By Abigail Beiler
This article will address the impact and outcomes of perinatal intimate partner violence (P-IPV) and the best practices to identify and prevent P-IPV. Perinatal intimate partner violence is defined as “violence exerted by one’s prior or current intimate partner in the year leading up to conception, throughout pregnancy, and during, and up to one year after, birth” (Bueso-Izquierdo et al., 2021, p. 574). Approximately 40% of women in the United States are victims of sexual violence and about 20% are victims of physical intimate partner violence (IPV) (Chisholm et al., 2017). The implications for social work are the opportunity to introduce interventions in the healthcare setting and to influence positive maternal and neonatal outcomes.
The information outlined has been obtained from scholarly journal articles, assigned readings from Research Design: Qualitative, Quantitative, and Mixed Methods Approaches by Creswell and Creswell (2018), and the NASW Code of Ethics (National Association of Social Workers [NASW], 2017). EBSCO and Google Scholar were used to obtain peer reviewed scholarly journal articles. Key terms searched include IPV, domestic violence (DV), pregnancy, women, health outcomes, fetal health OR newborn health, violence, outcomes OR effects, and interventions OR best practices.
The problem under investigation is how P-IPV affects newborn health and maternal health, as well as the best practices and interventions to employ. The value of social justice is important when discussing the topic of P-IPV as well as dignity and worth of the person. According to the NASW Code of Ethics, social workers strive to challenge social injustices such as oppression and lack of meaningful participation in decision making (NASW, 2017). These are two factors that are commonly experienced by women in IPV situations. The value of dignity and worth of the person expresses that each person is worthy of being treated with respect and compassion. Women in IPV situations may experience physical, emotional, economic, or sexual abuse, which does not align with that social work value.
Background
The topic of P-IPV is important to study because it is a violation of human rights that can lead to physical and mental ailments for both mother and child. It is estimated that in the US, more than 50 million women will experience IPV at some time in their lives (Bell et al., 2008). Intimate partner violence experienced during pregnancy may increase the risk of spontaneous abortion, preterm delivery, low birth weight (LBW), or neonatal death (Donovan et al., 2016).
Mental health impacts include risk of depression, anxiety, posttraumatic stress disorder (PTSD), and suicide (Chrisholm et al., 2017). “In many US localities, suicide and homicide are leading causes of pregnancy-associated mortality” (Chisholm et al., 2017, p. 141). Additionally, P-IPV is associated with substance abuse, poor weight gain, and late and missed prenatal care appointments. The prevalence of IPV is “grossly underreported,” which is especially concerning considering the high rates reported (Chisholm et al., 2017).
Women experiencing P-IPV have “complex needs that call for medical and social service providers’ attention” (Bell et al., 2008, p. 330). To address the problems that these women face, practitioners should attend to all types of abuse in their lives—physical, emotional, sexual, and economic. Several researchers have noted in their studies that IPV is a preventable social problem. Screening has proved to be a helpful intervention when used with women experiencing P-IPV. Many women report that their partners abuse alcohol and other drugs (Bell et al., 2008). Further research on substance abuse may provide insight to a correlation between the use of alcohol and increased violence.
Literature Review
In this literature review, I analyze eight articles organized by the following themes: newborn health outcomes of P-IPV, maternal health outcomes of P-IPV, and the best practices and interventions. From this analysis, I withdraw information about results and methods of the research as well as the strengths and limitations of the studies.
Newborn Health Outcomes of P-IPV
Donovan et al. (2016) studied the impact of IPV during pregnancy on preterm birth (PTB), LBW, and small-for-gestational-age (SGA) infants. “Intimate partner violence is of particular concern during pregnancy when not one, but two lives are at risk” (Donovan et al., 2016, p.1). This study is a meta-analysis of IPV during pregnancy. The hypothesis was that women experiencing P-IPV will be at greater risk of delivering PTB, LBW, and SGA infants than women who did not experience P-IPV. Data for the study came from 50 studies that the researchers found using PubMed and SCOPUS. The studies selected compared the rates of at least one adverse birth outcome in women who experienced P-IPV and those who did not. The findings of this study indicate that women who experience P-IPV are at increased risk of having an adverse birth outcome compared to women who do not experience P-IPV. The pooled odds ratios for PTB and LBW were considerably higher; however, authors identified a research gap in their study which is that evidence of risk for SGA was not as strong. They reported that studies concerning SGA were lower in quality and not as prevalent.
A primary strength of this study is that it provided “the first pooled effect estimates for the association of isolated violence types with adverse birth outcomes” (Donovan et al., 2016, p. 15). The authors identified heterogeneity and lack of account for race/ethnicity, maternal smoking, and pre-pregnancy body mass index as limitations to their study. However, I found that the search strategy and the sample size were limitations as well. The search for literature was conducted using studies from the time of the databases’ conception until May 2015. PubMed’s articles date as far back as 1809 and SCOPUS’s articles date back to 1788. The 50 studies used included 5,087,388 participants; however, only 14,906 of the participants experienced P-IPV. Additionally, only 795,605 of the participants experienced PTB, LBW, or SGA.
Aizer (2011) is the author of a seminal study of the impact of P-IPV on newborn health. This study focused on maternal hospitalizations and birth outcomes in California between 1991 and 2002. Of the more than five million births during that period, only 1,657 women were admitted to the hospital for an assault while pregnant. This study is based on “estimates from OLS [ordinary least squares] regressions of newborn health (weight, fetal death, infant death) on hospitalization for an assault while pregnant” (Aizer, 2011, p. 523). Aizer (2011) found that low-income, minority women have a higher rate of admission to the hospital for an assault while pregnant; when the probability of arrest for DV is increased, the hospitalizations of assaulted pregnant women decline, and severe violence during pregnancy reduces birth weight by 163 grams.
Aizer (2011) concludes that economically disadvantaged women are disproportionately exposed to violence which impacts newborn health and “may also contribute to the intergenerational persistence of poverty” (p. 536). A limitation was that the sample did not include participants who experienced violence but did not go to the hospital. Additionally, the women studied did not identify whether the violence they experienced was general or caused by IPV. As an economics professor, Aizer (2011) quantified her study by the cost of P-IPV in the US as $13.3 million annually.
A study by Bell et al. (2008) considered the perception of women who have experienced P-IPV. The data for this study were drawn from “a multimethod case study evaluation of an innovative program for pregnant and parenting battered women” (Bell et al., 2008, p. 321). This case study focused on an educational and support service program for women experiencing P-IPV. Creswell & Creswell (2018) say that case studies are an appropriate way to analyze a program in which researchers “collect detailed information using a variety of data collection procedures over a sustained period of time” (p. 14). For this study, surveys and open-ended interviews were used. Generally, mothers reported that their children were born without complications and remained healthy into their second month after birth.
Although mothers reported that their children were born with good health and they used good health practices, Bell et al. (2008) suggest that this may be the result of self-report and social desirability, “which would encourage mothers to minimize the reported impact of their abuse on their health and the health of their infants” (p. 330). Another limitation was participation. Bell et al. (2008) reported that participation in the research seemed to be a low priority when experiencing abuse.
Maternal Health Outcomes of P-IPV
Pregnant women with a history of adverse childhood experiences (ACEs) are especially vulnerable to risk of IPV. This study by Goldstein et al. (2020) examined a “person-centered method to empirically identify profiles of pregnant women based on type and severity of ACEs and past year IPV” (p. 337). Latent profile analysis (LPA) is a person-centered method that establishes subgroups of individuals based on a set of indicators, which may be associated with outcomes. The sample included 225 lower-income, Latinx women from urban settings. Participants were asked to complete nine questionnaires that applied to childhood trauma, revised conflict, perceived stress, prenatal distress, perceived social support, difficulties in emotion regulation, depression anxiety and stress, trauma related experiences, and home hardship. The results showed that greater exposure to ACEs and/or IPV leads to the worst stress and mental health outcomes.
The researchers identified a few strengths and limitations to their study. A strength was that they assessed multiple forms of abuse, neglect, and IPV. Additionally, the researchers used a higher risk sample. On the other hand, this sample did not name their country of origin or immigration status. Goldstein et al. (2020) noted that increased stress associated with migration can be a risk factor for IPV. Another limitation is that the measures were completed using self-report and the researchers had no access to any mental health diagnoses. Like the Bell et al. (2008) study, self-reporting affects reliability.
Unlike many IPV studies that only focus on physical, sexual, and psychological abuse, Postmus et al. (2012) researched the effects of economic abuse on maternal mental health and parenting as well. Data came from the Fragile Families and Child Wellbeing Study (FFCWS), which was designed to provide information on the characteristics of parents and the health of their children (Postmus et al., 2012). Interviews were conducted at the time of the baby’s birth, and follow-up surveys were given at year 1, 2, and 5. The final sample included 2,305 mothers who had completed all surveys and were involved with the same fathers of the child at year 1. The surveys measured maternal mental health (depression), parenting (engagement and use of spanking), economic, psychological and physical abuse, and other explanatory variables (characteristics of the mother, father, and child) (Postmus et al., 2012).
The results indicated that mothers who experienced physical, psychological, or economic abuse were more likely to experience a depressive episode. Surprisingly, when testing for changes in abuse over time, only economic abuse predicted maternal depression (Postmus et al., 2012). More specifically, mothers who experienced economic abuse at year 1 were 3.5 times more likely to experience depression (Postmus et al., 2012). Researchers also found that physical violence did not significantly relate to any parenting behavior, which contradicts previous cross-sectional studies. One limitation to be considered with this study is the sample. The final sample used in the article only included about 78% of the original sample due to dropouts and disqualification. Further analyses showed that many of the dropped cases were more likely to be African American and have a lower quality relationship with the father, which may limit the generalization of the findings (Postmus et al., 2012).
Best Practices and Interventions
Home visiting (HV) programs have been shown to improve infant development and improve maltreatment (Sharps et al., 2013). “The Domestic Violence Enhanced Home Visitation Program (DOVE) is a multistate longitudinal study testing the effectiveness of a structured IPV intervention integrated into health department perinatal HV programs” (Sharps et al., 2013, p. 134). Home visiting programs are largely reliant on parental involvement and research shows that families with greater participation experience more benefits. The empowerment-based intervention includes a 10-minute brochure based IPV intervention and a nurse home visitation. The sample included 92 women from urban sites and 147 women from rural sites.
The results of the study were positive; pregnant women who are screened for IPV will most likely disclose their abuse histories and remain in HV and research programs that address IPV. A limitation to the study was the assessment and participation of the home visitors. Home visitors participated in a four-hour training session that included topics specific to screening, assessment, safety, and strategies. Despite the training, home visitors reported that they experienced: difficulty assessing, fear of becoming a victim of violence, fear of the client withdrawing due to discussing a sensitive topic, and overall discomfort. However, later findings showed that home visitors’ confidence increased as they received more training and experience. These results indicate that abused women can be retained in HV programs, and screening for IPV shows women that health care providers have an interest in their health and well-being.
A literature review by McMahon and Armstrong (2012) studied the scope and impact of P-IPV and identified best practices for social workers. The researchers began by searching key terms and developing appropriate inclusion criteria. Then, articles were reviewed, analyzed, and coded according to themes. As a result, the literature identified several factors related to the potential risk of abuse during pregnancy. These include demographic risk factors, socio-structural risk factors, and risk factors for perpetrating IPV during pregnancy (McMahon & Armstrong, 2012). As for best practices, the findings showed that screening, assessing for health and safety, identifying support systems, and examining the contextual effects of IPV on work and employment are effective interventions.
A limitation to the study is that some important articles or reports may not have been included because of the choice of search terms. Additionally, although general suggestions were made, many must be altered to the specific needs of certain groups based on characteristics such as ethnicity, religion, immigration status, and culture (McMahon & Armstrong, 2012). One strength I identified is the multiple recommendations of best practices for social workers.
MOSAIC Interventions
A study by Hailemariam et al. (2022) evaluated MOthers’ AdvocateS In the Community (MOSAIC) blended with principles of interpersonal psychotherapy (IPT) to address symptoms of depression, PTSD, and prevent risk of IPV. The MOSAIC program uses trained mentor mothers and has been found to reduce subsequent IPV (Hailemariam et al., 2022). The sample included focus groups, open trial, and a randomized pilot trial included 40 pregnant women with children under 5 who report current/recent IPV and symptoms of depression and/or PTSD (Hailemariam et al., 2022). Outcomes were measured by surveys and questionnaires.
Previous studies of MOSAIC show that paraprofessional/mentor mother-delivered interventions reduce the risk of subsequent IPV among pregnant women. Subsequently, this study’s results showed that incorporating IPT principles into MOSAIC is a feasible and appropriate way to address depression and PTSD in addition to reducing the risk of IPV. A strength of the study is that it is informed by a qualitative approach to intervention development and involves a series of focus group discussions. A limitation is that a small sample size was used, resulting in the inability to draw firm conclusions about effectiveness.
Ethical Considerations
When studying and reviewing the literature of P-IPV, it is important to keep ethical considerations in mind. Much of the literature includes studies on the general population, not identifying possible differences within certain groups. Data can vary depending on cultural, ethnic, and religious differences. For example, in the Postmus et al. (2012) study, cases were dropped from the 5-year study if the mother’s relationship with the father ended. Further analyses of the study showed that the dropped cases were more likely to be African American who had a lower quality relationship with the father than others. As a result, the study did not include as many women from this population, limiting the generalization of the findings. Additionally, Aizer (2011) reports that Black women are at a significantly greater risk of violence and are subject to more severe attacks. Immigration status can also affect results due to maternal stress, as Goldstein et al. (2020) noted in their study.
In terms of policy, Aizer (2011) comments on the “gradient in health.” This term refers to the finding that wealthy individuals are healthier than low-income individuals. Aizer (2011) concludes that in addition to differences in ability of those in poverty to access healthcare, greater participation in unhealthy behavior, and differences in time preferences, the exposure to greater violence reduces health as well. “These results imply that efforts to reduce health disparities also should include a focus on reductions in exposure to violence” (Aizer, 2011, p. 536). However, Aizer’s (2011) analysis is limited by the fact that it relies on severe acts of violence that may be infrequent. To quantify the role that more frequent but less severe violence plays in perpetuating the gradient in health, more research is needed. The social work value of social justice outlines that social workers are devoted to change efforts that focus on issues of poverty and discrimination, as well as seeking knowledge about oppression and cultural and ethnic diversity (NASW, 2017).
Implications
Hailemariam et al. (2022) make several points as to why addressing IPV and its associated mental health symptoms is critical. Not only do unaddressed mental health challenges and IPV increase the woman’s risk of mortality, morbidity, future child abuse, suicidal ideation, and femicide, women with elevated depressive and PTSD symptoms are at greater risk of experiencing future IPV (Hailemariam et al., 2022). Additionally, “the stigma of mental illness also reinforces abusers’ ability to manipulate, control, and discredit survivors, and weaken vital social support” (Hailemariam et al., 2022, p. 14). Consequently, not only are mental health challenges associated with IPV, but they also potentiate the risk for future IPV. This relationship between mental health conditions and IPV suggests that addressing these issues simultaneously “may help the end of the vicious cycle of victimization and mental health vulnerability” (Hailemariam et al., 2022).
The findings of these studies can be used to better understand what women experiencing P-IPV go through and determine better practices for practitioners working with this population. “Social workers have the opportunity to influence the issue of IPV and pregnancy at multiple levels including the provision of effective services to survivors” (McMahon & Armstrong, 2012, p. 9). McMahon and Armstrong (2012) offer several suggestions of best practices for social workers, for example: training to identify and assess for IPV in all settings in conjunction with recognizing risk factors, working with healthcare personnel and training them to use screening tools, assessing clients for health and safety, connecting clients with appropriate supports, addressing IPV in a culturally competent manner, working collaboratively with organizations and agencies to effectively respond to victims of IPV, providing legal and medical referrals, and providing education for victims, family members, and the community on IPV prevention specifically during pregnancy. McMahon and Armstrong (2012) also note that confidentiality and safety are extremely important when working with clients experiencing IPV. The NASW Code of Ethics (2017) outlines that social workers should protect the confidentiality of all information obtained during services, except if disclosure is necessary to prevent “serious, foreseeable, and imminent harm to a client or others” (NASW).
McMahon and Armstrong (2012) state that further research is needed to better understand the occurrence of P-IPV to provide more contextual information that can shape intervention efforts for different groups. As noted before, the data is subject to change due to the population being studied. “The role of race and ethnicity as an influence in IPV is not well documented, with some studies finding African American women to be at a greater risk and others finding Hispanic women to be at a greater risk for IPV during pregnancy,” McMahon and Armstrong (2012) report (p. 12). Studies that further investigate how race and ethnicity influence the occurrence and progression of IPV both generally and specific to pregnancy are necessary (McMahon & Armstrong, 2012). Failing to study this problem further will never solve the preventable issue of IPV. Additionally, when Women of Color are not considered in research, it further perpetuates systemic racism.
Critical Analysis and Recommendations for Future Studies
Overall, P-IPV is a nationwide epidemic with the frequency heavily influenced by sociodemographic characteristics. “Significant health disparities exist in the prevalence of IPV based on race/ethnicity, age, income, and educational attainment” (Chisholm et al., 2017, p. 142). Experiencing P-IPV can have significant effects on a mother’s physical and mental health as well as her child’s development. Social workers and other social service and health professionals have the opportunity to practice interventions such as screenings and HV to reduce P-IPV and protect mothers’ safety.
As for designing a study for future research into this topic, I would suggest a quantitative survey design. Much of the research used in the literature review relied on surveys and interviews which I found to be helpful in supporting the findings. “Survey research provides a quantitative or numeric description of trends, attitudes, or opinions of a population by studying a sample of that population” and “includes cross-sectional and longitudinal studies using questionnaires or structured interviews for data collection” (Creswell & Creswell, 2018, p. 12). For this topic, understanding firsthand experiences is an important aspect to the research, specifically when participants are taking part in a new program, which interviews and surveys would enable better understanding. Additionally, I would suggest studies that involve women of different racial, cultural, and socioeconomic backgrounds to help fill the gaps that currently exist in this research.
References
Aizer, A. (2011). Poverty, violence, and health. The Journal of Human Resources, 46(3), 518-537.
Bell, H., Busch-Armendariz, N., Sanchez, E., & Tekippe, A. (2008). Pregnant and parenting battered women speak out about their relationships and challenges. Journal of Aggression, Maltreatment & Trauma, 17(3), 318-332.
Bueso-Izquierdo, N. (2022). Intimate partner violence and pregnancy during the COVID-19 pandemic. Journal of Gender Studies, 31(5), 573-583.
Chisholm, C., Bullock, L., & Ferguson, J. (2017, August). Intimate partner violence and pregnancy: epidemiology and impact. South Atlantic Association of Obstetricians and Gynecologists, 141-144.
Creswell, J. D., & Creswell, J. W. (2018). Research Design: Qualitative, Quantitative, and Mixed Methods Approaches (5th ed.). SAGE Publications.
Donovan, B., Spracklen, C., Schweizer, M., Ryckman, K., & Saftlas, A. (2016, March 9). Intimate partner violence during pregnancy and the risk for adverse infant outcomes: A systematic review and meta-analysis. International Journal of Obstetrics and Gynecology, 123(8), 1-24.
Goldstein, B., Briggs-Gowan, M., & Grasso, D. (2020). The effects of intimate partner violence and a history of childhood abuse on mental health and stress during pregnancy. Journal of Family Violence, 36, 337-346.
Hailemariam, M., Zlotnick, C., Taft, A., & Johnson, J. (2022). MOSAIC (MOthers’ AdvocateS In the Community) for pregnant women and mothers of children under 5 with experience of intimate partner violence: A pilot randomized trial study protocol. PLoS ONE, 17(5), 1-20.
McMahon, S., & Armstrong, D. (2012). Intimate partner violence during pregnancy: Best practices for social workers. Health and Social Work, 9-17.
National Association of Social Workers. (2017). NASW code of ethics. Retrieved June, 25, 2022, from https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
Postmus, J., Huang, C., & Mathisen-Stylianou, A. (2012). The impact of physical and economic abuse on maternal mental health and parenting. Children and Youth Services Review, 34, 1922-1928.
Sharps, P., Alhusen, J., Bullock, L., Bhandari, S., Ghazarian, S., Udo, I., & Campbell, J. (2013). Engaging and retaining abused women in perinatal home visitation programs. Pediatrics, 132(2), 134-139.
Abigail Beiler is a graduate student in the Master of Social Work program.