Elsevier

The Lancet

Volume 376, Issue 9744, 11–17 September 2010, Pages 903-910
The Lancet

Articles
Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study

https://doi.org/10.1016/S0140-6736(10)60887-2Get rights and content

Summary

Background

Partner violence against women is common during pregnancy and might have an adverse effect on the mental health of women after delivery. We aimed to investigate the association of postnatal depression with psychological, physical, and sexual violence against women by their intimate partners during pregnancy.

Methods

In a prospective cohort study undertaken in Recife, northeastern Brazil, between July, 2005, and December, 2006, we enrolled pregnant women (aged 18–49 years) in their third trimester of pregnancy who were attending primary health-care clinics. The women were interviewed during pregnancy and after delivery. The form of partner violence in pregnancy was assessed with a validated questionnaire, and the Edinburgh postnatal depression scale was used to measure postnatal depression. Associations were estimated with odds ratios (ORs), adjusted for confounding factors contributing to the association between postnatal depression and intimate partner violence.

Findings

1133 pregnant women were eligible for inclusion in the study, of whom 1045 had complete data for all variables and were included in the analysis. 270 women (25·8%, 95% CI 23·2–28·6) had postnatal depression. The most common form of partner violence was psychological (294 [28·1%, 25·4–31·0]). Frequency of psychological violence during pregnancy was positively associated with occurrence of postnatal depression, and although this association was attenuated after adjustment, women reporting the highest frequency of psychological violence were more likely to have postnatal depression even after adjustment (adjusted OR 2·29, 95% CI 1·15–4·57). Women who reported physical or sexual violence in pregnancy were more likely to develop postnatal depression (OR 3·28, 2·29–4·70), but this association was substantially reduced after adjustment for psychological violence and confounding factors.

Interpretation

Psychological violence during pregnancy by an intimate partner is strongly associated with postnatal depression, independently of physical or sexual violence. This finding has important policy implications since most social policies focus on prevention and treatment of physical violence.

Funding

Departamento de Ciência e Tecnologia da Secretaria de Ciência, Tecnologia, e Insumos Estratégicos, and Conselho Nacional de Desenvolvimento Científico e Tecnológico (Brazil).

Introduction

Violence against women is common, with the intimate male partner as the aggressor in most circumstances.1, 2, 3, 4, 5 Rates of violence perpetrated by intimate male partners during pregnancy vary worldwide from 3% in London6 to 31% in Mexico City,7 though this variation also depends on the methods of assessment. Partner violence during pregnancy affects 4–8% of pregnant women in the USA.5

Three types of partner violence are most often assessed—physical, sexual, and psychological (including verbal or emotional abuse)—and psychological violence is most frequently reported.8, 9 Few studies have examined the potential association between violence during pregnancy and postnatal depression,8, 10 which is important for women's health as well as that of their children.11 In India, Patel and colleagues10 showed that postnatal depression was more common among women who experienced marital violence during pregnancy than in those who did not. However, the study definition of partner violence did not include psychological violence, and the results were not adjusted for potential confounding factors. In a study of a Chinese community, Leung and co-workers8 also recorded an association between psychological violence and postnatal depression. However, the information about partner violence was obtained retrospectively and so is prone to recall bias.

In view of the limitations of previous studies, whether psychological violence by intimate male partners during pregnancy has an adverse effect on the mental health of women after delivery is still unclear. Longitudinal studies are needed to account for previous psychological problems. Also, women with postnatal depression are likely to retrospectively reinterpret acts as psychological violence.8

We aimed to investigate the association of postnatal depression with psychological, physical, and sexual violence against women perpetrated by their intimate partners during pregnancy. Our hypothesis was that violence, especially psychological, during pregnancy would be associated with an increase in risk of postnatal depression. We studied a population-based sample of pregnant women who were registered with publicly funded primary health care in a poor area of northeastern Brazil.

Section snippets

Participants

The study was undertaken in health district two (one of six health areas) in Recife, which is the capital of Pernambuco state in northeastern Brazil. Health district two has a population of 217 293 inhabitants,12 representing almost 15% of the total population of Recife, with a high proportion of low-income families. We enrolled all pregnant women aged 18–49 years who were in their third trimester and had registered with the primary health-care programme (family health programme, and community

Results

1133 pregnant women were eligible for inclusion in the study, of whom 1121 (99%) had completed their assessments during pregnancy. 1057 women completed the postnatal interview, which represented a high response rate of 94% of those who had completed their assessments during pregnancy. Median length of follow-up between the first and second interviews was 8·1 months (IQR 5·2–10·2). Response rate varied dependent on educational level: a higher proportion of the 64 women lost to follow-up after

Discussion

In this population-based cohort study, we identified a gradient of increasing risk of postnatal depression associated with the coexistence of different forms of intimate partner violence against women during pregnancy. The highest risk of postnatal depression was in women who reported physical or sexual violence plus psychological violence. Postnatal depression was strongly associated with psychological violence, even when it occurred without physical or sexual violence.

We recorded a clear

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