Background
Intimate partner violence (IPV) is currently recognised as a global health problem with serious clinical and societal implications, which affects women and men from all backgrounds, regardless of age, ethnicity, socio-economic status, sexual orientation or religion [
1‐
4]. IPV is defined as any behaviour within a present or former intimate relationship that leads to physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviour patterns [
5]. IPV is also known as domestic/family violence, spouse/partner abuse/assault, battering, violence against women or gender-based violence [
6‐
8]. Based on the Centers for Disease Control and Prevention’s definition of IPV [
9], we have chosen to consistently use the term ‘violence’ for physical and sexual types of violence, and ‘abuse’ for psychological types. The word ‘abuse’ clearly refers to a broader range of behaviours than the word ‘violence’, which is often associated with severe forms of violent behaviour.
Pregnancy and childbirth mark an important turning point at which the roles and relationships of couples and their families are redefined on different levels. While parenthood can bring joy, it also confronts couple relationships with new challenges [
10,
11]. As pregnancy may generate changes in physical, emotional, social and economic needs, it can be a stressful time. This period is associated with increased demands on individual capacities, the intimate partner relationship and household economic resources, and a reduction in leisure time and opportunities to socialise, which can exert adverse effects on emotional wellbeing [
10]. Individual and dyadic coping strategies tend to decrease under stress, leading to an increased risk of physical and psychological aggression [
12‐
14]. The vulnerable period for IPV associated with pregnancy extends further than the time between conception and birth - from a year before conception until one year after childbirth [
4,
12‐
15].
A wide range of prevalence rates, from 3 to 30 %, have been reported for IPV around the time of pregnancy. Prevalence rates are mainly situated at the high end of the continuum in African and Latin American countries, and at the lower end in European and Asian countries. Although estimates are highly variable due to methodological challenges, the majority of studies show rates within the range of 3.9 to 8.7 % [
3,
4,
6,
8,
10‐
17]. Although the exact prevalence of IPV around the time of pregnancy remains unclear, it is evident that it affects a substantial group of women. In Belgium, we recently showed [
17] that as many as 15.8 % (95 % CI 14.2–17.7) of women experience IPV (incl. psychological abuse) before and/or during pregnancy. In other words IPV during the perinatal period is more common than several maternal physical health conditions (e.g. pre-eclampsia, placenta praevia), yet IPV receives considerably less attention within perinatal care [
3,
4,
18,
19]. The Belgian perinatal health care system is based on the bio-medical model [
20] with obstetrician/gynaecologists (ob/gyn’s) not only accounting for obstetric and gynaecologic pathology, but also acting as primary care physicians to the general female population, e.g. in providing primary obstetric care and in offering preventive women's health medicine [
16,
21]. Although pregnancy brings women into regular contact with the health care system and therefore offers strategic opportunities to identify and ameliorate psychosocial concerns and risk factors [
22], screening or systematic inquiry for IPV and/or psychosocial health is not part of routine perinatal care (yet).
In recent decades, research from the Western world, and increasingly, from low and middle income countries [
23], has generated growing evidence that violence is associated with detrimental effects on the physical health of women, men and children, such as infection, miscarriage/abortion, placental abruption, foetal injury and perinatal death [
8,
18,
19,
24‐
35]. Evidence is emerging that on the one hand, poor psychosocial health is a negative consequence of IPV, and on the other hand, poor psychosocial health is simultaneously found to be a risk factor for IPV. Moreover, poor psychosocial health status is linked to adverse pregnancy outcomes. Women reporting depressive symptoms and poor overall psychosocial health during pregnancy are at increased risk of low birth weight (LBW) and preterm birth [
36]. Furthermore, reporting IPV, is associated with increased risk for anxiety disorders, eating disorders, anxiety attacks, nervousness, concentration problems, sexual dysfunctions, fear of intimacy, loss of self-esteem, psychosomatic complaints (e.g. headaches), pre- and postnatal depression, trauma symptoms (such as sleeping problems, flashbacks, panic attacks) post-traumatic stress syndrome, postpartum psychosis, and (attempted) suicide [
18,
19,
24‐
35]. Additionally, IPV is strongly linked with harmful health behaviours such as using tobacco, alcohol or illicit drugs, poor maternal nutrition, and high-risk sexual behaviour [
2,
8,
18,
19,
24‐
28,
31‐
35,
37‐
41].
The objective of this paper is to explore whether IPV 12 months before and/or during pregnancy is associated with poor psychosocial health in Flanders, Belgium.
Discussion
In this multi-centre cohort of pregnant women, we found a strong correlation between IPV and psychosocial health. Several other researchers have previously demonstrated a correlation between reporting IPV and poor psychosocial health [
2,
8,
18,
24‐
28,
31‐
34,
38,
56‐
58]. Notably, poor psychosocial health is frequently reported as a negative consequence of IPV, and simultaneously, psychosocial health is found to be a risk factor for IPV. As this association has been repeatedly documented mostly in cross-sectional studies, it remains to be determined whether poor psychosocial health puts women at risk of IPV, or whether IPV induces worse psychosocial health, though it is plausible that both pathways co-exist. Literature on this specific matter is scarce; most studies have focussed on the association between poor psychosocial health and pregnancy outcomes such as low birth weight and prematurity, though the influence of psychosocial factors (such as stress, anxiety, and depression) on birth outcomes remains inconclusive [
36,
51,
52]. However, psychosocial resources including self-esteem and mastery have been reported to protect women against stress from life events and chronic strains. These psychosocial resources could be even more relevant when women adapt to manage their lives and cope with the stress and vulnerability associated with IPV during pregnancy [
54].
Our data further suggest that, after taking all measured variables into account, the correlation between IPV and psychosocial health was mainly explained by “depression” and “stress” as psychosocial health indices. It has been noted that scales measuring affective states such depression or anxiety are likely to be highly correlated with each other and measure generalized distress rather than symptoms unique to depression or anxiety [
51]. Our results confirm the finding that there is a strong correlation between the different psychosocial health subscales. The strong association between the total psychosocial health scale and IPV might indeed refer to a more general form of distress in our population interconnected with a multitude of factors. Recently, there has been a shift towards envisaging psychosocial health as a multidimensional concept [
52]. We acknowledge that psychosocial health is a complex construct with many known and, presumably, many unknown determinants, although our study was not designed to explore this. Future research should be done to try to shed some light on the multitude of factors involved in the complex interaction between psychosocial health and IPV.
Our results need to be viewed within the context of certain limits. There is currently a lack of agreement on standard measures for psychological (partner) abuse/violence and in an effort to tackle this problem, we decided to construct our own scale and threshold for psychological abuse cut-off value. The threshold we chose for psychological abuse was based on a thorough literature search and extensive discussions with experts in the field. Nevertheless, it remains an arbitrary choice that is open for discussion. We have some indication that the cut-off might be on the low side, but this hypothesis obviously needs further investigation. Furthermore, our study design did not allow us to determine causal pathways between the factors analysed. Moreover, we were not able to analyse in depth the multitude of factors involved in the complex interaction between IPV and psychosocial health, and as a consequence, might have oversimplified reality. The findings presented in this paper are based on a sample of the Belgian obstetrical population and cannot be generalised to other populations or health care systems without the necessary caution.
Conclusion
Our research has demonstrated that IPV and psychosocial health are strongly associated. Due to the cross-sectional nature of our study design, we are not able to make any statements on causality with regard to these associations. However, it seems reasonable that a multitude of factors could have influenced the interaction, and more longitudinal and in-depth, qualitative analysis needs to be done to shed light on the complex interactions and confounding factors that define the relationship between IPV and psychosocial health.
Furthermore, linked to the important role of psychosocial health found in our study, we believe that the recommendation to routinely screen for IPV during pregnancy should be broadened and that IPV should not been seen as an isolated theme. IPV research is providing increasing evidence that addressing the multitude of risk factors related to IPV simultaneously has a larger effect than addressing a single factor. Therefore, we would like to join the growing number of authors advocating for the inclusion of IPV within a broader psychosocial health assessment as a standard part of antenatal care. Addressing psychosocial health in antenatal care has the potential to improve the health and well-being of women and their families.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ASVP conceived the study, acquired the data, performed the analysis and drafted the manuscript. ED assisted ASVP with the statistical analysis. KM, AG, MT and HV participated in the design of the study, were involved in drafting the article, and gave critical input. All authors read and approved the final manuscript.