Intimate Partner Violence, Maternal and Paternal Parenting, and Early Child Development Joshua Jeong, ScD,a Avanti Adhia, ScD,b Amiya Bhatia, ScD,c Dana Charles McCoy, PhD,d Aisha K. Yousafzai, PhDa BACKGROUND AND OBJECTIVES: Previous research has demonstrated associations between maternal abstract experience of intimate partner violence (IPV) and a range of adverse outcomes among women and their young children. However, few studies have examined the associations between maternal experience of IPV and early child development (ECD) outcomes in low- and middle- income countries (LMIC). Our objectives in this study were to examine the association between IPV victimization and ECD and assess whether the association was mediated by maternal and paternal stimulation. METHODS: We combined cross-sectional data from the Demographic and Health Surveys for 15 202 households representing mothers and fathers of children aged 36 to 59 months in 11 LMIC. We used multivariable linear regression models to estimate the association between IPV victimization in the year preceding the survey and ECD, which we measured using the Early Child Development Index. We used path analysis to determine if the association between IPV victimization and ECD was mediated through maternal and paternal stimulation. RESULTS: After adjusting for sociodemographic variables, IPV victimization was negatively associated with ECD (b = 2.11; 95% confidence interval = 2.15 to 2.07). Path analysis indicated that the direct association between IPV victimization and ECD was partially and independently mediated through maternal and paternal stimulation. CONCLUSIONS: Interventions that include components to prevent IPV may be effective for improving ECD in LMIC. aDepartment of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, WHAT’S KNOWN ON THIS SUBJECT: Previous studies, Boston, Massachusetts; bHarborview Injury Prevention and Research Center, University of Washington, Seattle, largely from high-income countries, have underscored Washington; cDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, the negative consequences of intimate partner d London, United Kingdom; and Graduate School of Education, Harvard University, Cambridge, Massachusetts violence (IPV) on early child development (ECD) Dr Jeong conceptualized the study, acquired the data, conducted the analyses, interpreted findings, outcomes. However, few studies in low- and middle- and drafted the manuscript; Drs Adhia and Bhatia conceptualized the study, interpreted findings, income countries have examined the association and drafted the manuscript; Drs McCoy and Yousafzai interpreted findings; and all authors revised between IPV and ECD. the manuscript critically, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work. WHAT THIS STUDY ADDS: In this study, we find that maternal experience of IPV was negatively associated DOI: https://doi.org/10.1542/peds.2019-2955 with ECD in 11 low- and middle-income countries. Accepted for publication Jan 7, 2020 Additionally, this association was partially and Address correspondence to Joshua Jeong, ScD, Department of Global Health and Population, independently mediated through maternal and Harvard T.H. Chan School of Public Health, 90 Smith St, 3rd Floor, Office 325, Boston, MA 02120. paternal stimulation. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). To cite: Jeong J, Adhia A, Bhatia A, et al. Intimate Partner Violence, Maternal and Paternal Parenting, and Early Copyright © 2020 by the American Academy of Pediatrics Child Development. Pediatrics. 2020;145(6):e20192955 Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 145, number 6, June 2020:e20192955 ARTICLE The period from conception to age consider both parents and explore the Out of the total 74 publicly available 5 years is one of the most critical relative degree to which the surveys from the first year when the periods in the life course, when the association between IPV and ECD Early Child Development Index brain develops most rapidly and may be mediated by maternal and (ECDI) was introduced into the DHS children begin to build foundational paternal parenting. (2011) until the time of analysis (May skills that have long-lasting effects on 15, 2019), only 11 national DHS Using data from 11 LMIC, the current learning, health, behavior, and well- included both the IPV questionnaire study investigates the direct and being outcomes later in life.1 Yet in in the women’s survey and the ECDI indirect associations between IPV, low- and middle-income countries questionnaire in the children’s survey. maternal and paternal stimulation, (LMIC), 250 million (∼43%) children This resulted in a sample of 18 166 and ECD outcomes. First, we ,5 years old are at risk for not children aged 3 and 4 years and their hypothesize that IPV, as measured by reaching their developmental mothers who had available maternal-reported experiences of potential.2 Although various information for ECD and IPV, victimization by their partners, is biological and psychosocial risks have respectively. We restricted our negatively associated with children’s been well established in relation to sample to mothers who were married ECD scores, as measured by an index early child development (ECD) or living with both their partners and of learning, literacy and numeracy, outcomes in LMIC, including children (2964 removed) because of socioemotional, and physical nutritional deficiencies, inadequate the study focus on disentangling the milestones. Second, we hypothesize stimulation, and other poverty- maternal and paternal parenting – that in families in which IPV occurs, related factors,3 7 few studies in LMIC mechanisms linking IPV and ECD in both mothers and fathers would have investigated the relationship the household context. Our final engage in fewer stimulation activities between intimate partner violence analytic sample included 15 202 (ie, play and learning), which would (IPV) and ECD.8,9 households with mothers and fathers independently mediate the direct of children aged 36 to 59 months association between IPV and ECD Globally, it is estimated that 30% of from 11 LMIC. outcomes. women experience some form of Measures physical or sexual violence from their husbands or partners in their METHODS Outcome lifetime.10 Evidence from high-income ECD was measured by using the Data countries has consistently shown ECDI.23 The ECDI comprises negative consequences of IPV We used national data from the 10 caregiver-reported, experience on young children’s latest publicly available dichotomously scored items – developmental outcomes.11 13 Demographic and Health Surveys covering cognitive, literacy and Several studies have highlighted (DHS).22 These standardized numeracy, socioemotional, and poorer maternal parenting behaviors household surveys collect physical development for (eg, greater aggression and less representative, cross-sectional children aged 36 to 59 months stimulation) as a primary mechanism data on a range of population and has demonstrated validity on underlying the effects of IPV on ECD and health indicators in LMIC. the basis of adequate model fit – outcomes.14 16 In addition, an All surveys employed a 2-stage statistics from the results of emerging body of literature has cluster-randomized sampling confirmatory factor analysis.24 In shown that fathers who perpetrate design, stratifying by region and keeping with previous work that IPV are less engaged in stimulation urban or rural area of residence. used the full 10-item index,4,25 we and may even extend harmful Within these stratified areas, created a composite score by – behaviors to their children.17 19 primary sampling units (PSUs) summing the number of positive However, few studies to date, neither were randomly selected on the responses (range: 0–10) and then in high-income countries nor LMIC, basis of the probability proportional normalized the total sum score to have specifically examined paternal to population size, and an average of mean = 0 and SD = 1 to allow for ease parenting as a mediator of the 25 houses were interviewed per PSU. of interpretation (ECDI z score). We relationship between IPV and ECD A household questionnaire was also conducted a sensitivity analysis outcomes. Considering how IPV administered, and women between using a 5-item version of the involves both a perpetrator (ie, most the ages of 15 and 49 years were ECDI that represents the most often the father)20 and victim (ie, identified to complete a detailed developmentally appropriate items most often the mother) and that each women’s questionnaire and a child for children aged 36 to 59 months parent independently influences questionnaire if they had a child (Supplemental Table 3 includes ECDI ECD,21 it is important to jointly ,5 years of age. items).24 Downloaded from www.aappublications.org/news by guest on September 30, 2021 2 JEONG et al Exposure assets) and place of residence (urban victimization and ECDI z score was Mothers’ IPV victimization by their or rural). mediated through maternal and husbands or cohabitating male paternal stimulation. Path analysis Mediators partners was measured by using can simultaneously estimate multiple a modified version of the Conflict Maternal and paternal stimulation linear regression models between Tactics Scale, which has been found was based on the primary caregiver’s