Relational trauma and posttraumatic stress symptoms among pregnant women

Women Friendly: The effectiveness of a woman-centered childbirth intervention in Israel

Women with symptoms of post-trauma are vulnerable during childbirth and often lack trust in the medical staff in the delivery rooms. They are therefore in need of a sensitive intervention to prevent the formation or exacerbation of trauma in the perinatal period. This study evaluated the feasibility and efficacy of a "Woman Friendly" (WF)intervention for women with a history of trauma. During this intervention, the women were informed about childbirth and prepared for the delivery. Fourteen mothers aged 28-41 with symptoms of post-trauma who had participated in the WF intervention were interviewed about their experience within six months after giving birth. Interviews were transcribed and analyzed using thematic analysis. Thematic analysis yielded six themes. One theme was during the pre-delivery period: 1) Preparation of the WF document. Four themes were during the delivery: 1) The WF document as an advocate; 2) security and safety; 3) Controlling the situation; and 4) Respect and kindness from the medical staff. The final theme was limitations of the WF intervention. It seems that a birth preparation intervention adapted to the needs of emotionally vulnerable women can help them to have positive birth experience. Childbirth preparation for these women should focus on their sensitivities rather than trauma-processing. The WF intervention holds promise for women with symptoms of post-trauma and should be further evaluated in future research.

Childhood abuse and perinatal outcomes for mother and child: A systematic review of the literature

Childhood abuse can have long-term adverse outcomes in adulthood. These outcomes may pose a particular threat to the health and well-being of perinatal women; however, to date, this body of knowledge has not been systematically collated and synthesized. This systematic review examined the child abuse literature and a broad range of perinatal outcomes using a comprehensive search strategy. The aim of this review was to provide a clearer understanding of the distinct effect of different abuse types and areas where there may be gaps in our knowledge. Following PRISMA guidelines, EBSCO, PsychInfo, Scopus, Medline, CINAHL, PubMed, and Google Scholar databases and gray literature including preprints, dissertations and theses were searched for literature where childhood abuse was associated with any adverse perinatal outcome between 1969 and 2022. Exclusion criteria included adolescent samples, abuse examined as a composite variable, editorials, letters to the editor, qualitative studies, reviews, meta-analyses, or book chapters. Using an assessment tool, two reviewers extracted and assessed the methodological quality and risk of bias of each study. From an initial 12,384 articles, 95 studies were selected, and the outcomes were categorized as pregnancy, childbirth, postnatal for the mother, and perinatal for mother and child. The prevalence of childhood abuse ranged from 5-25% with wide variability (physical 2-78%, sexual 2-47%, and emotional/psychological 2-69%). Despite some consistent findings relating to psychological outcomes (i.e., depression and PTSD), most evidence was inconclusive, effect sizes were small, or the findings based on a limited number of studies. Inconsistencies in findings stem from small sample sizes and differing methodologies, and their diversity meant studies were not suitable for a meta-analysis. Research implication include the need for more rigorous methodology and research in countries where the prevalence of abuse may be high. Policy implications include the need for trauma-informed care with the Multi-level Determinants of Perinatal Wellbeing for Child Abuse Survivors model a useful framework. This review highlights the possible impacts of childhood abuse on perinatal women and their offspring and areas of further investigation. This review was registered with PROSPERO in 2021 and funded by an internal grant from Charles Sturt University.

Maternal Childhood Maltreatment, Internal Working Models, and Perinatal Substance Use: Is There a Role for Hyperkatifeia? A Systematic Review

The parent-infant relationship is critical for socioemotional development and is adversely impacted by perinatal substance use. This systematic review posits that the mechanisms underlying these risks to mother-infant relationships center on 3 primary processes: (1) mothers' childhood maltreatment experiences; (2) attachment styles and consequent internal working models of interpersonal relationships; and (3) perinatal substance use. Further, the review considers the role of hyperkatifeia, or hypersensitivity to negative affect which occurs when people with substance use disorders are not using substances, and which drives the negative reinforcement in addiction. The authors performed a systematic review of articles (published 2000-2022) related to these constructs and their impact on mother-infant relationships and offspring outcomes, including original clinical research articles addressing relationships between these constructs, and excluding case studies, reviews, non-human animal studies, intervention studies, studies with fewer than 30% female-sex participants, clinical guidelines, studies limited to obstetric outcomes, mechanistic/biological studies, and studies with methodological issues precluding interpretation. Overall 1844 articles were screened, 377 were selected for full text review, and data were extracted from 157 articles. Results revealed strong relationships between mothers' childhood maltreatment experiences, less optimal internal working models, and increased risk for perinatal substance use, and importantly, all of these predictors interacted with hyperkatifeia and exerted a marked impact on mother-infant relationships with less data available on offspring outcomes. These data strongly support the need for future studies addressing the additive impact of maternal childhood maltreatment experiences, suboptimal internal working models, and perinatal substance use, with hyperkatifeia as a potential moderator, and their interacting effects on mother-infant socioemotional outcomes.

Preconception maternal posttraumatic stress and child negative affectivity: Prospectively evaluating the intergenerational impact of trauma

The developmental origins of psychopathology begin before birth and perhaps even prior to conception. Understanding the intergenerational transmission of psychopathological risk is critical to identify sensitive windows for prevention and early intervention. Prior research demonstrates that maternal trauma history, typically assessed retrospectively, has adverse consequences for child socioemotional development. However, very few prospective studies of preconception trauma exist, and the role of preconception symptoms of posttraumatic stress disorder (PTSD) remains unknown. The current study prospectively evaluates whether maternal preconception PTSD symptoms predict early childhood negative affectivity, a key dimension of temperament and predictor of later psychopathology. One hundred and eighteen women were recruited following a birth and prior to conception of the study child and were followed until the study child was 3-5 years old. Higher maternal PTSD symptoms prior to conception predicted greater child negative affectivity, adjusting for concurrent maternal depressive symptoms and sociodemographic covariates. In exploratory analyses, we found that neither maternal prenatal nor postpartum depressive symptoms or perceived stress mediated this association. These findings add to a limited prospective literature, highlighting the importance of assessing the mental health of women prior to conception and providing interventions that can disrupt the intergenerational sequelae of trauma.

Intimate partner violence during the perinatal period by disability status: Findings from a United States population-based analysis

AIMS

The aim of the current study was to compare the prevalence of intimate partner violence (IPV) during the perinatal period among respondents with self-reported disability compared with those without a disability.

DESIGN

We conducted a secondary analysis of nationally representative data from the Pregnancy Risk Assessment Monitoring System data from 24 participating United States between 2018 and 2020.

METHODS

A cross-sectional sample of 43,837 respondents provided data on disability, including difficulty in vision, hearing, ambulation, cognition, communication and self-care. The exposure was perinatal IPV, defined as experiencing abuse by a current or ex-partner in the year before or during pregnancy. Regression models were used to calculated odds of IPV by disability status while accounting for relevant sociodemographic characteristics.

RESULTS

Respondents who self-reported disabilities experienced IPV at a higher rate than those without disabilities, both before and during pregnancy. In fully adjusted models, respondents with disabilities had about 2.6 times the odds of experiencing IPV before pregnancy, and about 2.5 times the odds of experiencing IPV during pregnancy, compared with those without disabilities.

CONCLUSION

Respondents with disabilities experienced IPV at higher rates than the general population, and thus are at increased risk for adverse maternal, neonatal and infant health outcomes.

IMPACT

Perinatal IPV is a significant issue globally, and our findings suggest perinatal IPV is particularly salient for persons with disability. Findings highlight the need to screen women with disabilities for IPV during the perinatal period as well as the importance of providing them appropriate, accessible information, resources and referrals.

Psychosocial Risk Factors and Psychopathological Outcomes: Preliminary Findings in Italian Pregnant Women

The perinatal period may represent a particularly challenging time for expecting parents. Previous studies have highlighted an association between several perinatal risk conditions (e.g., childhood maltreatment, poor social support, and stress levels) and the development of psychopathological symptoms in pregnant women, especially depression symptoms. The current study examined the effects of psychosocial risk factors (childhood maltreatment, poor social support, and stressful events) on anxiety, depression, perceived stress, irritability/anger, relationship problems, psychosomatic symptoms, specific physiological problems, and addiction/at-risk behaviors. Sixty-one pregnant women (age range = 24–45) participating in a larger study completed questionnaires about childhood maltreatment (CECA Q.), Maternity Social Support Scale (MSSS), questionnaire on stressful events, and the Perinatal Assessment of Maternal Affectivity (PAMA) during their pregnancy. Results from regression analysis indicated that the presence of childhood maltreatment predicted elevated depressive symptoms, elevated irritability and anger, and elevated relationship problems. Further, stressful events in the year prior to pregnancy predicted elevated psychosomatic symptoms during pregnancy. No other significant associations were found. In this study, traumatic childhood events were strongly associated with mental health symptoms during pregnancy. This is an important finding that suggests the importance of screening and targeting psychotherapeutic interventions for vulnerable women during pregnancy.

Maternal childhood adversity and prenatal depression: the protective role of father support

Depression during pregnancy is common, and previous research suggests childhood adversity may increase the risk for prenatal depression. Support during pregnancy can buffer these risks, and paternal support is associated with improved maternal well-being during pregnancy. There is evidence to suggest that increased support from fathers may be particularly helpful in combatting depressive symptoms for mothers with adverse childhood experiences. The study aims to explore the role of biological father support as a protective factor against the risks associated with childhood adversity for maternal prenatal depression. Sample included 133 pregnant women recruited from two university-affiliated OB-GYN clinics serving diverse and low-income patients. Participants completed measures on childhood adversity, prenatal depressive symptoms, and father support. Results showed a significant moderating effect of father support on the relation between maternal ACEs and prenatal depressive symptoms, suggesting that higher levels of father support are protective against prenatal depressive symptoms, specifically in mothers with low-to-moderate ACEs. These results highlight the positive impact of paternal support for maternal well-being during pregnancy. Although mothers with low-to-moderate ACEs experience a buffering effect of father support, mothers with high levels of childhood adversity remain at elevated risk for prenatal depressive symptoms even with high father support. As such, screening mothers for ACEs in addition to father support may help identify those at higher risk of prenatal depression.

Patterns and predictors of perinatal posttraumatic stress symptoms: A latent transition analysis

BACKGROUND

Pregnancy is a time of increased risk for intimate partner violence (IPV), yet there is a dearth of prospective research examining the relationship between IPV and posttraumatic stress symptoms (PTSS) in the perinatal period. Further, relationships among different types of IPV and perinatal PTSS remain understudied.

METHODS

Latent class and transition analyses were used to examine classes of PTSS in pregnancy and postpartum, the longitudinal patterns of transitions across these classes, and the role of IPV types, childhood adversity, and depressive symptoms in PTSS presentation. Participants (N = 238) were drawn from two longitudinal studies of high-risk perinatal women.

RESULTS

Four latent PTSS classes emerged: High, Avoidant, Hypervigilant, and Low. Childhood adversity (χ²(3) = 13.09, p = .004), prenatal depression (χ²(3) = 17.58, p = .001), and psychological IPV (χ²(3) = 10.51, p = .01) were associated with membership in High, Avoidant, and Hypervigilant classes. Women with low prenatal PTSS continued to have low levels at postpartum. Women in higher severity classes during pregnancy tended to transition into classes with adjacent, and often lower, levels of symptom severity postpartum. Women in the High PTSS class in pregnancy with elevated levels of depression were significantly more likely to remain in the High PTSS class or transition into the Avoidant class at postpartum, compared to the Low PTSS class, χ²(3) = 11.84, p = .008.

LIMITATIONS

Relatively modest sample size precluded examination of a broader range of symptoms consistent with PTSD.

CONCLUSIONS

Findings highlight the importance of individualized approaches to assessing, monitoring, and treating perinatal PTSS.

The Role of Childhood Trauma on Prenatal Attachment: A Cross-Sectional Study

Although the quality of prenatal attachment is a strong predictor of the quality of postnatal mother-infant attachment and mother-child interaction, little is known about the specific impacts of maternal exposure to childhood traumas, and it deserves more attention. This study was conducted to determine whether there is a relationship between childhood traumas and prenatal attachment levels. Prenatal attachment and childhood trauma were evaluated in 104 pregnant women using the Prenatal Attachment Scale and Childhood Trauma Questionnaire. Our results showed that all kinds of childhood traumatic experiences were associated with lower prenatal attachment scores. Also, more severe childhood traumas were strongly associated with weaker prenatal attachment. This study contributes to the very limited literature on the prenatal attachment of expectant mothers with childhood traumas by emphasizing the importance of pregnant women's exposure to childhood traumas as a risk factor for low prenatal attachment.

Maternal stress and mental health before pregnancy and offspring diurnal cortisol in early childhood

The current study investigates whether prepregnancy maternal posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, and stress predict children's cortisol diurnal slopes and cortisol awakening responses (CARs) adjusting for relevant variables. Mothers were enrolled after delivering a baby and followed through their subsequent pregnancy with 5 years of longitudinal data on their subsequent child. This prospective design allowed assessment of PTSD symptoms, depressive symptoms, and perceived stress prior to pregnancy. Children provided three saliva samples per day on three consecutive days at two timepoints in early childhood (M age = 3.7 years, SD = 0.38; M age = 5.04 years, SD = 0.43). Mothers' PTSD symptoms prior to pregnancy were significantly associated with flatter child diurnal cortisol slopes at 4 and 5 years, but not with child CAR. Findings at the age of 4 years, but not 5 years, remained statistically significant after adjustment for maternal socioeconomic status, race/ethnicity, child age, and other covariates. In contrast, maternal prepregnancy depressive symptoms and perceived stress did not significantly predict cortisol slopes or CAR. Results suggest that maternal prepregnancy PTSD symptoms may contribute to variation in early childhood physiology. This study extends earlier work demonstrating risk of adverse outcomes among children whose mothers experienced trauma but associations cannot be disentangled from effects of prenatal mental health of mothers on children's early childhood.

Changes in Defense Mechanisms in Mothers From Pregnancy to 2 Years Postpregnancy

ABSTRACT

The objective of this study was to assess changes in maternal defensive functioning from the third trimester of pregnancy to 2 years postpregnancy. A community sample of at-risk mothers ( N = 84; non-White [61%], unmarried [67%], high school or less education [72%], and income less than $20,000 [50%]) were recruited for this longitudinal study. Mothers responded to a semistructured interview during pregnancy and at 2 years postpregnancy about the parent-infant relationship; interview transcripts were coded using the Defense Mechanism Rating Scale (DMRS). Results indicated a significant increase in both total defense mechanisms used and the relative percentage of immature defense mechanisms used over time. A significant decrease in the relative percentage of healthy/adaptive defenses was noted. When all seven levels of defenses of the DMRS were assessed, it was an increase in minor image-distorting defenses, mechanisms that supported vulnerable self-esteem, that accounted for most of the change in immature defenses. Stability coefficients of defense mechanisms were reported, with large effect sizes, for overall defensive functioning, and mature and immature defenses over a 2-year period. These findings lend support to the importance of assessing defense mechanisms to better understand stressful life transitions in mothers.

Intimate Partner Violence and Perinatal Post-Traumatic Stress and Depression Symptoms: A Systematic Review of Findings in Longitudinal Studies

The link between maternal violence exposure and adverse obstetric outcomes is well-documented, but less is understood about the relationship between intimate partner violence (IPV) exposure and perinatal post-traumatic stress symptoms(PTSS) and depression in women around the world. A systematic review was conducted to synthesize empirical literature on the associations between IPV (e.g., before pregnancy, during pregnancy, postpartum) and post-traumatic stress and depression symptoms in the perinatal period. This review acknowledged the effects of IPV exposure timing, timing of assessment, and IPV subtypes. Forty-seven longitudinal studies met inclusion criteria and were reviewed to determine the effects of IPV exposure on perinatal mental health. Findings suggested a strong relationship between IPV exposure and perinatal mental health. Results were more consistent between perinatal mental health and IPV sustained close to or during the perinatal period than for lifetime IPV exposure. In general, physical, sexual, and psychological IPV were independently associated with perinatal depression and PTSS. Findings underscore the importance of theoretically driven research and the development of treatment protocols for women worldwide.

Associations Between Adverse Childhood Experiences and Prenatal Mental Health and Substance Use Among Urban, Low-Income Women

This study examined associations between Adverse Childhood Experiences (ACEs) and perinatal mental health and substance use among 98 low-income women (mean age 25.4 years; 93% Black/African American) referred to a mental health care manager in an urban women's clinic. Self-report and retrospective chart review data were utilized. Chi-squared and Fisher's Exact tests were performed to assess bivariate relationships between ACEs and mental health and substance use outcomes. Multivariate logistic regressions were used to examine the impact of ACEs on mental health and substance use, adjusting for marital status, education, and age. Findings indicate high levels of childhood adversity, specifically childhood abuse, are associated with negative perinatal mental health and substance use outcomes, including suicidal thoughts, anxiety, mood dysregulation, and tobacco and marijuana use. Inquiring about ACEs during prenatal care and/or in community health clinics may help identify patients' overall risk and provide opportunities for intervention for mothers and their infants.

Depression and quality of life among pregnant women in first and third trimesters in Abeokuta: A comparative study

Background

Pregnancy is a dynamic time during which a woman’s emotional state may undergo extensive change. There have been conflicting views about the magnitude of emotional turmoil that occurs during pregnancy. Some investigators suggest that pregnancy is a time of particularly good psychological adjustment; others have reported high levels of psychological challenge.

Aim

Our study aimed to compare the prevalence and correlates of depression in the first and third trimesters of pregnancy and to determine the relationship between quality of life and depressive disorder.

Setting

The antenatal clinic of the State Hospital, Ijaiye.

Method

A descriptive, comparative study of depressive disorder and the quality of life between first- and third-trimester pregnant women (confirmed through a pregnancy test and an abdominopelvic ultrasound).

Result

For each trimester, 285 participants were recruited. The prevalence of depression among the pregnant women who participated in the study was 7.2%. In the first trimester of pregnancy, the prevalence of depression was 30 (10.5%), while it was 11 (3.9%) in the third trimester of pregnancy. Collectively, the relationship between depression and QoL was significant in the overall domain, satisfaction with general health domain (t = 2.27; p = 0.03), psychological domain (t = 2.74; p = 0.010, and environmental domain (t = 4.57; p ≤ 0.01).

Conclusion

Our study also highlights the need to pay closer attention to the psychological well-being and quality of life of all pregnant women and not just on their physical health and the baby’s well-being.

Exploring the relationships between child maltreatment and risk factors for pregnancy complications

OBJECTIVE

This study explored the pathway underlying the relationships between child maltreatment (CM) subtypes (i.e., physical, sexual, and emotional abuse and neglect) and factors associated with a heightened risk of pregnancy complications by examining post-traumatic stress disorder (PTSD) symptoms as a potential mediator.

METHODS

A sample of 98 pregnant parents between the ages of 18 and 29 years was recruited through social media and community organizations throughout Canada. Participants completed a series of surveys on their exposure to CM, PTSD symptoms, and pregnancy experiences on a secure online platform. Following data cleaning procedures, 85 participants were included in this study.

RESULTS

Four separate mediation analyses were conducted with child neglect, physical abuse, sexual abuse, and emotional abuse as factors associated with a heightened risk of pregnancy complications (i.e., a congregate score of limited prenatal care, weight gain concerns, smoking, second-hand smoke, alcohol consumption, substance use, and insufficient food intake during pregnancy). Each CM subtype was associated with increased PTSD symptoms, which were in turn associated with the presence of more factors known for increasing the risk of pregnancy complications. Neglect, physical abuse, sexual abuse, and emotional abuse were all indirectly associated with the presence of more factors associated with a heightened risk of pregnancy complications through their association with PTSD symptoms.

CONCLUSIONS

Findings from this study could encourage prenatal care providers to screen for CM history and PTSD symptoms. Furthermore, mental health treatment early in the prenatal period may improve pregnant parents' health and lower their risk of pregnancy complications.

Mothers' Self-focused Reflective Functioning Interacts with Childhood Experiences of Rejection to Predict Current Romantic Relationship Quality and Parenting Behavior

Parents exposed to rejection in their childhood could experience bonding disturbances in their current relationships. Reflective functioning (RF), the capacity to understand one's own and others' behavior through the lens of underlying mental states (cognitions, emotions), has been identified as a potential protective process. The aim of this longitudinal study was to examine whether RF moderates the effect of parents' experiences of rejection in childhood on later relationship functioning with partners and infants. Pregnant women with experiences of abuse and neglect were recruited and completed the Adult Attachment Interview, which was coded for RF and experiences of childhood rejection. During two follow-up assessments, when their infants were 5 and 17 months old, the mothers in our sample who had partners reported on dyadic cohesion with these partners. Further, at 5 months postnatal, mothers completed interaction tasks with their infants, which were later assessed using observational measures (i.e., CARE-Index). Results of mothers with partners (N = 93) indicated that RF moderated the relationship between dyadic cohesion with partners at 17 months only. Additionally, results with all mothers in the sample (N = 108) indicated that RF moderated the relationship between retrospectively reported experiences of rejection and controlling and unresponsive behaviors with infants. Adequate-to-high RF was associated with lower unresponsiveness and higher relationship satisfaction in the context of rejection, while being associated with higher levels of control. These findings have important clinical implications, as RF is amenable to change and can therefore be more prominently implemented within various interventions.

Synergistic Effects of Psychological Intimate Partner Violence Exposure and Gender Discrimination on Postnatal Mental Health Trajectories

While the literature examining physical intimate partner violence (IPV) is extensive, the impact of psychological IPV on mental health during high-risk times such as the period following childbirth is not well understood. The current study examined associations between psychological IPV and the course and severity of women's postnatal mental health symptoms (depression, anxiety, and trauma symptoms). Both main effects of psychological IPV exposure and possible exacerbation by broader social victimization (i.e., gender discrimination) were considered. Participants were 76 mothers from a larger longitudinal study, who completed self-report measures of IPV, gender discrimination, and affective symptoms at 3, 6, 12, and 18 months postnatal. Hierarchical linear modeling revealed a main effect of psychological IPV on the course of trauma symptoms only. As hypothesized, gender discrimination moderated the effect of psychological IPV on all symptom trajectories in a synergistic manner. At moderate to high levels of gender discrimination only, psychological IPV predicted higher affective symptom severity and an escalating course of postnatal anxiety symptoms. These findings underscore the importance of expanding current conceptualizations of IPV impacts to incorporate relevant aspects of individuals' social-ecological context. Future directions and implications for prevention and intervention are discussed.

Pregnancy as a period of risk, adaptation, and resilience for mothers and infants

The pregnancy period represents a unique window of opportunity to identify risks to both the fetus and mother and to deter the intergenerational transmission of adversity and mental health problems. Although the maternal-fetal dyad is especially vulnerable to the effects of stress during pregnancy, less is known about how the dyad is also receptive to salutary, resilience-promoting influences. The present review adopts life span and intergenerational perspectives to review four key areas of research. The first part describes how pregnancy is a sensitive period for both the mother and fetus. In the second part, the focus is on antecedents of maternal prenatal risks pertaining to prenatal stress response systems and mental health. The third part then turns to elucidating how these alterations in prenatal stress physiology and mental health problems may affect infant and child outcomes. The fourth part underscores how pregnancy is also a time of heightened fetal receptivity to maternal and environmental signals, with profound implications for adaptation. This section also reviews empirical evidence of promotive and protective factors that buffer the mother and fetus from developmental and adaptational problems and covers a sample of rigorous evidence-based prenatal interventions that prevent maladaptation in the maternal-fetal dyad before babies are born. Finally, recommendations elaborate on how to further strengthen understanding of pregnancy as a period of multilevel risk and resilience, enhance comprehensive prenatal screening, and expand on prenatal interventions to promote maternal-fetal adaptation before birth.

Dyadic Profiles of Posttraumatic Stress Symptoms in Mothers and Children Experiencing Intimate Partner Violence

Children who witness intimate partner violence (IPV) develop posttraumatic stress disorder at alarmingly high rates. Research suggests that caregivers' symptoms of posttraumatic stress (PTSS) often co-occur alongside children's PTSS, a phenomenon termed "relational posttraumatic stress." The goal of this study is to use dyad-centered analyses to examine heterogeneity in relational PTSS presentations in mother-child dyads, and to determine factors differentiating relational PTSS profiles. Data were drawn from a sample of 231 IPV-exposed, ethno-racially diverse mother-child dyads, with children ranging from ages 4 to 12. The results of a latent profile analysis indicated that a two-profile model was the best fit with the data. Both profiles indicated similar levels of PTSS across the dyad; however, they differed in overall symptom severity. Parenting and IPV severity significantly predicted profile membership; however, age did not. Results suggest that similarities in PTSS presentation should be expected in mother-child dyads, at least in families who experience IPV.

Depression and Domestic Violence Experiences Among Asian Women: A Systematic Review

Purpose

To determine the association of postpartum depression with domestic violence experiences among women in Asia.

Background

Postpartum depression (PPD) is an important cause of maternal morbidity as well as mortality. There is increasing evidence that domestic violence (DV) increases the risk of PPD.

Methods

We performed literature searches using the databases PUBMED, SCOPUS, Web of Science and Google Scholar, for studies published between January 2010 and May 2019. The keywords “postpartum”, “postnatal”, “depression”, and “violence” were used. Observational studies conducted within Asia, and written in the English language, were included.

Results

In the 38 studies included in this review (with 37,087 participants), the prevalence of PPD ranged between 8.2% to 70% and that of DV between 6.1% to 67.4%. There were 1.6 to 7.1 higher odds of PPD among sufferers of DV. Intimate partner violence (IPV) was the most relevant factor that women experiencing psychological abuse (which was the most prevalent form of IPV) were more at risk for, and violence/intimidation by other family members was also associated with PPD. Domestic violence increased the risk of suicidal ideation in PPD.

Discussion

The findings of the review unequivocally shows the association between domestic violence and PPD. Maternal mental health is a neglected area of healthcare in many parts of Asia. Likewise, domestic violence is a readily recognized, but inadequately addressed social issue. We recommend that healthcare workers be trained to recognize and support the women who are vulnerable to violence and depression during pregnancy and postpartum. Policies need to be developed at national and global levels to tackle these issues with utmost urgency.

The relationship between interpersonal trauma and substance misuse in pregnancy

Background

There is a strong body of evidence supporting associations between interpersonal trauma (IPT) and substance use; however, this tends to focus on associations between childhood trauma and substance use in non-pregnant populations. Neonatal and obstetric outcomes are poorer among pregnant women with problematic substance use, yet few studies have explored IPT as a possible mechanism underlying their use of substances.

Aim

To explore the literature regarding the relationship between IPT and substance misuse among pregnant women.

Method

A systematic search of relevant databases was conducted and a narrative review of the literature was undertaken. Titles, abstracts and full articles were screened against inclusion criteria. Data were extracted and quality assessed.

Findings

A total of 15 studies were identified that suggested associations between negative life events and substance misuse in pregnant women/new mothers.

Conclusions

Although a link between IPT and substance misuse is suggested, this review has highlighted a number of important gaps in the literature that warrant further investigation. These include a paucity of UK-based studies, and a lack of research that fully explores possible associations between IPT and substance use in pregnant women. Moreover, research to date has employed quantitative methodology.

The moderating effects of traumatic stress on vulnerability to emotional distress during pregnancy

Emotional distress during pregnancy is likely influenced by both maternal history of adversity and concurrent prenatal stressors, but prospective longitudinal studies are lacking. Guided by a life span model of pregnancy health and stress sensitization theories, this study investigated the influence of intimate partner violence (IPV) during pregnancy on the association between childhood adversity and prenatal emotional distress. Participants included an urban, community-based sample of 200 pregnant women (aged 18-24) assessed annually from ages 8 to 17 for a range of adversity domains, including traumatic violence, harsh parenting, caregiver loss, and compromised parenting. Models tested both linear and nonlinear effects of adversity as well as their interactions with IPV on prenatal anxiety and depression symptoms, controlling for potential confounds such as poverty and childhood anxiety and depression. Results showed that the associations between childhood adversity and pregnancy emotional distress were moderated by prenatal IPV, supporting a life span conceptualization of pregnancy health. Patterns of interactions were nonlinear, consistent with theories conceptualizing stress sensitization through an "adaptive calibration" lens. Furthermore, results diverged based on adversity subdomain and type of prenatal IPV (physical vs. emotional abuse). Findings are discussed in the context of existing stress sensitization theories and highlight important avenues for future research and practice.

Early Childhood Victimization and Physical Intimate Partner Violence During Pregnancy: A Developmental and Person-Oriented Approach

Intimate partner violence (IPV) victimization during pregnancy is a major public health concern, yet little is known about how risk factors for IPV during pregnancy may depend on whether women have histories of victimization dating back to early childhood (ages 0-5 years). This study examined whether risk factors for physical IPV victimization during pregnancy (a pregnancy that was not planned and prenatal substance use) differed for women with versus without early childhood victimization. Participants were 236 ethnically diverse, low-income biological mothers ( M = 30.94 years; 50.0% Latina, 16.9% Caucasian, 13.1% African American, and 16.9% multiracial) of children aged 0 to 6 years. Mothers were classified into four groups based on whether they had experienced early childhood victimization and physical IPV victimization during pregnancy with the target child. Multinomial logistic regressions, controlling for demographic characteristics, examined whether a pregnancy not planned and prenatal substance use predicted group membership. Compared to mothers with early victimization only, mothers with both early childhood victimization and physical IPV during pregnancy were more than 3 times as likely to report that their pregnancy with the target child was not planned. In follow-up analyses, mothers with early victimization and physical IPV during pregnancy also reported higher lifetime parity than mothers with physical IPV during pregnancy but no early victimization. Early childhood victimization may place women on a risk pathway to physical IPV during pregnancy, particularly if the pregnancy is not planned. Prevention and policy efforts should screen women for early childhood victimization to understand risks for physical IPV during pregnancy.

Development of a prenatal program for adults with personal histories of childhood abuse or neglect: a Delphi consensus consultation study

INTRODUCTION

Pregnancy and the birth of a child present particular challenges for adults with personal histories of childhood abuse or neglect. However, few prenatal interventions address the specific needs of this population. This research aims to determine a list of actions that should be achieved during group interventions designed for expectant parents who experienced childhood trauma.

METHODS

Fifteen stakeholders representing nine different Quebec health care and community organizations that work with families and/or trauma survivors participated in a Delphi process in two rounds. In round 1, three project leaders identified, from clinical and empirical literature, a set of 36 actions relevant for expectant parents who experienced childhood trauma. Using an anonymized online survey, stakeholders coded how important they considered each action and whether they were already conducting similar interventions in their clinical setting. Stakeholders subsequently participated in a one-day in-person meeting during which they discussed the pertinence of each action, proposed new ones and refined them. This was followed by a second anonymized online survey (round 2). A consensus was reached among the stakeholders regarding a final list of 22 actions.

RESULTS

Two central clusters of actions emerged from the consultation process: actions aiming to support mentalization about self and parenthood, and actions aiming to support mentalization of trauma.

CONCLUSION

The Delphi process helped to identify what should be the core of a prenatal intervention targeting adults who experienced childhood trauma, from the viewpoint of professionals who will ultimately deliver such a program.

Integrative Review of Pregnancy Health Risks and Outcomes Associated With Adverse Childhood Experiences

OBJECTIVE

To identify pregnancy risk factors and outcomes associated with a woman's history of adverse childhood experiences (ACEs) and summarize what is known about routine screening for ACEs as part of prenatal care.

DATA SOURCES

The Academic Search Premier, Academic Search Complete, CINAHL, Health Source: Nursing Academic Edition, MEDLINE, PsychINFO, and PubMed databases were searched. The terms adverse childhood experiences or ACEs, trauma informed care, and childhood trauma were each paired individually with the terms pregnancy or pregnant or prenatal or antenatal or perinatal or maternal; obstetrics; and maternal-child health.

STUDY SELECTION

Database and reference list searches resulted in 1,626 articles with 230 retained for full review and 17 included in the final sample. Studies were included if results were reported specific to pregnancy and ACEs as operationally defined in the ACE Study.

DATA EXTRACTION

Studies were evaluated for methodologic quality using Joanna Briggs Institute appraisal tools. Data were extracted with the matrix method. Tabular synthesis was used to cluster and compare findings and identify themes.

DATA SYNTHESIS

Five categories of pregnancy health risks and outcomes related to ACEs were identified: physiologic risk, psychologic risk, social risk, behavioral risk, and negative pregnancy outcomes. Limited research was found on routine screening for ACEs as part of prenatal care, but findings indicated women's support for ACE screening during prenatal appointments.

CONCLUSION

Routine prenatal ACE screening may be accepted by women and may help identify significant pregnancy health risks. This could provide opportunities for interventions that improve pregnancy outcomes. More research is needed to determine the most effective and efficient methods to screen pregnant women for ACEs and intervene for those with high screening scores. To optimally advance science in this area, conceptual and operational clarity in ACE research is important. Nurses should be at the forefront of these research and practice translation efforts.

Correlates of Perinatal Post-Traumatic Stress among Culturally Diverse Women with Depressive Symptomatology

Post-traumatic stress disorder (PTSD) is an important and often neglected comorbidity of pregnancy; left untreated, it can lead to serious health complications for the mother and developing fetus. Structured interviews were conducted to identify risk factors of PTSD among culturally diverse women with depressive symptomatology receiving perinatal services at community obstetric/gynecologic clinics. Women abused as adults, with two or more instances of trauma, greater trauma severity, insomnia, and low social support were more likely to present perinatal PTSD symptoms. Perinatal PTSD is prevalent and has the potential for chronicity. It is imperative healthcare providers recognize salient risk factors and integrate culturally sensitive screening, appropriate referral, and treatment services for perinatal PTSD.

Adverse Childhood Experiences and Mental and Behavioral Health Conditions During Pregnancy: The Role of Resilience

INTRODUCTION

Little is known about how exposure to adverse childhood experiences (ACEs) and protective factors, such as resilience, influence prenatal mental and behavioral health. This study examined associations between exposure to ACEs and mental and behavioral health during pregnancy overall and among women with high versus low levels of resilience.

MATERIALS AND METHODS

Women in two Kaiser Permanente Northern California medical centers were screened for ACEs and resilience during prenatal care (∼14-23 weeks of gestation; N = 355). Multivariable logistic regression analyses examined associations between ACEs and prenatal mental and behavioral health conditions overall and for women with low (≤32) versus high (>32) resilience on the 10-item Connor-Davidson Resilience Scale.

RESULTS

Overall, 54% of women reported 0 ACEs, 28% 1-2 ACEs, and 18% 3+ ACEs. Relative to women with 0 ACEs, those with 1-2 ACEs had higher odds of an anxiety or depressive disorder and intimate partner violence (IPV) (odds ratios [ORs] 2.42-3.12, p < 0.05), and those with 3+ ACEs had higher odds of an anxiety or depressive disorder, depression symptoms, and IPV (ORs 3.08-4.71, p < 0.05). In stratified analyses by high (56%) and low (44%) resilience, having one or more ACEs (vs. 0 ACEs) was only associated with worse mental and behavioral health in women with low resilience.

CONCLUSIONS

ACEs predicted mental and behavioral health conditions among pregnant women, and associations were the strongest among women with low levels of current resilience. Longitudinal research is needed to understand the causal mechanisms underlying these associations.

Perinatal Intimate Partner Violence

This article reviews the prevalence and outcomes of perinatal intimate partner violence (IPV). Reported rates of perinatal IPV range from 3.7% to 9.0%. Perinatal IPV is associated with a multitude of mental and obstetric health outcomes that affect the mother and child. Perinatal medical providers have an opportunity to detect victims of IPV and facilitate services for this population. Screening, safety planning, and referral procedures are essential for addressing this public health problem.

Relación entre la violencia contra la mujer y el índice de masa corporal: revisión integradora

Objetivo: el propósito de esta revisión es conocer la evidencia científica existente de la relación entre la violencia contra la mujer (VCM) y su índice de masa corporal (IMC) (alto y bajo).Síntesis del contenido: se realizó una revisión integradora de las publicaciones científicas que abordaran y relacionaran la VCM y el IMC en diferentes bases de datos. Se consideraron los siete pasos de Cooper. Se analizaron por título, año de publicación, autores y fuente; finalmente, se estudiaron los aspectos metodológicos. Se identificaron 85 artículos y se excluyeron 67 por no cumplir con los criterios de inclusión. De los artículos incluidos en la revisión, 5 reportaron correlación positiva y significativa entre la VCM con el índice de masa corporal alto (sobrepeso/obesidad). Asimismo, 6 de los artículos refieren una relación positiva entre la VCM y el IMC bajo; es decir, a mayor violencia, se reporta un IMC alto. Pero, también, 1 reporta una relación negativa y significativa; es decir, a menor violencia, menor el IMC de las mujeres.Conclusión: los resultados encontrados muestran la existencia escasa literatura científica que aborde la temática de la VCM y el IMC. Algunos estudios muestran la relación entre la VCM y el IMC alto y bajo. Los resultados no son concluyentes, por lo que se requiere generar líneas de acción y atención a las mujeres receptoras de los diferentes tipos de violencia.

Positive childhood experiences predict less psychopathology and stress in pregnant women with childhood adversity: A pilot study of the benevolent childhood experiences (BCEs) scale

This pilot study examined the psychometric properties of the Benevolent Childhood Experiences (BCEs) scale, a new instrument designed to assess positive early life experiences in adults with histories of childhood maltreatment and other adversities. A counterpart to the Adverse Childhood Experiences (ACEs) questionnaire, the BCEs was developed to be multiculturally-sensitive and applicable regardless of socioeconomic position, urban-rural background, or immigration status. Higher levels of BCEs were hypothesized to predict lower levels of psychopathology and stress beyond the effects of ACES in a sample of ethnically diverse, low-income pregnant women. BCEs were also expected to show adequate internal validity across racial/ethnic groups and test-retest stability from the prenatal to the postnatal period. Participants were 101 pregnant women (M=29.10years, SD=6.56, range=18-44; 37% Latina, 22% African-American, 20% White, 21% biracial/multiracial/other; 37% foreign-born, 26% Spanish-speaking) who completed the BCEs and ACEs scales; assessments of prenatal depression and post-traumatic stress disorder (PTSD) symptoms, perceived stress, and exposure to stressful life events (SLEs) during pregnancy; and demographic information. Higher levels of BCEs predicted less PTSD symptoms and SLEs, above and beyond ACEs. The BCEs showed excellent test-retest reliability, and mean levels were comparable across racial/ethnic and Spanish-English groups of women. Person-oriented analyses also showed that higher levels of BCEs offset the effects of ACEs on prenatal stress and psychopathology. The BCEs scale indexes promising promotive factors associated with lower trauma-related symptomatology and stress exposure during pregnancy and illuminates how favorable childhood experiences may counteract long-term effects of childhood adversity.

The Association of Maternal Exposure to Domestic Violence During Childhood With Prenatal Attachment, Maternal-Fetal Heart Rate, and Infant Behavioral Regulation

Human and animal models suggest that maternal hormonal and physiological adaptations during pregnancy shape maternal brain functioning and behavior crucial for offspring care and survival. Less sensitive maternal behavior, often associated with psychobiological dysregulation and the offspring's behavioral and emotional disorders, has been observed in mothers who have experienced adverse childhood experiences. Strong evidence shows that children who are exposed to domestic violence (DV) are at risk of being abused or becoming abusive in adulthood. Yet little is known about the effect of childhood exposure to DV on the expecting mother, her subsequent caregiving behavior and related effects on her infant. Thus, the present study examined the association of maternal exposure to DV during childhood on prenatal maternal attachment, maternal heart rate reactivity to an infant-crying stimulus and post-natal infant emotional regulation. Thirty-three women with and without exposure to DV during childhood were recruited during the first trimester of pregnancy and followed until 6-month after birth. The Maternal Antenatal Attachment Scale (MAAS) was used to measure prenatal attachment of the mother to her fetus during the second trimester of pregnancy, maternal and fetal heart rate reactivity to an infant-crying stimulus was assessed at the third trimester of pregnancy, and the Infant Behavior Questionnaire-Revised (IBQ-R) was used to assess infant emotional regulation at 6-months. Results showed that pregnant women that were exposed to DV during childhood had a poorer quality of prenatal attachment of mother to fetus, regardless of whether they also experienced DV during adulthood. In addition, maternal exposure to DV during childhood was associated with increased maternal heart rate to infant-crying stimulus and worse infant emotional regulation. These findings highlight the importance of prenatal screening for maternal exposure to DV during childhood as a risk factor for disturbances in the development of maternal attachment, dysfunctional maternal behavior and emotion dysregulation.

Childhood physical and sexual abuse experiences associated with post-traumatic stress disorder among pregnant women

PURPOSE

We sought to evaluate the extent to which childhood physical and/or sexual abuse history is associated with post-traumatic stress disorder (PTSD) during early pregnancy and to explore the extent to which the childhood abuse-PTSD association is mediated through, or modified by, adult experiences of intimate partner violence (IPV).

METHODS

In-person interviews collected information regarding history of childhood abuse and IPV from 2,928 women aged 18-49 years old prior to 16 weeks of gestation. PTSD was assessed using the PTSD Checklist-Civilian Version. Multivariate logistic regressions were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Compared to women with no childhood abuse, the odds of PTSD were increased 4.31-fold for those who reported physical abuse only (95% CI, 2.18-8.49), 5.33-fold for sexual abuse only (95% CI, 2.38-11.98), and 8.03-fold for those who reported physical and sexual abuse (95% CI, 4.10-15.74). Mediation analysis showed 13% of the childhood abuse-PTSD association was mediated by IPV. Furthermore, high odds of PTSD were noted among women with histories of childhood abuse and IPV compared with women who were not exposed to either (OR = 20.20; 95% CI, 8.18-49.85).

CONCLUSIONS

Childhood abuse is associated with increased odds of PTSD during early pregnancy. The odds of PTSD were particularly elevated among women with a history of childhood abuse and IPV. Efforts should be made to prevent childhood abuse and mitigate its effects on women's mental health.

Intimate partner violence and anxiety disorders in pregnancy: the importance of vocational training of the nursing staff in facing them

OBJECTIVE

to identify the relationship between posttraumatic stress disorder, trait and state anxiety, and intimate partner violence during pregnancy.

METHOD

observational, cross-sectional study developed with 358 pregnant women. The Posttraumatic Stress Disorder Checklist - Civilian Version was used, as well as the State-Trait Anxiety Inventory and an adapted version of the instrument used in the World Health Organization Multi-country Study on Women's Health and Domestic Violence.

RESULTS

after adjusting to the multiple logistic regression model, intimate partner violence, occurred during pregnancy, was associated with the indication of posttraumatic stress disorder. The adjusted multiple linear regression models showed that the victims of violence, in the current pregnancy, had higher symptom scores of trait and state anxiety than non-victims.

CONCLUSION

recognizing the intimate partner violence as a clinically relevant and identifiable risk factor for the occurrence of anxiety disorders during pregnancy can be a first step in the prevention thereof.

Current Reports on Perinatal Intimate Partner Violence

PURPOSE OF REVIEW

The purpose of this study was to review the literature on perinatal intimate partner violence, focusing on recent knowledge to guide mental health professionals on the best approaches to identify and treat women exposed to perinatal intimate partner violence.

RECENT FINDINGS

Risk factors have been broadened from individual victim and perpetrator factors to include relationship, community, and societal factors which interact together. Better information is now available on how to identify, document, and treat women exposed to violence around the time of conception, pregnancy, and the postpartum period. Recent information helps psychiatrists and other mental health professionals assist women exposed to violence related to the perinatal period; however, further research is needed to provide improved evidence for optimal interventions for better patient outcomes.

Childhood Maltreatment and Perinatal Mood and Anxiety Disorders: A Systematic Review

Perinatal mood and anxiety disorders (PMADs) compromise maternal and child well-being and may be influenced by traumatic experiences across the life course. A potent and common form of trauma is childhood maltreatment, but its specific impact on PMADs is not well understood. A systematic review was undertaken to synthesize empirical literature on the relationship between maternal histories of childhood maltreatment and PMADs. Of the 876 citations retrieved, 35 reports from a total of 26,239 participants met inclusion criteria, documenting substantial rates of childhood maltreatment and PMADs. Robust trends of association were observed between childhood maltreatment and perinatal depression, as well as post-traumatic stress disorder, but findings for anxiety were less consistent. Examining multivariate results suggested that childhood maltreatment predicts PMADs above and beyond sociodemographic, psychiatric, perinatal, and psychosocial factors, but may also be partially mediated by variables such as later victimization and moderated by protective early relationships. Future research should test mediating and moderating pathways using prospective cohorts, expanding to cross-cultural settings and other disorder outcomes. Treatment and prevention of childhood maltreatment and its sequelae may help mitigate risk for perinatal psychopathology and its impact on maternal and child outcomes.

Physical, Sexual, Emotional and Economic Intimate Partner Violence and Controlling Behaviors during Pregnancy and Postpartum among Women in Dar es Salaam, Tanzania

Background

Intimate partner violence (IPV) during pregnancy and postpartum is a serious global health problem affecting millions of women worldwide. This study sought to determine the prevalence of different forms of IPV during pregnancy and postpartum and associated factors among women in Dar es Salaam, Tanzania.

Methods

We conducted a cross-sectional study among 500 women at one to nine months postpartum in three health facilities in the three districts of Dar es Salaam: Temeke, Kinondoni and Illala. Two trained research assistants administered the questionnaire, which aimed to examine sociodemographic characteristics and different forms of IPV.

Results

Of the 500 women who were interviewed, 18.8% experienced some physical and/or sexual violence during pregnancy. Forty-one women (9%) reported having experienced some physical and/or sexual violence at one to nine months postpartum. Physical and/or sexual IPV during pregnancy was associated with cohabiting (AOR 2.2, 95% CI 1.24–4.03) and having a partner who was 25 years old or younger (AOR 2.7, 95% CI 1.08–6.71). Postpartum, physical and/or sexual IPV was associated with having a partner who was 25 years old or younger (AOR 4.4, 95% CI 1.24–15.6).

Conclusion

We found that IPV is more prevalent during pregnancy than during the postpartum phase. There is also continuity and maintenance of IPV during and after pregnancy. These results call for policy and interventions to be tailored for pregnant and postpartum women.

Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives

BACKGROUND

Midwives frequently witness traumatic birth events. Little is known about responses to birth trauma and prevalence of posttraumatic stress among Australian midwives.

AIM

To assess exposure to different types of birth trauma, peritraumatic reactions and prevalence of posttraumatic stress.

METHODS

Members of the Australian College of Midwives completed an online survey. A standardised measure assessed posttraumatic stress symptoms.

FINDINGS

More than two-thirds of midwives (67.2%) reported having witnessed a traumatic birth event that included interpersonal care-related trauma features. Midwives recalled strong emotions during or shortly after witnessing the traumatic birth event, such as feelings of horror (74.8%) and guilt (65.3%) about what happened to the woman. Midwives who witnessed birth trauma that included care-related features were significantly more likely to recall peritraumatic distress including feelings of horror (OR=3.89, 95% CI [2.71, 5.59]) and guilt (OR=1.90, 95% CI [1.36, 2.65]) than midwives who witnessed non-interpersonal birth trauma. 17% of midwives met criteria for probable posttraumatic stress disorder (95% CI [14.2, 20.0]). Witnessing abusive care was associated with more severe posttraumatic stress than other types of trauma.

DISCUSSION

Witnessing care-related birth trauma was common. Midwives experience strong emotional reactions in response to witnessing birth trauma, in particular, care-related birth trauma. Almost one-fifth of midwives met criteria for probable posttraumatic stress disorder.

CONCLUSION

Midwives carry a high psychological burden related to witnessing birth trauma. Posttraumatic stress should be acknowledged as an occupational stress for midwives. The incidence of traumatic birth events experienced by women and witnessed by midwives needs to be reduced.

Maladaptive coping mediates the influence of childhood trauma on depression and PTSD among pregnant women in South Africa

Antenatal mental disorders compromise maternal and child health, and women who have experienced childhood trauma may be at increased risk for such disorders. One hypothesis is that early trauma leads to the development and use of maladaptive coping strategies as an adult, which in turn could predict mental health difficulties during stressful transitions such as pregnancy. To test this hypothesis, this study examined the relationship between childhood trauma and mental health (depression, PTSD) in a sample of 84 pregnant women seeking antenatal care in Cape Town, South Africa, and explored whether maladaptive coping mediated this relationship. The majority of women (62 %) met established criteria for antenatal depression and 30 % for antenatal PTSD; in addition, 40 % reported a history of childhood trauma. Childhood trauma, especially childhood sexual abuse and emotional abuse, was significantly associated with depression and PTSD. The relationships between childhood trauma and depression and PTSD were significantly mediated by maladaptive coping, even when adjusted for the woman's age, gestational age, and HIV status. Findings highlight the need for coping-based interventions to prevent and treat antenatal mental disorders among women with childhood trauma, particularly in high-trauma settings such as South Africa.

[Child abuse and parenting]

Maltreatment suffered during childhood has long-term consequences which risk impacting on parenthood. Supporting victims of violence in childhood as they adapt to parenthood represents a challenge for health professionals working in perinatal services.

Another step closer to measuring the ghosts in the nursery: preliminary validation of the Trauma Reflective Functioning Scale

The aim of this study was to examine preliminary evidence of the validity of the Trauma Reflective Functioning Scale and to investigate reflective functioning (RF) and attachment in pregnant women with histories of trauma, with a particular focus on the capacity to mentalize regarding trauma and its implications for adaptation to pregnancy and couple functioning. The Adult Attachment Interview was used to assess attachment, unresolved trauma and mentalization (measured as RF) regarding relationships with attachment figures (RF-G) and trauma (RF-T) in 100 pregnant women with histories of abuse and neglect. The majority (63%) of women had insecure attachment states of mind and approximately half were unresolved regarding trauma. Furthermore, the majority of women manifested deficits specific to RF-T. Their RF-T was significantly lower than their RF-G; the findings indicate that women with histories of childhood abuse and neglect do not manifest a generic inhibition of reflectiveness, but a collapse of mentalization specific to trauma. Low RF-T, indicative of difficulty in considering traumatic experiences in mental state terms, was associated with difficulty in investment in the pregnancy and lack of positive feelings about the baby and motherhood. In addition, low RF-T was also associated with difficulties in intimate relationships. Results of a regression analysis with RF indicated that RF-T was the best predictor of investment in pregnancy and couple functioning. In sum, the study provides preliminary evidence that RF-T can be reliably measured and is a valid construct that has potential usefulness for research and clinical practice. It highlights the importance of mentalization specifically about trauma and suggests that it is not the experience of trauma per se, but the absence of mentalization regarding trauma that is associated with difficulties in close relationships and in making the transition to parenthood.

Intimate partner violence during pregnancy: maternal and neonatal outcomes

The effects of intimate partner violence (IPV) on maternal and neonatal outcomes are multifaceted and largely preventable. During pregnancy, there are many opportunities within the current health care system for screening and early intervention during routine prenatal care or during episodic care in a hospital setting. This article describes the effects of IPV on maternal health (e.g., insufficient or inconsistent prenatal care, poor nutrition, inadequate weight gain, substance use, increased prevalence of depression), as well as adverse neonatal outcomes (e.g., low birth weight [LBW]), preterm birth [PTB], and small for gestational age [SGA]) and maternal and neonatal death. Discussion of the mechanisms of action are explored and include: maternal engagement in health behaviors that are considered "risky," including smoking and alcohol and substance use, and new evidence regarding the alteration of the hypothalamic-pituitary-adrenal axis and resulting changes in hormones that may affect LBW and SGA infants and PTB. Clinical recommendations include a commitment for routine screening of IPV in all pregnant women who present for care using validated screening instruments. In addition, the provision of readily accessible prenatal care and the development of a trusting patient-provider relationship are first steps in addressing the problem of IPV in pregnancy. Early trials of targeted interventions such as a nurse-led home visitation program and the Domestic Violence Enhanced Home Visitation Program show promising results. Brief psychobehavioral interventions are also being explored. The approach of universal screening, patient engagement in prenatal care, and targeted individualized interventions has the ability to reduce the adverse effects of IPV and highlight the importance of this complex social disorder as a top priority in maternal and neonatal health.

Intimate partner violence and infant socioemotional development: the moderating effects of maternal trauma symptoms

The aim of the present study was to investigate the impact of intimate partner violence (IPV) on infant regulatory difficulties at 3 months of age and infant socioemotional problems at 12 months of age. Maternal trauma symptoms were explored as potential moderators of these associations. Participants included 120 primarily low-income, ethnically diverse women and their infants. Results revealed that infants whose mothers experienced IPV during pregnancy did not have significantly more regulatory difficulties at 3 months than did infants whose mothers did not experience prenatal IPV. However, infants whose mothers experienced IPV during the first year after birth displayed significantly more socioemotional problems at 12 months, as evidenced by both maternal report and observational data. Furthermore, maternal posttraumatic stress avoidance symptoms served as a moderator of the association between prenatal IPV and infant regulatory difficulties at 3 months whereas maternal posttraumatic stress hyperarousal and reexperiencing symptoms served as moderators of the association between IPV during the first year after birth and infant socioemotional problems at 12 months. The findings highlight the detrimental impact that IPV can have on very young children and the importance of maternal trauma symptoms as a context for understanding the effect of IPV on young children's functioning.