selected from client’s preferences are also incorporated.18 four electronic databases, as follows: LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Comprehensive Index of In this study, the method used was a comprehensive Scientific and Technical Literature of Latin literature review, one of the resources of America and the Caribbean]), PubMed, PsycINFO evidence-based practice, which offers support e CINAHL (Cumulative Index to Nursing and for professionals to make decisions on the daily Allied Health Literature). The adopted inclusion provision of health services and allows for the criteria were: papers published in Portuguese, identification of specific knowledge gaps that may English and Spanish and that described the be addressed in future research.19 The objective of relationship between IPV during pregnancy and this study was to identify evidences available in the mental disorders in women in the pregnancy- literature regarding the relationship between IPV puerperal cycle. The adopted exclusion criteria during pregnancy and mental disorders in women were: narrative review/traditional, editorial in the pregnancy-puerperal cycle, highlighting literature or letter-response studies. No period pregnancy depressive disorder, postpartum limitation was imposed regarding the publication depression, PTSD, anxiety and suicidal ideation. period of the papers, and all papers published until March 2014 were considered. Non- controlled descriptors (key words) and controlled descriptors were used. These words were used as Method a filter between the author’s appropriate language and the area-specific terminology, acknowledged In order to reach the objective, a comprehensive worldwide.22,23 To ensure a strict and wide literature review was conducted, which gathers search, the descriptors presented in Table 1 were and summarizes scientific knowledge produced combined in each database whenever needed.19

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Table 1. Controlled and non-controlled descriptors established for each database

Databases Controlled descriptors Non-controlled descriptors PubMed Pregnancy OR Postpartum period Postnatal period (MeSH) Spouse abuse Intimate partner violence OR Violence against women OR Domestic violence Mental health OR Depression OR Depression postpartum OR Anxiety OR Anxiety disorders OR Suicide OR Stress disorders post-traumatic CINAHL Pregnancy OR Postnatal period Postpartum period (CINAHL headings) Domestic violence Violence against women OR Spouse abuse Anxiety OR Anxiety disorders OR Depression Violência por parceiro íntimo OR Mental Health OR Suicide LILACS Gravidez OR Gestação OR Período pós-parto (DeCS) OR Puerpério Maus-tratos conjugais OR Violencia contra a mulher OR Violencia domestica AND Saúde mental OR Depressão pós-parto OR Depressão OR Ansiedade OR Transtornos de ansiedade OR Suicídio OR Transtornos de estresse pós-traumáticos PsycINFO Pregnancy OR Postnatal period Postpartum period

Spouse abuse OR Intimate partner violence OR Violence against women Domestic violence Mental health OR Depression OR Postpartum depression OR Anxiety OR Anxiety disorders OR Suicide OR Posttraumatic stress disorder

Basedon the descriptors defined for this The main reasons for excluding those papers comprehensive review, 261 papers were found in this phase were related to the undetermined in the PubMed database; 173 the CINAHL; 06 moment of the IPV onset and also to the different (six) in LILACS; and 34 in PsycINFO. The primary concepts of violence used in those studies, which studies were selected with regard to their title and made it difficult to identify the one responsible for summary, and selection was guided based on the perpetrating the violent acts. One study selected outlined inclusion and exclusion criteria. After this from the PubMed database was not fully available initial analysis, 401 papers were excluded for electronically or could not be obtained through a reasons described in Table 2. Thus, 73 papers were Reference Interchanging System (COMUT) and selected for thorough reading. After exhaustive was excluded from the review. Thus, the final reading of those 73 papers, 56 were excluded as sample of this comprehensive review included 17 they did not describe the theme and, therefore, did papers, as presented in Table 2. not relate to the guideline question of this review.

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For the extraction of the data from the papers the reader with a summary of each included study included in the review, a previously validated tool and allowing for comparisons to emphasize the was used.24 Analysis and summary of the primary difference and similarities among studies.25 studies were conducted descriptively, providing

Table 2. Reasons for exclusion of papers found in the databases and description of final sample

Excluded Database Search Total Duplicate Not related to Selected Final Sample Others* Papers theme Papers PubMed 261 0 152 50 59 13 PsycINFO 34 15 9 4 6 1 CINAHL 173 58 78 31 6 3 LILACS 6 0 2 2 2 0 Total 474 73 241 87 73 17

*Others: Reviews, Editorials, Response Letters, Other Language

Results

The 17 papers included in the comprehensive studies, gestational depression and postpartum review were published between the years of 2006 depression; one (5.9%) study, gestational PTSD; and 2013, with 14 (82.4%) published since and one (5.9%) study, gestational depression, 2010. All studies were published in English. Table anxiety and PTSD. It was noted that none of the 3 points out that the countries that have published studies investigated the association between IPV more papers related to the theme were the United during pregnancy and suicidal ideation in the States (29.4%), Bangladesh and Brazil (11.8% pregnancy-puerperal cycle. each). Studies developed in Brazil were published in international journals. In addition, only one Table 4 summarizes the primary studies included paper (5.9%) mentions the authors’ profession, in the comprehensive review which investigated all of them nurses. Regarding the study design, all the existence of an association between IPV of them were observational studies, nine (52.9%) and depressive disorders, both occurring during cross-sectional and eight (47.1%) longitudinal. As pregnancy. Based on the results evidenced by for the study population, eight (47.1%) included the primary studies included in the present pregnant subjects as participants; three (17.6%) comprehensive review, which verified the existence included postpartum subjects; and six (35.3%) of an association between IPV and depressive included both pregnant and postpartum subjects. disorder/symptoms, both during pregnancy, it Table 3 summarizes the primary studies included was observed that women who suffer physical, in the comprehensive review. psychological and/or sexual violence perpetrated by their intimate partners during pregnancy Outcomes were as follows: six (35.3%) studies, are more likely to show depressive disorders/ postpartum depression; four (23.5%) studies, symptoms during the prenatal period when gestational depression; three (17.6%) studies, compared to those who have not suffered this gestational depression and anxiety; two (11.8%) type of violence.

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Table 3. Summary of primary studies included in the comprehensive review

Reference Type of Study Country Sample Objective(s) Mahenge et Observational Tanzania N=1 180 To determine the prevalence of IPV du- al.10 (2013) cross-sectional pregnant sub- ring pregnancy and its associated mental jects symptoms. Ogbonnaya et Observational United N=104 To investigate the changes in depressive al.26 (2013) longitudinal States pregnant and symptoms levels during pregnancy and postpartum postpartum period of women undergoing subjects physical IPV during pregnancy. To compare these levels with the levels of women who do not suffer physical IPV during pregnancy. Almeida et al.27 Observational Portugal N=184 preg- To understand the influence of violence (2013) cross-sectional nant subjects during pregnancy on women’s mental health during this period. Huth-Bocks et Observational United N=120 preg- To examine associations between different al.28 cross-sectional States nant subjects forms of IPV and the presence of PTSD (2013) in 120 women during pregnancy last tri- mester. Budhathoki et Observational Nepal N=72 To identify the prevalence of IPV and pos- al.29 cohort Pregnant and tpartum depression and the relation bet- (2013) postpartum ween these two variables. subjects Faisal-Cury et Observational Brazil N=701 To estimate if there is a temporal associa- al.30 cross-sectional pregnant and tion between postpartum depression and (2013) postpartum IPV. subjects To assess the potential role of social support regarding this relation. Zhang et al.31 Observational China N=846 To investigate the prevalence of domestic (2012) cross-sectional pregnant and violence during pregnancy and postpar- postpartum tum depression. subjects To explore the relationship between domestic violence and postpartum depression among Chinese women. Groves et al.32 Observational South Africa N=1 500 To describe the proportion of South- (2012) cross-sectional pregnant sub- African women showing depression and jects anxiety symptoms during pregnancy. To assess if the different types of IPV affect the risk for depression and anxiety differently. To test if the social support changes the relationship between IPV and depression/ anxiety. Miszkurka, Observational Canada N=5 162 To describe the violence phenomenon du- Zunzunegui and cross-sectional pregnant sub- ring pregnancy during pregnancy. Goulet33 jects To examine the association between vio- (2012) lence and the presence of depressive symptoms during pregnancy, taking into account the pregnant subject’s immigra- tion status.

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Table 3. Summary of primary studies included in the comprehensive review (Cont.)

Reference Type of Study Country Sample Objective(s) Flach et al.34 Observational United King- N=13 617 To investigate if domestic violence during (2011) Cohort dom pregnant and pregnancy is associated with a child’s ad- postpartum verse development and if it is mediated subjects by maternal mental disorders, especially depressive symptoms. Nasreen et al.35 Observational Bangladesh N=720 preg- To examine and identify the prevalence of (2011) cross-sectional nant subjects potential factors associated with depression and anxiety symptoms among pregnant women in a rural area in Bangladesh. Melville et al.36 Observational United N=1 888 To estimate the prevalence of major and (2010) longitudinal States pregnant sub- minor depression, panic disorder and sui- jects cidal ideation during pregnancy. To identify potential risk factors for these depressive disorders. Ludermir et Observational Brazil N=1 133 To investigate the association between al.37 cohort pregnant and postpartum depression and psychological, (2010) postpartum physical and sexual IPV during pregnancy. subjects Hayes et al.38 Observational United N=7 154 To analyze postpartum depression among (2010) longitudinal States pregnant and Asian groups and population in the postpartum Hawaiian pacific islands, aiming at com- subjects paring these projections with other racial and ethnical groups. To assess if the differences are related to demographic characteristics. Gomez-Beloz39 Observational Peru N=2 394 To identify the prevalence of IPV during (2009) cross-sectional postpartum lifetime and during pregnancy. subjects To assess the risk for depressive symptoms in relation to IPV exposure before and during pregnancy in a group of Peru- vian women. Gausia et al.40 Observational Bangladesh N=95 preg- To identify the prevalence and related (2009) cross-sectional nant subjects factors to gestational depression among pregnant women from Bangladesh, who also showed suicidal ideation. Martin et al.41 Observational United N=95 preg- To verify the existence of associations bet- (2006) longitudinal States nant subjects ween IPV situations and depressive symptoms before and during pregnancy.

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Table 4. Main results of primary studies included in the comprehensive review which investigated the existence of an association between IPV and depressive disorders both occurring during pregnancy

Reference Main result(s) Mahenge et al.10 Women who suffered physical and/or sexual IPV during pregnancy were significantly (2013) more likely to show depressive symptoms during pregnancy (OR 3.31; CI 2.39-4.59) than women who had not reported this type of violence. Ogbonnaya et al.26 Women who were victims of physical IPV during pregnancy showed a significantly hig- (2013) her level of depressive symptoms during pregnancy than women who had not suffered this type of violence. Almeida et al.27 Gestational depression scores were higher among pregnant women who had been abu- (2013) sed by their intimate partner during pregnancy (p < 0.01). Groves et al.32 The chance of women showing depression/anxiety during pregnancy increased 1.41 (2012) fold (CI=1.26-1.57) for each episode of psychological IPV; and 2.01 fold (CI=1.16- 3.77) for each episode of sexual violence. Miszkurka, Zunzu- There was a strong association between IPV occurring during pregnancy and gestational negui and Goulet33 depression (OR 5.81; CI=4.19-8.08). (2012) Flach et al.34 There was an association IPV and depressive symptoms both during pregnancy (OR (2011) 4.02; CI=3.4-4.8; p<0.001). Nasreen et al.35 No evidences have been found on the association between IPV occurring exclusively (2011) during pregnancy and pre-natal depression. Melville et al.36 IPV occurring during pregnancy has come up as one of the independent predictors of (2010) major depression during the prenatal period (OR 2.20; CI=1.002-4.84). Gausia et al.40 Participants in physical IPV situations during pregnancy showed higher risk for gesta- (2009) tional depression (OR 6.75). Martin et al.41 Women who were victims of physical IPV during pregnancy had a median score in the (2006) gestational depression scale higher than those who had not been abused (p = 0.01). There has been an increase in the gestational depression scale scores with the increase of the type of violence suffered during pregnancy.

Table 5 summarizes the primary studies included in Table 6 summarizes the primary studies included the comprehensive review, which investigated the in the comprehensive review which investigated existence of an association between IPV occurring the existence of an association between IPV during pregnancy and postpartum depression. and anxiety both occurring during pregnancy. The main results of the studies included in the Results of the four studies included in the present comprehensive review, which verified the present comprehensive review, which verified existence of an association between IPV occurring the existence of an association between IPV and during pregnancy and postpartum depression, anxiety both occurring during pregnancy, showed indicated that women in physical, psychological evidence that women in physical, psychological and/or sexual violence situations perpetrated and/or sexual violence situations perpetrated by by their intimate partners during pregnancy are their intimate partners during pregnancy are more more likely to show postpartum depression when likely to show anxiety/anxiety symptoms when compared to those who have not suffered this compared to those who have not suffered this type of violence. type of violence.

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Table 5. Main results of primary studies included in the comprehensive review which investigated the existence of an association between IPV occurring during pregnancy and postpartum depression

Reference Main result(s) Ogbonnaya et al.26 Women who were victims of physical IPV during pregnancy showed a significant higher (2013) level of depressive symptoms in the postpartum period than those women who had not suffered this type of violence. Budhathoki et al.29 No significant statistical relation was found between the different natures of violence (2013) during pregnancy and postpartum depression. Faisal-Cury et al.30 No evidences of an association between IPV occurring exclusively during pregnancy and (2013) postpartum depression were found. Zhang et al.31 Psychological violence during pregnancy was a risk factor for postpartum depression (2012) (OR 4.032; CI=1.698–9.615). Postpartum depression severity was positively correlated with psychological IPV during pregnancy. Ludermir et al.37 Women who reported higher frequencies of psychological IPV during pregnancy were (2010) more likely to show postpartum depression, (OR 2.29; CI=1.15-4.57).Women who reported physical or sexual IPV during pregnancy were more likely to develop postpartum depression (OR 3.28; CI= 2.29-4.70). Hayes et al.38 Women who suffered IPV during the prenatal period reported high estimates of postpar- (2010) tum depression symptoms (OR 3.7; CI=2.6-5.5). Gomez-Beloz39 Women in the postpartum period who suffered physical, sexual and/or psychological (2009) IPV during pregnancy showed higher severity levels of depressive symptoms than those women who had not been abused.

Table 6. Main results of primary studies included in the comprehensive review which investigated the existence of an association between IPV and anxiety both occurring during pregnancy

Reference Main result(s) Mahenge et Women who suffer physical and/or sexual IPV during pregnancy were significantly more likely al.10 to show anxiety symptoms during pregnancy (OR 3.98; CI=2.85-5.57) than those women (2013) who have not reported this type of violence. Almeida et Gestational anxiety scores were higher among pregnant women who had been abused by al.27 their intimate partner during pregnancy (p < 0.01). (2013) Groves et The chance of women showing depression/anxiety during pregnancy increased 1.41 fold al.32 (CI=1.26-1.57) for each episode of psychological IPV; and 2.01 fold (CI=1.16-3.77) for (2012) each episode of sexual violence. Nasreen et The presence of gestational anxiety symptoms was directly associated to physical IPV occu- al.35 rring during pregnancy. (2011)

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Table 7 presents a summary of the two primary PTSD both occurring during pregnancy, showed studies included in the comprehensive review evidence that women in physical, psychological which investigated the existence of an association and/or sexual violence situations perpetrated by between IPV and PTSD both occurring during their intimate partners during pregnancy are more pregnancy. The two studies included in the likely to show PTSD when compared to those who present comprehensive review, which verified have not suffered this type of violence. the existence of an association between IPV and

Table 7. Main results of primary studies included in the comprehensive review which investigated the existence of an association between IPV and PTSD both occurring during pregnancy

Reference Main result(s) Mahenge et Women who suffer physical and/or sexual IPV during pregnancy were significantly more al.10 likely to show moderate PTSD (OR 2.94; CI 1.71-5.06) than those women who have not (2013) reported this type of violence. Huth-Bocks et The severity of psychological and physical IPV during pregnancy was significantly associated al.28 with PTSD symptoms in the prenatal period. (2013) Among the IPV nature, the psychological violence was the one mostly associated with PTSD symptoms.

Discussion

In the 17 papers included in the comprehensive acts of different natures during the pregnancy in review, the outcomes were as follows: ten course.10,41 On the other hand, a study developed (58.8%) studies, gestational depressive disorder; in Bangladesh,35 did not find evidences of an seven (41.2%) studies, postpartum depression; association between IPV occurring exclusively four (23.5%) studies, gestational anxiety; two during pregnancy and gestational depression. Of (11.8%) studies, gestational PTSD; and none note, among the ten studies, one was developed addressed suicidal ideation. in Tanzania,10 one in Portugal,27 one in South Africa,32 one in Canada,33 one in the United Of the ten studies included in the review which Kingdom34, two in Bangladesh,35,40 and three in investigated the association between IPV and the United States.26,36,41 Six had a Cross-sectional depressive disorders both occurring during design and four had a longitudinal design. pregnancy, nine evidenced the existence of the referred association. Depressive symptoms were The presence of depressive disorders/symptoms specifically associated with the psychological and during the prenatal period is strongly related sexual IPV in South Africa;32 psychological and to the frequency and severity of the violence physical IPV in the United Kingdom;34 physical experienced since the beginning of pregnancy. In IPV in the United States26,41 and Bangladesh;40 this sense, to acknowledge violence as a clinically and physical and sexual IPV in the United relevant and identifiable risk factor for gestational States36 and Tanzania.10 In addition, violence depression may be a first step in the prevention pattern analysis showed that the depressive of mental health problems,33 as the severe cases symptoms level in pregnant women were higher of depression, characterized by suicidal or self- and more severe in the groups experiencing mutilation ideas, are also relatively common moderate or severe IPV episodes and/or violent during pregnancy.

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Thus, these studies results may sensitize violence. In addition, self-reported postpartum researchers, managers and health professionals depression was associated with physical IPV with regard to the existence of violence in the occurring during pregnancy.38 Investigations life of women during pregnancy, highlighting the conducted in São Paulo – Brazil and in China importance of tracking routine both of the violence did not find evidence of an association between episodes and the depressive symptoms. Despite IPV during pregnancy and the occurrence of that fact that universal screening for gestational postpartum depression. depression and violence is an achievable goal, in many obstetric contexts such screening is not These results support the importance and the conducted.36 Professionals who provides care to impact of psychological violence and suggest women who are victims of violence, especially that the approach of physical and sexual violence those who work in emergency departments, during pregnancy may not be enough to reduce should ensure that their patients be assessed with the rates of postpartum depression. In this regards to the presence of depressive symptoms context, prevention of psychological violence and other mental health problems, and that the and psychological rebounds resulting from appropriate care in more complex levels is made physical and sexual violence are considered to be available to those who may need it. Therefore, essential, as such aspects may trigger postpartum mental health specialists should track female depression.37 In addition, women who are found to patients with regards to the presence of physical, be in IPV situations should have depression signs sexual and psychological violence, and refer and symptoms assessed during pregnancy, and the victims to the appropriate services. In order they should be followed during the postpartum for those tracking and reference procedures to period, as they become particularly more likely to succeed, professionals need to be trained and develop postpartum depression.27 be aware of these problems occurrence during pregnancy.20,22 All four studies which investigated the relationship between IPV and anxiety symptoms, However, when compared to postpartum both occurring during pregnancy, had a cross- depression, depression during pregnancy has not sectional design. These studies were developed in received much attention from health professionals. Tanzania,10 Portugal,27 Bangladesh35 and South This can be due to a greater concern with the Africa.32 The results found revealed the existence wellbeing of the pregnant woman, putting her of an association between IPV during pregnancy mental health to the background.40 and the occurrence of anxiety symptoms in pregnant women. Such symptoms were Regarding the seven studies included in the specifically associated with the psychological comprehensive review which analyzed the and sexual IPV in South Africa; physical IPV in association between IPV during pregnancy and Bangladesh; physical and sexual IPV in Tanzania; the occurrence of postpartum depression, four had and all natures of this type of violence in Portugal. a longitudinal design, with one developed in the These results confirm that IPV during pregnancy United States,26 one in Nepal,29 one in Brazil,37 is an independent factor associated with the and one in Hawai.38 Additionally, three papers occurrence of anxiety in pregnant women.35 with a cross-sectional design were developed in Brasil,30 in China31 and in Peru.39 Associations Based on the fact the women in a psychological between the different levels of postpartum IPV situation during pregnancy showed greater depression (mild, moderate, moderate/severe, risk for the onset of anxiety symptoms, it is severe) and IPV during pregnancy have been found. important to acknowledge that the different types Specifically, psychological IPV was considered of violence may differently affect the mental to be an important risk factor to postpartum health of women during pregnancy. Therefore, depression,31,37 regardless of physical or sexual tracking of the women with regard only to

Invest Educ Enferm. 2014;32(2) • 301 Mariana de Oliveira Fonseca-Machado • Lisiane Camargo Alves • Patrícia Scotini Freitas • Juliana Cristina dos Santos Monteiro • Flávia Gomes-Sponholz physical or sexual violence may not be enough between IPV and suicidal ideation both during to improve this population mental health during pregnancy. pregnancy.32 The two cross-sectional studies developed in Tanzania10 and in the Unites States28 However, it was also noted that among the 17 which approached the relationship between IPV studies, one developed in Bangladesh40 showed and PTSD both occurring during pregnancy have a qualitative analysis of the reasons why study evidenced the existence of an association between participants showed suicidal thoughts, with IPV these two public health problems. Women who being the main reason stated by the women. suffered physical or sexual IPV during pregnancy Nevertheless, the authors did not specify if the were more likely to develop mild and moderate violence happened during pregnancy. In this study PTSD symptoms in comparison to women who the majority (89.5%) of the pregnant women have not suffered such violence.10 In addition, who showed suicidal thoughts had a score in the severity of the physical and psychological IPV the Edinburgh Postpartum Depression Scale during pregnancy were significantly associated indicating gestational depression. In this context, with the occurrence of PTSD symptoms. the occurrence of IPV contributed to worsening Curiously, the severity of sexual violence has not the women’s depression condition, leading to been associated with this disorder symptoms.28 suicidal ideation symptoms among the one who had been abused. Severe depression conditions PTSD is an anxiety disorder characterized by a characterized by suicidal ideation are relatively reaction of intense fear, impotence or horror common in pregnancy, and it is necessary to when a person experiences, witnesses or is develop quantitative studies to investigate the confronted by stressing events which involve existence of an association between IPV and death, severe injury, threat to physical integrity, suicidal ideation in this period of a woman’s vital a communication of an unexpected or violent cycle.40 death, or a severe life-threatening illness diagnosis. It is not the physiological outcome of In view of all results found in this review and the another medical condition, medications, drugs fact that an impaired mental health may lead to or alcohol. Traumatic events include but are multiple negative results to the mother, fetus/ not limited to military combats, interpersonal child and Family,32 there is a need to incorporate violence, kidnappings, terrorist attacks, tortures, mental health attention to routine care provided incarceration, natural disasters or disasters to women in the pregnancy-puerperal cycle, caused by man, car accidents, or diagnosis of especially during the prenatal period. Health a severe illness. With this mental disorder, the professionals in their global assessment need person relives the traumatic event multiple times to pay attention to the presence of symptoms when exposed to internal or external evidences indicating mental disorders in this period of a that symbolizes or recalls the actual event.9 woman’s life, as well as to relevant risk factors. In addition, nurses should adopt strategies and Investigations in this area have become more reference mechanisms with the women showing frequent due to the need to develop strategies such indicative factors to provide assess and and interventions to prevent both abuse obvious appropriate support in specialized secondary and physical consequences and rebounds in the mental tertiary facilities, where psychological treatment is health of these women. Despite these limitations, offered free of charge. In this sense, the practical PTSD is common enough to become a concern support offer to women during pregnancy through in the obstetric practice, especially because its groups and the access to health facilities and/or symptoms may directly or indirectly affect birth non-governmental organizations are important and postnatal results.42 It was noted that none of preventive strategies to be adopted at a local level, the studies included in the present comprehensive and such provide mental health improvement review investigated the existence of an association during the prenatal period.35

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Therefore, it is necessary to train health natures of IPV (physical, sexual and psychological) professionals on the best methods to discuss occur simultaneously during pregnancy and they and approach the physical and psychological are associated with mental health adverse effects components of IPV; to broaden their knowledge in women throughout the entire pregnancy- with regards to the appropriate reference services. puerperal cycle, highlighting the mental disorders These strategies may help health professionals herein investigated. These evidences become with the care provided to mothers and their families stronger as the longitudinal design of some studies and reduce maternal-infant morbidity/mortality,38 allow us to establish a causal relationship between as it is ensured that appropriate resources are the risk factor (IPV) and the outcomes (mental made available to meet the women’s needs. disorders). In addition, this comprehensive review results strengthen the importance of prevention, Currently, the evidences related to interventions early detection and universal tracking of both IPV that approach violence and the mental disorders during pregnancy and mental disorders. In this during pregnancy are limited, as well as evidences context, the role of the nurse is highlighted as a related to educational groups and the offer of non- professional who is inserted in all levels of care professional support by women in the community. provided to health, while the evidences that were This should be a priority for future studies.34 To found may support their decision-making process ensure a qualified and humanized prenatal and during care delivery to women in the pregnancy- puerperal care, it is essential to address these puerperal cycle. phenomena and maternal-infant health. For that, it is necessary to build a new look on the health- To sum up, among the gaps identified in the disease process which considers a person a whole, present comprehensive review, the need to body and mind, and takes into account the social, conduct studies that investigate the existence of an economic, cultural and physical environment in association between IPV and the above mentioned which this person lives, in addition to establishing disorders both occurring during pregnancy is a new basis for the relationship of the involved emphasized in Latin-American countries, where subjects in the production of health, professionals, the perpetration of violence with regard to gender 43 managers and users. is favored by sociocultural rules that grant man power of sovereignty and domination in public Additionally, although there are laws that support and private environments. In addition, no studies women considered to be in violent situations, referring to an association between IPV during 21 its practical enforcement is limited. Thus, the pregnancy and the occurrence of suicidal ideation creation of international policies that allow the in pregnant woman and/or in postpartum women early detection of this phenomenon is essential, were found. Also, studies need to be developed as the pregnancy period is a moment when relating to nursing care for women who are women establish a frequent contact with health victims of violence during pregnancy, which will professionals and, therefore, are more open to contribute to the improvement of nursing care reveal a violent situation they may be experiencing provided to the population. and their psychiatric symptoms.31 Studies as the ones included in the present comprehensive review are the first steps to portray the severity and consequences of IPV against women and may References help to reinforce protection laws for women found to be in situations of violence.39 1. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet. Based on the synthesis of the knowledge acquired 2002; 360: 1083-8. with this review, it can be concluded that both 2. Anderson JE, Abraham M, Bruessow DM, Coleman in emergent and developed countries, the three RD, McCarthy KC, Harris-Odimgbe T, et al. Cross-

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