Psychological Violence During Pregnancy Linked to Postnatal Depression

From Medscape Medical News

Fran Lowry

September 9, 2010 — Psychological violence during pregnancy by an intimate partner is strongly linked to postnatal depression, independent of physical or sexual violence.
This finding, published online September 6 in The Lancet, has important implications for prevention policies because most focus only on physical violence, Ana Bernarda Ludermir, MD, from Universidade Federal de Pernambuco, Recife, Brazil, and her colleagues conclude.

"Our results have both clinical and public health implications," Dr. Ludermir told Medscape Medical News. "Interventions for victims of partner violence have included a variety of approaches, such as the use of women's empowerment protocols, referral to shelters, transitional housing, legal advice, and psychological support. However, there is still insufficient evidence on the effectiveness of such interventions in improving psychosocial health."

Most Common Form of Partner Violence

In this prospective cohort study, which was undertaken between July 2005 and December 2006 in Recife, northeastern Brazil, Dr. Ludermir and her team enrolled pregnant women aged 18 to 49 years who were in their third trimester and who were attending primary healthcare clinics.

The women were interviewed during pregnancy and after delivery. The antenatal interview was done most often at the healthcare clinic, although some were done at home at the woman's request. Most of the follow-up interviews were done at home at a median of 8.1 months (interquartile range, 5.2 – 10.2 months) after the antenatal interview.

The investigators used the Edinburgh Postnatal Depression Scale (EPDS) to assess postnatal depressive symptoms. The form of partner violence in pregnancy was assessed with a validated questionnaire.

Of the 1045 women who were included in the final analysis, 270 women (25.8%; 95% confidence interval [CI], 23.2 – 28.6) had postnatal depression.

The most common form of partner violence was psychological (28.1%; 95% CI, 4 – 31.0).

Table 1. Forms of Psychological Violence Reported by Respondents

Type of Violence No. of Women % of Women (95% CI)
Insulted you or made you feel bad about yourself 247 23.6 (21.1 – 26.3)
Belittled you or humiliated you in front of others 127 12.2 (10.2 – 14.3)
Done things to scare or intimidate you on purpose 84 8.0 (6.5 – 9.9)
Threatened to hurt you or someone you care about 81 7.8 (6.2 – 9.5)

CI = confidence interval

The frequency of psychological violence during pregnancy was positively associated with postnatal depression. Although this association was reduced after adjustment, women reporting the highest frequency of psychological violence were more than twice as likely to have postnatal depression, even after adjustment, than those who had not experienced psychological violence, the researchers report.

Psychological violence was more common than physical or sexual violence, and this is in keeping with findings from previous studies, Dr. Ludermir said. "We need to understand more about why psychological violence occurs and develop interventions to prevent it from occurring, as well as treatments to reduce its impact."

She added that prenatal care could provide an opportunity to identify women at risk. "Currently, we place emphasis, and rightly so, on preventing and treating physical violence, but psychological violence is also a serious problem, as this study shows. Interventions that might prevent psychological violence or help treat its consequences could reduce the substantial burden of postnatal depression that affects mothers, children, and the healthcare system as a whole.”

Dr. Ludermir noted that her study had some important limitations, including the use of the EPDS questionnaire to ascertain postnatal depression. "EPDS is a symptom questionnaire, and there is much debate about the appropriate criteria for defining depression and its relationship with the need for treatment," she noted. "Also, partner violence is more common in women with limited schooling and who live in poverty, so the high frequency of partner violence could reflect the characteristics of the community we studied. It is possible that violence was actually underreported because of the associated stigma and shame."

Screening Not Currently Recommended, But Should Be

In an accompanying editorial, Rachel Jewkes, MD, from the Medical Research Council, Pretoria, South Africa, writes that emotional abuse probably has a greater importance in women's mental ill-health than originally thought "and should therefore receive more attention from researchers and health services."

She adds that the high prevalence of postnatal depression reported in the study "shows the great need for improved mental healthcare."

Finally, Dr. Jewkes points out that emotional abuse screening in pregnant women is not currently recommended by official bodies, such as the American Congress of Obstetricians and Gynecologists, but suggests that it should be.

There is mounting evidence, she writes, "that guidelines should include questions about emotional abuse, as well as physical and sexual abuse. Prevention of all forms of intimate partner violence is very important for improving women's health, particularly their mental health."

Lancet. Published online September 6, 2010.