Birth outcomes in a Swedish population of women reporting a history of violence including domestic violence during pregnancy: a longitudinal cohort study

Violence against women (VAW) continues to be one of the biggest violations against human rights with every third woman worldwide being exposed to physical and/or sexual violence [1]. Women living in Sweden are no exception to such statistics [2, 3]. Pregnancy is not a safeguard or protector against intimate partner (IPV) or family violence [4‐6].

In this study, the terms ‘history of violence’, Domestic Violence (DV), Intimate Partner Violence (IPV) and the concept of ‘domestic and family violence’ (DFV), will be used interchangeable to describe DV. “A history of violence is defined as a lifetime experience of emotional, physical or sexual abuse occurring during childhood (< 18 years), adulthood (≥ 18 years) or both, regardless of the level of abuse or the perpetrator’s identity” [3]. The definition of DV used in the study is in agreement with the World Health Organization (WHO) description [7]. DV commonly takes place in the woman’s ´own home’ [8].

Home is often considered as a place of safety, a haven for women and children, a place where there is physical and psychological safety, trust and care [9]. However, for many women, what should be a place of safety, becomes an environment which is characterised by threat, fear and victimisation for many women experiencing DV [10]. Over the past two decades, research has highlighted the multidimensional effects of DV [11]. Women who experience DV have more medical and stress related symptoms, higher risk of substance misuse than non-abused women. It is also known that women living with violence are higher users of health care services with an estimated 30–50% higher use rate of Emergency Department [12]. Despite this, the response from healthcare in relation to DV is often inadequate and DV remains undetected also for pregnant women [13].

According to WHO, globally 1 to 28% of women are physically abused during pregnancy by an intimate partner [14]. In Australia, 36% of women who experienced violence by a partner reported that this occurred when they were pregnant and around 17 % of these women experienced, violence for the very first time during pregnancy [15]. A meta-analysis by James and colleagues exposed an overall prevalence rate of 13.3% of DV during pregnancy in high-income countries [16]. In Europe, 20% of pregnant women experienced IPV from a current partner with 42% of the women reporting IPV from a previous partner [17]. Whereas in Sweden, recent results from a longitudinal cohort study completed in southwest Sweden revealed a DV prevalence rate of 2.5% of the pregnant population [18, 19].

A growing body of evidence exploring the effects of IPV during pregnancy confirms that it leads to an increase in behavioural risk factors associated with adverse birth outcomes, such as maternal smoking, alcohol or drug misuse, inadequate prenatal care, or insufficient prenatal weight gain [20, 21]. Women who are subjected to IPV are predisposed to have higher levels of stress-related hormones which can be accelerated through physical and sexual trauma leading to preterm birth and low birth weight [22] resulting in reducing mother’s and child’s immune system [21]. A history of sexual violence may lead to fear of childbirth [23, 24] increasing the risk of both planned and emergency caesarean section (CS) [24].

In addition, being exposed to violence and abuse during pregnancy facilitates direct and indirect path-ways to adverse birth outcomes [20]. For example, placental damage, uterine contractions, premature rupture of membranes, and genitourinary infections are among some of the pregnancy complications and adverse outcomes caused by direct physical assault and sexual assault [21]. Women exposed to DV during pregnancy and the postpartum period are also at a greater risk of lifelong health consequences [22]. The condition of the mother’s health and wellbeing is also reflected in the health and wellbeing of the foetus and the new-born infant [25]. Consequences of abuse for maternal, foetal, and child health outcome is poorer physical and psychological health during pregnancy [26‐28]. International literature has also revealed that women who are exposed to DV have a significantly increased risk for depression during both prenatal and postpartum period [28].

Currently, in Sweden, there continues to be limited knowledge relating to birth outcomes in women who have been subjected to DV before and/or during pregnancy. Consequently, the overall aim of this study is to explore childbirth outcomes in a Swedish population of women reporting a history of violence including domestic violence during pregnancy.

The study used a longitudinal design and is part of a previous published project ‘Pregnant women and new mothers’ health and life experience, with ‘life experience’ which also included collecting data around intimate partner violence [3, 18, 19]. Included participants were primigravida and multiparous women ≥18 years of age, receiving antenatal care (ANC), and who could read and write in Swedish or English.

Accessible data to investigate for birth outcomes comprised of 87.4% (n = 1694) of the original cohort (N = 1939). The mean age (at recruitment) was 30 years (mean 30.12, SD 4.8; min 18–48 years) and for the majority of women Swedish was their first language. Among those women, almost 4 in 10 women reported a history of violence (n = 656), categories of significant difference were single or living apart, unemployed and experiencing financial distress (Table 1). In this particular cohort 2% (n = 34) women reported experiencing DV during pregnancy (Q-I – Q-II) and all had a history of experiencing violence.

In the self-reported maternal characteristics and lifestyle questionnaire, more women were multipara, of normal weight or were underweight with less than 4% reporting fear of birth. Smoking or used wet-tobacco were significantly higher among women with a history of violence. Exposed women also reported a significant lower SOC score and higher EDS scores than women who did not report a history of violence (OR 2.40, 95% CI (1.90–3.01) respectively (OR 2.41, 95% CI 1.71–3.40). Alcohol consumption were similar in the two groups, regardless of whether they reported a history of violence or not (Table 2).

Maternal birth outcomes were similar in both groups apart from CS, women who had a history of violence had a 33% increased risk of CS (OR 1.33, 95% CI 1.02–1.70) (Table 3). In the total 15.3% (n = 259) of the study population experienced a CS. They were divided between 5.8% (n = 99) women who chose a planned CS and 9.4% (n = 160) who had an emergency CS (exclusively presented in the text). Women with history of emotional abuse had significantly increased risk having CS (OR 1.50, 95% CI 1.09–2.06) (Table 4). There was also an increased risk of prematurity for women who were experiencing history of violence 6.6% (n = 43) compared to those who were not 4.4. % (n = 45) (Table 5).

Confounding effects of the increased incidence of lower socioeconomic status (cohabiting, employment, economy) and tobacco use on the rate of the two adverse pregnancy outcomes i.e. premature birth and CS showed no potential cause and effect or significant association.

Infant characteristics were similar in the two groups. In addition, there were two intra uterine foetal deaths before gestational week 34 (mothers had not reported experience of violence).

The findings from this study clearly indicate that women who are experiencing DV are at a significantly higher risk of a CS, irrespectively whether the CS is planned or emergency. In line with previous studies, women with a history of violence were also at an increased risk of a premature birth before 37 week of gestation. Tomasdóttir et al. [37] also reported that women with a history of violence were at an increased risk of a CS, however Tomasdóttir did not report on whether the CS was an emergency or planned. BIDENS large cohort study which was conducted in six European countries demonstrated the risk of a planned CS for non-obstetrical reasons in primiparous women who had experienced sexual abuse as an adult was high when compared with women who had not experienced sexual violence [24].

The same study also highlighted an association of an increased risk of preterm birth and DV, validating a recent prospective cohort study by Rishal et al. [38] and a large meta-analysis in 2016 by Hill et al. [21] which also demonstrated a significant increase risk of a preterm birth among women subjected to DV. The consequences of a preterm birth have short- and long-term consequences in infants. Infants born before 37 gestational weeks are vulnerable to major health and developmental risks such as increased risk of respiratory distress and immature brains requiring special care in NICU which in turn result in longer hospitalization [39]. Preterm infants are at higher risk of being readmitted to the hospital and are at an increased risk of death after returning home [40, 41]. In this study women who reported a history of violence experienced higher levels of depressive symptoms than women who were not experiencing DV. It is established that depression will influence a mother’s ability and willingness to bond and take care of her new-born child [42]. A systematic review by Staneva and colleagues reported a significant interface between depression, anxiety and stress, risk factors and preterm birth [43]. Previous research has also revealed that maternal psychosocial stress, and/or fear of childbirth, may have an association with specific complications and increase the women’s risk of undergoing a CS [44]. Pregnancy and childbirth can also be psychological memory triggers for women who have experienced childhood sexual abuse [45]. Simkin [46] supports this theory suggesting such complex psychosocial factors, whether remembered or not, have the capacity to play a greater role in perinatal care and outcomes. Finnbogadóttir and Mellgren [47] in a previous study from the same cohort of women revealed that more than one in ten women with a history of emotional abuse had never actually talked to anyone about their experience. Indicating that many women are embarking upon their pregnancy with unprocessed trauma which can adversely affect the woman’s pregnancy and childbirth outcome. However, in this study women with an exclusive history of physical and/or sexual abuse, did not display a significant association with increased risk of CS. This finding however, is in contraindication with some former studies which have shown an increased risk between IPV and CS and physical violence [48, 49]. Furthermore, a European a large multi-country cohort study in 2016 confirmed that primiparous women who were sexually abused as adults were more likely to have an elective CS for non-obstetrical reasons and multiparous for an emergency CS [24]. To summarize, irrespective of the type of violence a woman experiences a history of violence and ongoing abuse during pregnancy has an overall negative impact on childbirth outcomes. Therefore, it’s crucial for midwives to be focussed and observant during the antenatal visits with a pregnant woman. Therefore, it’s central that midwives are concentrating and observant in the antenatal period. It is also important that the midwife strives to develop a trusting relationship from the very first encounter and focuses on a woman’s holistic health needs. Thereby, providing an opportunity to identify the women who require extra resources and need extra support during such a vulnerable period of their lives.

Previous studies from Sweden testify that on average 2.6% of women have reported physical abuse by a current or former partner during the year preceding pregnancy, with 1.3% reporting a history of abuse in the postpartum period [50]. Evidence has shown that a brief training program can improve midwives’ ability to recognize the signs of DV, increase their knowledge, preparedness, and confidence to responding sensitively to women [51]. However currently in Sweden it is not routine to ask about DV. For that reason, this study sought to bring forward new knowledge to help midwives and other health care professionals recognize women who are a higher risk of experiencing DV during pregnancy. Pregnancy is an opportune time for early intervention, it is time when women may be open to accessing support. A disclosure which is met with a sensitive, caring and considered response may support and empower women to reach and seek support. Therefore, it is important that a woman-centred approach is secured, this can be achieved by providing care within a midwifery continuity of care model [52]. Providing midwifery continuity of care provides women with care from a known midwife. Continuity of midwifery care provides a greater level of trust and connection between a midwife and the woman thereby increasing the possibility of a disclosure from the woman. However, to provide women centred care, midwives must be supported by their health care organizations to re-organise their current fragmented systems of care. DV education and training is also vital to increase midwives’ knowledge and confidence, ongoing training, support and mentoring are vital if midwives are to continue to undertake this sensitive work in a trauma informed way. In addition, DV training programs should be long enough to address the complexities of DV, including addressing attitudes and stereotypes as well as ousting common myths, which surround DV. Continuity of midwifery care through midwifery caseload models is essential, as it provides women with the opportunity to build up a trusting and ongoing relationship with a known midwife. Continuity of midwifery care also offers a greater level of trust and connection between a midwife and the woman and increases the possibility of a disclosure from the woman. However, to provide women centred care, midwives must be supported by their health care organizations to re-organise their current systems of care. Education and training is also vital to increase the midwives’ knowledge and confidence, ongoing training, support and mentoring are vital if midwives are to continue to undertake this sensitive work. In addition, DV training program should be long enough to address the complexities of DV, including addressing attitudes and stereotypes as well as ousting common myths, which surround DV [51].

There are several strengths to this study the large sample size and the use of a well-defined cohort. This longitudinal study, based on prospective data, also allowed for the robust comparison between those who had history of violence and those who did not. Another strength of the study is the use of validated instruments to evaluate the data [29, 30, 33, 35, 53‐55].

The results of the study ascertain that a history of violence has a negative impact on a woman’s mode of birth and increases the risk of premature birth. Therefore, it is important that midwives strive to develop a relationship which is respectful and built on trust with women during the antenatal period. Early identification of a history of violence and abuse before or during pregnancy could decrease the rates of premature birth and/or CS. The effects of a history of violence including experiencing psychological violence without other forms of violence has serious effects on both maternal and childbirth outcome.