This study among relatively affluent and well-educated Canadian women found that 29.7% of women had experienced at least one incident of interpersonal violence at some point in their lives. A recent Canadian study of postpartum women showed that 30% reported adult emotional abuse, 7% reported adult physical abuse, 13% reported adult sexual abuse, and 14% and 7% reported child sexual and physical abuse, respectively
]. Although it is difficult to compare prevalence rates across populations, the prevalence of interpersonal violence in this study and other studies reveals that exposure to interpersonal violence cannot be predicted by adverse socioeconomic circumstances or maternal education. Results from multivariable regression analyses showed that that a history of child maltreatment had an independent effect on depression in the postpartum, while both child maltreatment and intimate partner violence were associated with low parenting morale. Interpersonal violence did not have an independent effect on anxiety or stress in the postpartum.
Exposure to child maltreatment was an independent risk factor for postpartum depression, even while controlling for other factors that are known to influence postpartum depression such as a history of mental illness, social support, and income
]. There is strong evidence in the literature that child maltreatment is associated with adult depression
], but few studies have examined the association between child maltreatment and postpartum depression. To our knowledge, no studies have considered all
types of child maltreatment in a general population of postpartum women. In one of the few studies that have been done on this topic, more severe depression was noted among women with a history of child abuse
]. Two studies have found an association between child sexual and physical abuse and postpartum depression
] and depressive symptoms
]. However, both of these studies had small sample sizes, and did not consider other forms of child maltreatment such as psychological abuse and neglect.
Both child maltreatment and intimate partner violence were significantly associated with low parenting morale at 4 months postpartum. Parenting morale is an outcome that has not been considered previously in postpartum women in the literature, but can be useful in understanding parenting enthusiasm or attitudes of women to the parenting role
]. Previous research has shown that abused women had a more negative parent–child interaction observed in an assessment of parenting stress
], and research has shown that abusive experiences have a range of negative effects on parenting such as poorer maternal-child interaction, more psychological aggression and physical punishment, less parental warmth, a negative view of self as a parent, decreased parenting satisfaction, problems establishing boundaries as parents, and being too permissive as parents
]. Research indicates that a mother’s current state of mind regarding the abuse and whether the abuse has been resolved is important in experiencing a more healthy adjustment to parenthood
]. In light of these findings, and the results of this study, it may be useful to identify women with histories of child maltreatment and provide support during the antenatal period to help these women navigate a healthy transition as parents in the postpartum period.
Major strengths of this study refer to its inclusion of all possible types of abuse throughout a woman’s life and its examination of important mental health outcomes that are relatively understudied in postpartum women. For example, this study included psychological abuse, which is often ignored in research and policies, but may have an even greater negative impact on women than physical abuse
]. Other strengths of the study include its community-based sample of women (rather than a clinical sample), relatively large sample size, and prospective nature of data collection, with interpersonal violence information obtained during pregnancy before the assessment of postpartum depression and parenting morale. In multivariable analyses, this study was able to adjust for a number of relevant confounding variables across the perinatal period, such as fatigue, optimism, and social support, which allowed for a more detailed understanding of the independent influence of interpersonal violence.
Study limitations include the use of several models that were run simultaneously, which could have resulted in an increased risk for type 1 error. However, given the number and quality of adjustment variables used in the multivariable models, independent effects of the interpersonal violence exposure variables for depression and parenting morale suggest that they are robust. Other limitations include the tendency of underreporting that occurs among victims of abuse, as well as barriers that prevent women from disclosing details of their experiences of interpersonal violence. Examples of possible barriers are a hesitancy to discuss traumatic experiences and a fear of disclosing information regarding abuse. Indeed, 7% of women in the study reported at least one incident of abuse, yet did not provide sufficient details for the abusive experiences to be classified as child maltreatment or intimate partner violence. In an effort to not exclude these women from the study or discount their traumatic experiences, they were categorized as ‘other abuse’, along with women who experienced other types of abusive experiences as adults or sexual assault as adults (1.7%). For the purpose of this analysis, dating violence was included in the category of intimate partner violence, which has been supported by the Centers for Disease Control
], but is differentiated by WHO
]. Although we cannot discount exposure misclassification, the collection of detailed information on experiences of interpersonal violence in the present study allowed for the differentiation and examination of different types of experiences, albeit crude, not seen in previous studies. This information was especially useful for classify past abuse experiences. Unfortunately the level of detail was not enough to fully understand more recent and/or current abuse experiences. For example, we could not distinguish whether interpersonal violence resulted in any of the pregnancies in our study (i.e., sexual assault), nor were we able to fully differentiate current and past intimate partner violence. Despite this, our ability to examine both child maltreatment and intimate partner violence in the same study in relation to a range of postpartum mental health outcomes adds to the evidence base in this area.
There are limitations associated with the use of the SSAI and the EPDS. The SSAI assessed state anxiety only, not general symptoms of anxiety. Although not employed in this study, the trait subscale of the Spielberger Anxiety Inventory may have provided additional information to help in the assessment of anxiety. The cut-off scores for the EPDS in the literature are 10 and 13. In this study, a score of 10 was used to identify women who are experiencing distress and who may be at risk of major depression. Although there is a greater likelihood of including false-positives when using a cut-off score of 10 instead of 13, use of the latter may have led to the exclusion of women with milder symptomatology, whose distress or depression needs identification and support, and whose parenting or ability to bond with their newborn may be compromised by depressive mood.
The results of this study provide direction for further research in this area, including validation of study findings. Further quantitative studies as well as qualitative studies are needed to understand the full impact of previous experiences of violence on mothering and how to provide specific services to this population of women during pregnancy and the postpartum period. Study findings have implications for pregnancy and postpartum care as they indicate that a history of child maltreatment may be an important consideration in prenatal screening as well as prenatal and postpartum services. While it has been recommended that adult women in the general population be questioned about past abusive experiences, including child abuse
], a history of child maltreatment is not routinely considered during prenatal or postpartum care since assessments by clinicians focus on current domestic violence. The Society of Obstetrics and Gynaecology Canada clinical practice guidelines recommend that health care providers ask about intimate partner violence during assessment of new patients, as a part of prenatal care, at annual preventative visits, and if symptoms or conditions are present which are linked with interpersonal violence. However, evidence suggests that only 22.4% and 25.7% of women are asked about emotional and physical abuse, respectively, during pregnancy
]. Consideration of child maltreatment in screening and follow-up could help to identify women who are at risk, and additional treatment and support may reduce the burden of depression and parenting difficulties in the postpartum period for these women. An emerging area of research in antenatal screening for postpartum depression refers to psychosocial assessment tools that incorporate questions across a number of domains of functioning and experiences in a woman’s life beyond current symptomatology. An important area of focus in these tools includes a woman’s past history of adverse child experiences and abuse. A number of recent studies in this area advocate for routine psychosocial assessment as part of a revised perinatal mental health agenda
]. The results of this study suggest that experiences of interpersonal violence constitute an important area to consider as part of a comprehensive examination of a woman’s risk profile.