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Intimate partner abuse before and during pregnancy as risk factors for postpartum mental health problems Desmarais, Sarah L; Pritchard, Ashley; Lowder, Evan M; Janssen, Patricia A Apr 7, 2014

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RESEARCH ARTICLE Open AccessIntimate partner abuse before and duringpregnancy as risk factors for postpartummental health problemsSarah L Desmarais1*, Ashley Pritchard2, Evan M Lowder1 and Patricia A Janssen3AbstractBackground: Although research has established the profound effects that intimate partner abuse can have onpostpartum mental health, little is known regarding how this association may change as a function of the timingand type of abuse. This study examined associations of psychological, physical and sexual abuse experienced asadults before and during pregnancy with symptoms of postpartum mental health problems in a non-clinicalsample of women.Methods: English-speaking mothers aged 18 years and older in the metropolitan area of a large, Western Canadiancity were recruited to participate in a study of women’s health after pregnancy. The study was advertised inhospitals, local newspapers, community venues, and relevant websites. One-hundred women completed standardized,self-report questionnaires during semi-structured interviews conducted by female research assistants at approximately2 months postpartum. In addition to questions about their general health and well-being, participants answeredquestions about their experiences of intimate partner abuse and about their mental health during the postpartumperiod.Results: Almost two-thirds (61.0%) of women reported postpartum mental health symptoms above normal levels,with 47.0% reporting symptoms at moderate or higher levels. The majority reported some form of intimate partnerabuse before pregnancy (84.0%) and more than two-thirds (70.0%), during pregnancy; however, the abuse was typicallyminor in nature. Multivariate models revealed that women who experienced intimate partner abuse—whether beforeor during pregnancy—reported higher levels of postpartum mental health problems; however, associations differedas a function of the timing and type of abuse, as well as specific mental health symptoms. Multivariate models alsoshowed that as the number of types of intimate partner abuse experienced increased, so did the negative effects onpostpartum mental health.Conclusions: Results of this study provide further evidence that intimate partner abuse is a risk factor for postpartummental health problems. They also underscore the complex risks and needs associated with intimate partner abuseamong postpartum women and support the use of integrated approaches to treating postpartum mental healthproblems. Future efforts should focus on the extent to which strategies designed to reduce intimate partner abusealso improve postpartum mental health and vice versus.Keywords: Intimate partner abuse, Psychological aggression, Physical assault, Sexual coercion, Postpartum mentalhealth, Stress, Anxiety, Depression, Obsessive-compulsive disorder, Posttraumatic stress disorder* Correspondence: sdesmarais@ncsu.edu1Department of Psychology, North Carolina State University, Campus Box7650, Raleigh NC 27695-7650, USAFull list of author information is available at the end of the article© 2014 Desmarais et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly credited.Desmarais et al. BMC Pregnancy and Childbirth 2014, 14:132http://www.biomedcentral.com/1471-2393/14/132BackgroundPostpartum mental health problems are major publichealth issues with significant implications for maternaland child health [1]. Indeed, this is the period duringwhich women demonstrate the highest incidence ofcommon mental disorders [2-4]. The most prevalent post-partum mental health problem is postpartum depression,affecting between 10% and 15% of new mothers [5-7].However, women also are at heightened risk postpartumfor other mental health problems, such as generalizedanxiety disorder, obsessive-compulsive disorder and post-traumatic stress disorder, as well as psychosis [8-13].Research has documented the profound effects untreatedpostpartum mental health problems can have on familiesand children [14]. Postpartum depression, for example,has been associated with early breastfeeding discontinu-ation [15], and untreated mental health problems havebeen associated with bonding impairment and fewerpositive parenting behaviors [16]. Moreover, impairedinteractions between mother(s) and children have beenassociated with long-term impairments in children’s cog-nitive and emotional development [14]. They also increaserisk for maternal engagement in other risky behaviors,such as substance abuse and self-harm [17,18]. As a result,there is a need for improved knowledge and identificationof risk factors for postpartum mental health problems,such as intimate partner abuse [19].Intimate partner abuse includes “any behaviour withina current or past intimate relationship that involves(actual, attempted, or threatened) harm… that may im-pact or detract from the victim’s physical, psychological,sexual, economic, or spiritual well-being” [20]. Acrossstudies, prevalence of intimate partner abuse duringpregnancy has ranged anywhere from 0.9% to 20.1% [21],with variability attributable to differences in study designs,such as inclusion criteria, sample characteristics, responserates, modes of inquiry, assessment tools, and operationaldefinitions of intimate partner abuse [22,23]. Recentpopulation-based studies have estimated the prevalence ofphysical and sexual violence during pregnancy to bebetween 8.5% and 10.9% [22,24,25]. Overall, studies con-verge on the finding that risk for physical forms of intim-ate partner abuse is lower during pregnancy compared toother periods in women’s lives [26,27]. However, someresearch suggests relative risk during pregnancy comparedto other timeframes may differ by type of intimate partnerabuse; for example, one study of 914 pregnant womentreated in health clinics in Mexico found increases in ratesof emotional abuse during pregnancy, but decreases inrates of physical and sexual abuse [28].Importantly, the postpartum period may be a particu-larly vulnerable time for experiencing harms associatedwith intimate partner abuse, with many prior studies em-phasizing the physical effects of intimate partner abuse onmaternal and child health [29-31]. A small but growingbody of research describes postpartum mental health risksassociated with intimate partner abuse [32-35]. Forexample, a recent study found that women exposedto intimate partner abuse during pregnancy (includingphysical, sexual, emotional, financial and neglect) reportedrates of depression, anxiety, and stress that were appro-ximately twice the rates reported by mothers who did notexperience intimate partner abuse [36]. Another studyreported that mothers of infants under 14 months report-ing intimate partner abuse (defined as threat of physicalharm, physical assault or forced sex) in the past 12 months(which may or may not have included pregnancy) weremore likely to be diagnosed with depressive and panic dis-orders [9]. Examined much less frequently, psychologicalabuse in an intimate relationship also has been tied todepression during pregnancy [37]. Few studies, however,have reported effects of psychological aggression disaggre-gated from the effects of other forms of intimate partnerabuse [32]. Importantly, fear associated with intimate part-ner abuse during pregnancy—independent of the abuseitself—has physical (e.g., urinary incontinence) and psycho-logical (e.g., anxiety) consequences [38].Despite advances in our understanding of the postpar-tum mental health risks associated with intimate partnerabuse, extant findings are limited in several ways. Forinstance, the associations of psychological, physical andsexual intimate partner abuse with diverse postpartummental health problems have been examined infrequently.When examined, studies have focused on one postpartummental health problem, most commonly postpartumdepression, to the exclusion of others [32,39]. Whenassociations between intimate partner abuse and diversepostpartum mental health symptoms have been examined,researchers have focused on one type of abuse, typicallyphysical assault [27], or have combined findings acrosstypes of intimate partner abuse [9]. In fact, a recent reviewfound that more than two-thirds of existing studies reporton the effects of physical violence on postpartum mentalhealth, with fewer than half of the extant studies reportingeffects by type of abuse [32]. In these studies, the defin-ition of “postpartum” also has varied considerably withinand between studies, ranging anywhere from one to12 months or more after childbirth [30,32,36,9]; research,however, suggests the first three months postpartum is thehighest risk period for the development of mental healthproblems [8,40,41].Additionally, few studies have compared the effects ofintimate partner abuse experienced during different pe-riods of women’s lives—and before and during pregnancy,specifically—on postpartum mental health outcomes inthe same sample of women [33,34]. This point should notbe overlooked as intimate partner abuse may be differen-tially associated with postpartum mental health problemsDesmarais et al. BMC Pregnancy and Childbirth 2014, 14:132 Page 2 of 12http://www.biomedcentral.com/1471-2393/14/132as a function of the timing of abuse. To demonstrate, find-ings of a recent meta-analysis suggest that higher rates ofpostpartum depression may be associated with abuseexperienced during compared to before pregnancy [32].When different time frames of abuse have been con-sidered, study samples often comprised women alreadyidentified as being at-risk, such as urban, low incomewomen [39] or first time, low income mothers [27]; assuch, generalizability to other populations is unknown.Results of this meta-analysis also suggested differences inassociations between intimate partner abuse and specificpostpartum mental health problems: rates of postpartumdepression appear to be higher than rates of anxietyamong women who experienced intimate partner abuse atsome time in their lives, though direct comparisons werenot possible.Importantly, an increased understanding of how associa-tions between intimate partner abuse and postpartum men-tal health may differ as a function of the timing of abuse,type of abuse, and specific symptoms can be used to informtargeted intervention strategies. Thus, there is a need for re-search examining the differential effects of intimate partnerabuse experienced before and during pregnancy on post-partum mental health outcomes in a non-clinical sample.The present studyTo address these knowledge gaps, we explored the rela-tionship between intimate partner abuse on postpartummental health problems in a non-clinical, community-based sample of new mothers using a cross-sectional,retrospective design. Specifically, we examined the effectsof psychological, physical and sexual abuse experienced asadults before and during pregnancy on symptoms ofstress, anxiety, depression, obsessive compulsive disorderand posttraumatic stress disorder within the first threemonths postpartum. Our specific research questions were:1. Do women who have experienced intimate partnerabuse as adults before or during pregnancy havehigher levels of postpartum mental health symptomsthan women who have not experienced intimatepartner abuse during these time frames?2. Do associations between intimate partner abuseand postpartum mental health symptoms differas a function of the timing of abuse (i.e., before orduring pregnancy), type of abuse (i.e., psychological,physical, or sexual), or specific mental health problem(stress, anxiety, depression, obsessive compulsivedisorder, and posttraumatic stress disorder)?3. Are there cumulative effects of intimate partnerabuse on postpartum mental health symptoms,such that severity of postpartum mental healthsymptoms increases as women experience moretypes of abuse?MethodsThe Research Ethics Boards of the University of BritishColumbia, the Children’s and Women’s Health Centre ofBritish Columbia, and the Vancouver Coast HealthResearch Institute approved this study. All participantsprovided written informed consent.Study population and recruitmentThe study population was English-speaking mothersaged 18 years and older in the metropolitan area of alarge, western Canadian city who were within threemonths postpartum. Women were recruited to partici-pate in a one-time interview of factors that may affectwomen’s health and well-being after pregnancy. Thestudy was advertised in area hospitals, local newspapers,and community venues frequented by new mothers (e.g.,recreational centers, yoga and fitness studios, commu-nity centers, women’s centers), as well as on websitestargeting new mothers and on websites of other relevantorganizations (e.g., community websites). The recruitmentmaterials did not specify a focus on intimate partner abuseor mental health, but rather described a broad interest inexperiences occurring before and during pregnancy thatmay be associated with health and well-being after preg-nancy. In total, 100 women participated in the study.MeasuresDepression, Anxiety and Stress Scales (DASS-21)The DASS-21 [42] is a 21-item self-report questionnairedesigned to measure the severity of a range of symptomcommon to depression, anxiety, and tension/stress. Eachof the three DASS-21 scales contains seven items. Re-spondents use a 4-point scale to rate the extent to whichthey have experienced each state over the past week.Each item is scored from 0 (did not apply to me at all)to 3 (applied to me very much or most of the time).Scores for Depression, Anxiety and Stress are calculatedby summing relevant item ratings and multiplying by afactor of two. Total scores are calculated in the sameway, using all items. In the present study, reliability ofthe scale scores ranged from adequate (α = .67 for Anxiety)to excellent (α = .87 for Stress). Reliability of the totalscores was excellent (α = .89).Severity of symptomatology was calculated for eachsubscale following the guidelines provided by the DASS-21 developers [42]. Specifically, for the Depression scale,scores from 0–9 indicate normal levels of depressivesymptoms; scores of 10–13 indicate mild symptoms;scores of 14–20 indicate moderate symptoms; scores of21–27 indicate severe symptoms; and scores greater orequal to 28 indicate extreme symptoms. For the Anxietyscale, scores from 0–7 indicate normal levels of depressivesymptoms; scores of 8–9 indicate mild symptoms; scoresof 10–14 indicate moderate symptoms; scores of 15–19Desmarais et al. BMC Pregnancy and Childbirth 2014, 14:132 Page 3 of 12http://www.biomedcentral.com/1471-2393/14/132indicate severe symptoms; and scores greater or equal to20 indicate extreme symptoms. For the Stress scale, scoresfrom 0–7 indicate normal levels of depressive symptoms;scores of 8–9 indicate mild symptoms; scores of 10–14indicate moderate symptoms; scores of 15–19 indicatesevere symptoms; and scores greater or equal to 20 indicateextreme symptoms.Yale-Brown Obsessive-Compulsive Scale (YBOCS)The YBOCS [43,44] measures the presence and severityof obsessive-compulsive disorder symptoms. The instru-ment is divided into the Obsessions scale and the Com-pulsions scale. For each scale, five aspects of obsessiveand compulsive pathology are each rated on a scaleranging from 0 (no symptoms) to 4 (extreme symptoms):time spent, degree of interference, distress, resistance(greater resistance is assigned lower scores), and per-ceived control over the symptom. Subscale scores aresummed to yield a total score. In the present study,reliability of the Obsessions and Compulsions scales wasexcellent (both α = .90), as was reliability of the totalscores (α = .93).As for the DASS-21, severity of obsessive-compulsivedisorder symptomatology can be calculated using theYBOCS total scores following the guidelines provided bythe instrument developers [43,44]. Specifically, scoresfrom 0–7 indicate subclinical levels of obsessive-compul-sive disorder symptoms; scores of 8–15 indicate mildsymptoms; scores of 16–23 indicate moderate symptoms;scores of 24–31 indicate severe symptoms; and scoresgreater or equal to 32 indicate extreme symptoms.Posttraumatic Stress Disorder Symptom Scale (PSS-SR)The PSS-SR [45] is a 17-item self-report measuringposttraumatic stress disorder symptomatology which dir-ectly corresponds to Diagnostic and Statistical Manualof Mental Disorders-III-Revised (DSM-III-R) criteria.For all items, symptom frequency over the precedingtwo weeks is reported on a 4-point scale, where 0 = notat all, 1 = once per week, 2 = 2 to 4 times per week, and3 = 5 or more times per week. A total score is obtainedby summing each symptom rating [45]. Typically, totalscores of 14 or greater indicate symptom severity con-sistent with posttraumatic stress disorder [46,47]. Scalescores are calculated by summing symptoms in the re-experiencing (4 items), avoidance (7 items), and arousal(6 items) clusters. In the present study, reliability of thescale scores was good (α = .76-.80) and reliability of thetotal scores was excellent (α = .90).Conflict Tactics Scale Revised (CTS-2)The CTS2 [48] is a self-report, behavioral measure ofpsychological aggression (8 items), physical assault(12 items), sexual coercion (7 items), physical injury(6 items), and negotiation (6 items) occurring in thecontext of conflict between intimate partners. The 39items are rated on a 8-point frequency scale (never,once, twice, 3–5 times, 6–10 times, 11–20 times, andmore than 20 times, not in the past year but it didhappen before) in terms of the respondent and herpartner’s behaviors. This study used the CTS2 itemsthat assessed the partner’s violent behaviors towardour participants. Because of our focus on intimatepartner abuse rather than relationship behaviors morebroadly, the negotiation scale items were excluded fromanalyses. Response options were modified to querywhether or not the behavior occurred within each of twospecified periods: as an adult before the woman becamepregnant and during the pregnancy. Specifically, for eachitem, first participants were asked whether the behaviorhad occurred during pregnancy (yes, no), and second theywere asked whether it had occurred at any point in her lifeprior to pregnancy (yes, no).For each of the CTS2 scales used in this study, womenwere classified as having been victims of the particulartype of abuse if they reported experiencing one or moreof the scale items within the relevant time period. Forexample, a woman who reported having experienced oneor more of the 8 psychological aggression items at somepoint prior to getting pregnant would be classified ashaving been a victim of psychological aggression beforepregnancy. We then calculated overall prevalence (yes,no) and prevalence by type (psychological, physical,sexual) and severity (minor, severe) of intimate partnerabuse for each time period following the guidelinesdetailed in the CTS2 coding manual [48]. We addition-ally created variables describing the number of types ofintimate partner abuse experienced during each refer-ence period, collapsing across participants who experi-enced 2 or 3 types of abuse due to small cell sizes (0, 1, 2or 3). Reliability of the modified CTS2 scores was good toexcellent (α = .75 or greater).ProceduresPotential participants contacted us via secure phone oremail, at which time they were screened for eligibilityand interviews were scheduled. Participants completedthe study measures during semi-structured, calendar-based interviews conducted by female research assistantsat safe locations of the women’s choice. Briefly, calendar-based interviews are the state-of-the-art in surveyingand interviewing [49-51]. These methods require respon-dents to retrospectively report, using a calendar as a mem-ory aid. Personally significant and easy-to-rememberlandmark dates are marked on the calendar to serve astemporal anchors [50]. In the present study, the deliverydate was used to calculate the approximate date ofconception. These two dates then served as the primaryDesmarais et al. BMC Pregnancy and Childbirth 2014, 14:132 Page 4 of 12http://www.biomedcentral.com/1471-2393/14/132temporal anchors. Additional anchors included dates ofadmission and discharge to the hospital.Following the interviews, information regarding localmental health services and abuse resources (e.g., helplinephone numbers, shelter information, legal services, etc.)was provided as necessary. Women received an hono-rarium of $20 for their participation, and up to $5 forexpenses associated with participation (e.g., parking, busor cab fare).Statistical analysesWe calculated descriptive statistics for all variables andconducted bivariate analyses to examine women’s meanlevels of postpartum mental health symptoms by theirsociodemographic characteristics (participant age, race/ethnicity, education, income, relationship status, andprior children) and by prevalence (yes, no) of each typeof intimate partner abuse (psychological, physical, andsexual) both before pregnancy and during pregnancy. Toanswer our research questions, we then tested a series ofmultivariate analysis of covariance models. Specifically,to answer our first two research questions, we testedtwo multivariate analysis of covariance models withpsychological, physical and sexual abuse (yes, no) as thedichotomous independent variables and symptoms ofstress, anxiety, depression, obsessive-compulsive disorder,and posttraumatic stress disorder as the continuousdependent variables, controlling for participant character-istics. To answer our third research question, we testedtwo additional multivariate analysis of covariance modelswith number of types of intimate partner abuse expe-rienced before and during pregnancy as the categoricalpredictors and symptoms of stress, anxiety, depression,obsessive-compulsive disorder, and posttraumatic stressdisorder as the continuous dependent variables, againcontrolling for participant characteristics. Statistical sig-nificance was set at α = .05. All analyses were conductedwith IBM SPSS Statistics 21.ResultsDescriptive statisticsMean participant age was 32.47 years (SD = 4.97, range =20-49) and that of their babies was 2.01 months (SD =1.32, range = 0-5)a. Almost half (41.0%) already hadchildren (biological or otherwise). The majority of respon-dents (71.0%) and their partners (68.4%) were Caucasian;a substantial minority were Asian (13.0% and 11.2%,respectively), which is representative of the study area.Most (96.0%) had completed high school or equivalent,and were employed (82.0%), either part-time (17.0%) orfull time (65.0%). Almost two-thirds reported familialincomes of $60,000 or more (62.0%). All but five women(95.0%) were in a serious or committed relationship withthe father of their new baby at the time of the interview.Overall, almost two-thirds of women (61.0%) reportedpostpartum mental health symptoms that were abovenormal levels, with 47.0% reporting symptoms at moder-ate or higher levels. For stress, anxiety, depression, andobsessive-compulsive disorder, scores were above thenormal range for 41.0%, 27.0%, 26.0%, and 32.0% of partici-pants and in the clinical range for 30.0%, 20.0%, 14.0%, and13.0% of participants, respectively. Almost one-quarter ofwomen (22.0%) met diagnostic criteria for posttraumaticstress disorder.The vast majority of participants reported experien-cing some form of intimate partner abuse before theirpregnancy (84.0%) and more than two-thirds (70.0%)reported experiencing intimate partner abuse duringtheir pregnancy. Both before and during pregnancy,psychological aggression was most common (83.0% and68.0%), followed by physical assault (20.0% and 12.0%) andthen sexual coercion (15.0% and 12.0%). Minor abuse wasmore common than severe abuse in both referenceperiods; still, almost one-third (31.0%) of women reportedsevere psychological, physical and/or abuse before preg-nancy, and 12.0% during pregnancy.Bivariate analysesTable 1 shows postpartum mental health symptoms as afunction of participant characteristics and prevalence ofintimate partner abuse before and during pregnancy.Bivariate results revealed some differences in postpartummental health symptoms as a function of participantcharacteristics. Significantly higher levels of anxiety andposttraumatic stress disorder symptoms were seen inwomen who had not completed their high school edu-cation compared to those who had completed at leasthigh school. Significantly higher levels of anxiety andposttraumatic stress disorder symptoms also were seenin women whose annual household incomes were $60,000or greater compared to those whose annual householdincomes were less than $60,000. Women who were singleshowed significantly higher levels of stress, anxiety, de-pression, and posttraumatic stress disorder than womenin relationships at the time of the interview. No significantdifferences in postpartum mental health symptoms werefound as a function of age, race/ethnicity, or prior chil-dren; thus, these 3 participant characteristics will not beincluded as covariates in the multivariate analyses.Bivariate comparisons also revealed that women whoexperienced intimate partner abuse—whether before orduring pregnancy—reported significantly more postpar-tum mental health symptoms compared to those whodid not experience intimate partner abuse. Psychologicalaggression before and during pregnancy was associatedwith postpartum stress. Psychological aggression during,but not before, pregnancy also was associated with symp-toms of posttraumatic stress disorder. Physical assault andDesmarais et al. BMC Pregnancy and Childbirth 2014, 14:132 Page 5 of 12http://www.biomedcentral.com/1471-2393/14/132Table 1 Bivariate comparisons of postpartum mental health symptoms by participant characteristicsParticipant characteristicsPostpartum mental health symptomsStress Anxiety Depression OCD PTSDM (SD) 95% CI t M (SD) 95% CI t M (SD) 95% CI t M (SD) 95% CI t M (SD) 95% CI tAgeLess than 33 years (n = 50) 14.76 (9.78) 11.98-17.54 0.43 5.72 (6.50) 3.87-7.57 1.29 5.88 (5.71) 4.26-7.50 0.24 5.90 (7.61) 3.74-8.06 0.46 7.58 (8.86) 5.06-10.10 0.2733 years or older (n = 50) 13.96 (8.68) 11.49-16.43 4.32 (4.03) 3.17-5.46 5.60 (5.74) 3.97-7.23 5.26 (6.12) 3.52-7.00 7.16 (6.71) 5.25-9.07RaceCaucasian (n = 71) 14.85 (9.44) 12.61-17.08 0.82 5.04 (5.52) 3.74-6.35 0.06 5.77 (5.89) 4.38-7.17 0.09 6.42 (7.43) 4.66-8.18 1.94 6.93 (7.28) 5.21-8.65 0.88Other (n = 29) 13.17 (8.66) 9.88-16.47 4.97 (5.28) 2.96-6.97 5.66 (5.29) 3.64-7.67 3.52 (4.81) 1.69-5.35 8.45 (9.06) 5.00-11.86EducationLess than high school (n = 4) 17.50 (12.79) 2.86-37.86 0.69 13.50 (9.57) 1.73-28.73 3.35*** 11.00 (6.63) 0.44-21.55 1.91 10.00 (10.10) 6.07-26.07 1.32 19.00 (14.90) 4.71-42.71 3.17**High school or greater (n = 96) 14.23 (9.10) 12.39-16.07 4.67 (4.96) 3.66-5.67 5.52 (5.59) 4.39-6.65 5.40 (6.72) 4.03-6.76 6.89 (7.13) 5.44-8.33Annual IncomeLess than $60,000 (n = 21) 15.2 4 (8.40) 11.41-19.06 0.18 8.29 (7.05) 5.08-11.50 3.34*** 7.14 (5.78) 4.51-9.77 1.05 6.29 (8.29) 2.51-10.06 0.57 11.43 (9.76) 6.99-15.87 2.92**$60,000 or more (n = 62) 14.81 (9.68) 12.35-17.26 3.87 (4.49) 2.73-5.01 5.61 (5.77) 4.15-7.08 5.31 (6.32) 3.70-6.91 5.89 (6.63) 4.20-7.57Relationship StatusSingle (n = 5) 22.40 (8.53) 11.81-32.99 2.03* 12.40 (6.07) 4.87-19.93 3.27*** 12.40 (3.29) 8.32-16.48 2.77** 7.20 (7.33) 1.90-16.30 0.54 22.40 (8.44) 11.92-32.88 4.89***In a relationship (n = 95) 13.94 (9.09) 12.09-15.79 4.63 (5.14) 3.58-5.68 5.39 (5.59) 4.25-6.53 5.49 (6.88) 4.09-6.90 6.58 (6.98) 5.16-8.00Prior ChildrenNo (n = 59) 13.46 (9.33) 11.03-15.89 1.18 4.68 (4.91) 3.40-5.96 0.75 5.22 (5.45) 3.80-6.64 1.09 6.05 (7.48) 4.10-8.00 0.82 6.59 (7.29) 4.69-8.49 1.19Yes (n = 41) 15.66 (8.99) 12.82-18.50 5.51 (6.13) 3.58-7.45 6.49 (6.03) 4.58-8.39 4.90 (5.94) 3.03-6.78 8.49 (8.50) 5.80-11.17Note. N = 100. OCD = obsessive-compulsive disorder. PTSD = posttraumatic stress disorder. Comparisons are t-tests of the mean scores on the postpartum mental health scales. *p < .05. **p < .01. ***p < .001.Desmaraisetal.BMCPregnancyandChildbirth2014,14:132Page6of12http://www.biomedcentral.com/1471-2393/14/132sexual coercion before pregnancy were associated withsymptoms of anxiety, obsessive-compulsive disorderand posttraumatic stress disorder. Physical assault beforepregnancy additionally was associated with symptoms ofdepression. Physical assault and sexual coercion duringpregnancy both were associated symptoms of obsessive-compulsive disorder; however, physical assault duringpregnancy also was associated with posttraumatic stressdisorder, whereas sexual coercion during pregnancy wasassociated with anxiety. Even when significant differencesin postpartum mental health symptoms as a function ofintimate partner abuse were not observed, there wasnonetheless a trend for increased symptomatology amongwomen who reported abuse. Finally, as the number oftypes of abuse reported before and during pregnancyincreased, so did symptoms of obsessive-compulsive dis-order and posttraumatic stress disorder. Number of typesof abuse reported before, but not during, pregnancy add-itionally was associated with increased symptoms ofanxiety.Multivariate analysesTable 2 shows results of the multivariate analysis ofcovariance examining the effects of psychological, physicaland sexual abuse before and during pregnancy (in separatemodels) on symptoms of stress, anxiety, depression,obsessive-compulsive disorder, and posttraumatic stressdisorder, with education, annual income, and relationshipstatus as covariates. Only the multivariate model of phys-ical assault during pregnancy was significant (see Table 3).However, the corrected univariate models for both in-timate partner abuse before and during pregnancy weresignificant for stress (F[6, 75] = 3.87, p < .05, ηp2 = .18; andF[6, 75] = 2.99, p < .01, ηp2 = .19), anxiety (F[6, 75] = 2.65,p < .01, ηp2 = .24; and F[6, 75] = 3.71, p < .01, ηp2 = .23),obsessive-compulsive disorder (F[6, 75] = 2.42, p < .05,ηp2 = .15; and F[6, 75] = 3.77, p < .01, ηp2 = .23), andposttraumatic stress disorder (F[6, 75] = 5.69, p < .001,ηp2 = .31; and F[6, 75] = 8.29, p < .001, ηp2 = .30). Thecorrected univariate model for intimate partner abuse dur-ing, but not before, pregnancy additionally was significantfor depression (F[6, 75] = 2.60, p < .05, ηp2 = .17).Table 3 shows results of the multivariate analysis ofcovariance models examining associations between psy-chological, physical and sexual abuse (yes, no) before andduring pregnancy (in separate models) and symptoms ofstress, anxiety, depression, obsessive-compulsive disorder,and posttraumatic stress disorder as the continuousdependent variables, with education, annual income, andrelationship status as covariates. After accounting for theother types of abuse and the covariates, sexual coercionwas the only type of abuse experienced before pregnancythat was associated with postpartum mental healthsymptoms; obsessive-compulsive disorder, specifically(see Table 3). In contrast, all types of intimate partnerabuse experienced during pregnancy were association withpostpartum mental health symptoms. Psychological ag-gression during pregnancy showed independent effects onstress and posttraumatic stress disorder; physical assaultduring pregnancy showed independent effects on symp-toms of depression, obsessive-compulsive disorder andposttraumatic stress disorder; and sexual coercion duringpregnancy showed independent effects on symptoms ofstress, depression, and posttraumatic stress disorder(see Table 3).Table 4 shows results of the multivariate analysis ofcovariance models examining associations between thenumber of types of intimate partner abuse before andduring pregnancy (in separate models) and symptoms ofstress, anxiety, depression, obsessive-compulsive dis-order, and posttraumatic stress disorder as the continu-ous dependent variables, with education, annual income,and relationship status as covariates. The multivariatemodel for abuse during, but not before pregnancy, wassignificant (see Table 4). In terms of the specific postpar-tum mental health problems, univariate models indicatedthat symptoms of stress, obsessive-compulsive disorderand posttraumatic stress disorder increased with the num-ber of types of abuse experienced, both before and duringpregnancy (see Table 4).DiscussionThe present study explored associations of psychological,physical and sexual intimate partner abuse among post-partum mental health in a non-clinical, community-basedsample of new mothers using a retrospective, cross-sectional design. Though many studies have examinedassociations between intimate partner abuse and postpar-tum mental health [32], this study adds to the empiricalliterature by disaggregating effects of psychological, phys-ical and sexual abuse experienced at two different timesduring women’s lives, namely before and during preg-nancy, on diverse postpartum mental health problems.Multivariate analyses showed important differences inthe impact of intimate partner abuse on postpartummental health as a function of the type and timing ofabuse. Psychology aggression during, but not before,pregnancy was associated with symptoms of stress andposttraumatic stress disorder, whereas sexual coercion,both before and during pregnancy, was associated withsymptoms of obsessive-compulsive disorder. Physicalassault during pregnancy appeared to have the greatestimpact on postpartum mental health and was associatedwith depression, obsessive-compulsive disorder, and post-traumatic stress disorder when it occurred duringpregnancy. However, we found no independent effectsof physical assault before pregnancy on postpartum men-tal health, after accounting for psychological aggression,Desmarais et al. BMC Pregnancy and Childbirth 2014, 14:132 Page 7 of 12http://www.biomedcentral.com/1471-2393/14/132Table 2 Bivariate comparisons of postpartum mental health symptoms by intimate partner abuseIntimate partner abusePostpartum mental health symptomsStress Anxiety Depression OCD PTSDM (SD) 95% CI t M (SD) 95% CI t M (SD) 95% CI t M (SD) 95% CI t M (SD) 95% CI tBefore pregnancyPsychological aggressionNo (n = 17) 10.00 (8.00) 5.89-14.11 2.18* 3.29 (4.24) 1.11-5.47 1.45 4.12 (4.61) 1.75-6.49 1.29 3.12 (5.59) 0.24-5.99 1.63 4.29 (6.23) 1.09-7.50 1.80Yes (n = 83) 15.25 (9.23) 13.24-17.27 5.37 (5.60) 4.15-6.60 6.07 (5.86) 4.79-7.35 6.08 (7.04) 4.55-7.62 8.00 (8.00) 6.25-9.75Physical assaultNo (n = 80) 13.50 (9.01) 11.50-15.50 1.89 4.47 (5.00) 3.36-5.59 2.04* 5.12 (5.32) 3.94-6.31 2.20* 4.75 (6.24) 3.36-6.14 2.47* 6.04 (6.80) 4.52-7.55 3.61***Yes (n = 20) 17.80 (9.42) 13.39-22.21 7.20 (6.57) 4.13-10.27 8.20 (6.58) 5.12-11.28 8.90 (8.38) 4.98-12.82 12.70 (9.44) 8.28-17.12Sexual coercionNo (n = 85) 13.74 (9.08) 11.78-15.70 1.61 4.35 (4.68) 3.34-5.36 3.05** 5.44 (5.68) 4.21-6.66 1.28 4.68 (5.92) 3.41-5.96 3.25** 6.55 (7.43) 4.95-8.16 2.55*Yes (n = 15) 17.87 (9.46) 12.63-23.10 8.80 (7.66) 4.56-13.04 7.47 (5.68) 4.32-10.61 10.67 (9.58) 5.36-15.97 12.00 (8.60) 7.24-16.76Number of types0 (n = 16) 10.12 (8.25) 5.73-14.52 4.21* 3.50 (4.29) 1.21-5.79 1.05 4.00 (4.73) 1.48-6.52 1.16 3.31 (5.71) 0.27-6.36 5.63** 3.87 (6.18) 0.58-7.17 3.41*1 (n = 58) 13.97 (8.60) 11.71-16.23 4.38 (4.72) 3.14-5.62 5.38 (5.43) 3.95-6.81 4.67 (5.64) 3.19-6.16 6.50 (6.69) 4.74-8.262 or 3 (n = 26) 17.85 (10.10) 13.77-21.93 7.38 (6.83) 4.63-10.14 7.62 (6.48) 5.00-10.23 9.00 (8.82) 5.44-12.56 11.46 (9.51) 7.62-15.30During pregnancyPsychological aggressionNo (n = 32) 11.31 (7.98) 8.44-14.19 2.32* 4.50 (4.74) 2.79-16.19 0.66 5.06 (4.60) 3.40-6.72 0.81 3.44 (5.45) 1.47-5.40 2.18* 5.69 (7.78) 2.88-8.49 1.48Yes (n = 68) 15.79 (9.45) 13.51-18.08 5.26 (5.74) 3.88-6.21 6.06 (6.15) 4.57-7.55 6.59 (7.27) 4.83-8.35 8.16 (7.77) 6.28-10.04Physical assaultNo (n = 88) 13.82 (8.99) 11.91-15.72 1.61 4.80 (5.20) 3.69-5.90 1.12 5.39 (5.37) 4.25-6.52 1.70 4.81 (6.23) 3.49-6.13 3.18** 6.65 (7.65) 5.03-8.27 2.57*Yes (n = 12) 18.33 (10.19) 11.86-24.81 6.67 (6.89) 2.29-11.05 8.33 (7.48) 3.58-13.08 11.25 (8.85) 5.62-16.88 12.67 (7.27) 8.05-17.28Sexual coercionNo (n = 88) 13.75 (9.07) 11.83-15.67 1.81 4.55 (4.83) 3.52-5.57 2.42* 5.55 (5.62) 4.35-6.74 0.92 4.70 (5.98) 3.44-5.97 3.66*** 6.84 (7.75) 5.20-8.48 1.85Yes (n = 12) 18.83 (9.40) 12.86-24.80 8.50 (8.10) 3.36-13.64 7.17 (6.29) 3.17-11.17 12.00 (9.57) 5.92-18.08 11.25 (7.53) 6.46-16.04M (SD) 95% CI F M (SD) 95% CI F M (SD) 95% CI F M (SD) 95% CI F M (SD) 95% CI FNumber of types0 (n = 30) 11.60 (8.16) 8.55-14.65 5.94** 4.80 (4.74) 3.03-6.57 1.68 5.20 (4.66) 3.46-6.94 2.59 3.67 (5.56) 1.59-5.74 11.46*** 5.70 (7.91) 2.74-8.66 7.91***1 (n = 53) 14.19 (8.84) 11.75-16.63 4.34 (5.02) 2.96-5.72 5.25 (5.66) 3.69-6.81 4.58 (5.67) 3.02-6.15 6.87 (7.47) 4.81-8.932 or 3 (n = 17) 19.76 (10.22) 14.51-25.02 7.53 (7.16) 3.85-11.21 8.24 (7.03) 4.62-11.85 12.06 (8.80) 7.53-16.58 11.88 (7.49) 8.03-15.73Note. N = 100. OCD = obsessive-compulsive disorder. PTSD = posttraumatic stress disorder. Comparisons are t-tests or F-tests, as appropriate, of the mean scores on the postpartum mental health scales. *p < .05.**p < .01. ***p < .001.Desmaraisetal.BMCPregnancyandChildbirth2014,14:132Page8of12http://www.biomedcentral.com/1471-2393/14/132sexual coercion, participant education, annual income,and relationship status. This latter finding is inconsistentwith prior studies and may be attributable to the fail-ure of most extant research to account for experiences ofnon-physical types of intimate partner abuse in theirmodels [32].Consistent with the findings of prior meta-analyticwork, we observed stronger associations between abuseexperienced during compared to before pregnancy [32],though we extended this pattern of results from depres-sion and posttraumatic stress disorder to stress andobsessive-compulsive disorder and posttraumatic stressdisorder. In contrast with prior research, associationsbetween intimate partner abuse (any type) and symp-toms of postpartum anxiety were not significant aftercontrolling for participant education, annual income,and relationship status [32]. Multivariate analyses alsoshowed that risk for postpartum mental health prob-lems—specifically, stress, obsessive-compulsive disorderand posttraumatic stress disorder—increases as the numberof types of intimate partner abuse increases. To our know-ledge, this is the first study to demonstrate the cumulativeeffects of intimate partner abuse on postpartum men-tal health.Our results build upon prior empirical evidence linkingexposure to psychological intimate partner abuse withpostpartum mental health problems [37,52]; indeed, psy-chological aggression during pregnancy was associatedwith higher rates of both stress and posttraumatic stressdisorder. Given the high rates of exposure and mentalhealth sequelae, there is need to conduct routine screen-ing for non-physical forms of abuse during pregnancy.Moreover, results suggest that knowledge of whetherwomen have experienced psychological, physical and/orsexual abuse in an intimate relationship may assist healthcare professionals to target postpartum mental healthtreatment and intervention efforts.This is one of the few studies to examine associationsbetween intimate partner abuse and postpartum mentalhealth in a non-clinical as opposed to a hospital, clinicor at-risk sample. Our analyses have revealed high ratesof intimate partner abuse and postpartum mental healthproblems. More than two-thirds of women in this non-clinical sample reported elevated levels of postpartummental health symptoms, and almost half reported symp-toms that were moderate in severity or higher. These ratesare slightly higher but generally in keeping with thosereported elsewhere [3,5,7,10,13]. In contrast, rates ofTable 3 Multivariate analyses of covariance of prevalence of intimate partner abuse predicting postpartum mentalhealth problemsUnivariatebMultivariatea Stress Anxiety Depression OCD PTSDF ηp2 F ηp2 F ηp2 F ηp2 F ηp2 F ηp2Model 1Intimate partner abuse before pregnancyPsychological aggression 1.19 .08 3.67 .05 1.61 .02 0.73 .01 1.49 .02 3.27 .04Physical assault 1.48 .09 1.03 .01 0.01 .00 3.53 .04 3.37 .04 3.00 .04Sexual coercion 2.01 .12 2.32 .03 1.80 .02 0.01 .00 4.78* .06 0.02 .00CovariatesEducation 0.47 .03 0.05 .00 1.93 .02 0.59 .01 0.28 .00 0.15 .00Annual income 2.25 .14 0.64 .01 2.02 .03 0.10 .00 1.19 .02 1.60 .02Relationship status 1.65 .10 3.44 .04 1.96 .02 2.47 .03 0.41 .00 6.36* .08Model 2Intimate partner abuse during pregnancyPsychological aggression 2.03 .12 4.15* .05 0.68 .01 0.56 .01 1.53 .02 7.41** .09Physical assault 2.86* .17 1.55 .02 0.23 .00 5.59* .07 7.16** .09 7.48** .09Sexual coercion 2.24 .14 2.63 .03 1.65 .02 0.02 .00 7.31** .09 0.09 .00CovariatesEducation 0.49 .03 0.01 .00 1.44 .02 0.61 .01 0.10 .00 0.01 .00Annual income 2.04 .13 0.64 .01 1.59 .02 0.53 .01 2.40 .03 0.79 .01Relationship status 3.51** .20 8.64** .10 3.38 .04 7.24** .09 1.17 .01 17.24*** .19Note. Intimate partner abuse variables are the dichotomous predictors (yes, no). Postpartum mental health variables are the continuous outcomes. OCD =obsessive-compulsive disorder. PTSD = posttraumatic stress disorder. Multivariate F ratios were generated from Wilks’ Lambda’s statistic. aMultivariate df = 5, 71.bUnivariate df = 1, 75. ηp2 = partial eta-squared. *p < .05. **p < .01. ***p < .001.Desmarais et al. BMC Pregnancy and Childbirth 2014, 14:132 Page 9 of 12http://www.biomedcentral.com/1471-2393/14/132intimate partner abuse, both before and during preg-nancy, were notably higher than those reported inrecent population-based research [22,24,25]. Inconsisten-cies may be attributable to measurement differences: weused a modified version of the CTS-2 to measure intimatepartner abuse, whereas most prior work has relied onmeasures with fewer items and/or that are restricted tomoderate to severe intimate partner abuse [27]. Studiesemploying the CTS-2 tend to find higher rates of intimatepartner abuse compared to those using other measures[23]. Additionally, most studies have focused on physicalintimate partner abuse, our operational definition inclu-ded not only physical assault, but also psychologicalaggression and sexual coercion [21,32]. Indeed, examiningsevere physical intimate partner abuse alone, we see ratesmore consistent with those reported in prior research[22,27,29]. Finally, we took great care to establish rapportwith participants prior to interview administration and thequestions regarding postpartum mental health and intim-ate partner abuse were placed about two-thirds of the waythrough the interview; these two strategies may haveincreased the degree to which women were willing todisclose their experiences.The present study is limited in several ways. First, thedata are cross-sectional and do not afford longitudinalanalyses of the effects of intimate partner abuse onwomen’s mental health over time. Future researchshould examine the long-term unique and cumulativeimpact of psychological, physical and sexual intimatepartner abuse on maternal and child health over time.Second, we employed convenience sampling; generali-zability of experiences reported by women who volun-teered for a study on health after pregnancy is unknown.Third, our sample was relatively small and power todetect significant associations in our analyses may belimited. Fourth, we focused on whether or not womenexperienced intimate partner abuse, rather than frequencyof intimate partner abuse over time. Fourth, our data werederived from retrospective, self-reports and may be sus-ceptible to recall bias and errors, as well as social desir-ability [23]. Yet, retrospective, self-report has been shownto be a valid and reliable method for collecting sensitivedata, including reports of postpartum mental health prob-lems [53] and intimate partner abuse during the perinatalperiod [54]. Fifth, and finally, our data on intimate partnerabuse experienced before and during pregnancy werecollected at the same time. The ideal approach would havebeen to interview women at multiple times before andduring the perinatal period; however, this was not possible.To enhance the quality of data given our study constraints,we employed a calendar-based interviewing approach,which has been shown to increase reliability and validity ofretrospective, behavioral reports [49-51].ConclusionResults of this study provide further evidence that intim-ate partner abuse is a risk factor for postpartum mentalhealth problems. A majority of women, even in a non-Table 4 Multivariate analyses of covariance of number of types of intimate partner abuse predicting postpartummental health problemsUnivariatebMultivariatea Stress Anxiety Depression OCD PTSDF ηp2 F ηp2 F ηp2 F ηp2 F ηp2 F ηp2Model 1Intimate partner abuse before pregnancyNumber of types 1.76 .11 4.21* .10 1.05 .03 1.16 .03 5.63** .13 3.41* .08CovariatesEducation 0.48 .03 0.03 .00 1.73 .02 0.68 .01 0.16 .00 0.20 .00Annual income 2.40* .14 0.18 .00 3.43 .04 0.00 .00 0.13 .00 2.64 .03Relationship status 1.96 .12 2.84 .04 1.40 .02 3.16 .04 0.90 .01 7.25** .09Model 2Intimate partner abuse during pregnancyNumber of types 3.51*** .20 5.94** .13 1.68 .04 2.59 .06 11.46*** .23 7.91** .17CovariatesEducation 0.53 .03 0.00 .00 1.81 .02 0.65 .01 0.16 .00 0.04 .00Income 2.27 .14 0.32 .00 2.69 .03 0.09 .00 0.55 .01 2.28 .03Relationship Status 3.24* .18 8.19** .10 3.08 .04 6.24* .08 0.35 .00 15.98*** .17Note. Intimate partner abuse variables are the categorical predictors (0, 1, 2 or 3). Postpartum mental health variables are the continuous outcomes. OCD =obsessive-compulsive disorder. PTSD = posttraumatic stress disorder. Multivariate F ratios were generated from Wilks’ Lambda’s statistic. aMultivariate df = 5, 72.bUnivariate df = 1, 76. ηp2 = partial eta-squared. *p < .05. **p < .01. ***p < .001.Desmarais et al. BMC Pregnancy and Childbirth 2014, 14:132 Page 10 of 12http://www.biomedcentral.com/1471-2393/14/132clinical, community-based sample, retrospectively repor-ted experiences of intimate partner abuse that occurredboth before and during pregnancy. As such, there is acritical need for the development, implementation andevaluation of strategies designed to reduce intimate part-ner abuse during the perinatal period. The perinatalperiod presents a unique opportunity to identify womenwho may be at risk for both intimate partner abuse, aswell as postpartum mental health problems, because itbrings otherwise healthy women contact with healthcare providers [9]. However, in contrast to the significantbody of research evaluating screening and assessmentstrategies, there is a dearth of empirical evidence sup-porting the effectiveness of intimate partner abuse inter-vention and prevention strategies [55]; this remains animportant avenue for future research.EndnoteaThough women were recruited within 0–3 months post-partum, some interviews were completed after 3 monthspostpartum (n = 12) due to scheduling conflicts.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsSLD and PAJ conceived of the study. SLD oversaw all aspects of the studydesign, data collection, and analysis of the data. AP participated in the studycoordination and data collection. EML contributed to the manuscriptrevisions. All authors contributed to the preparation of the manuscript,and read and approved the final manuscript.Authors’ informationSLD is an Assistant Professor in the Psychology in the Public InterestProgram at North Carolina State University. Her program of research focuseson issues at the nexus of psychology and law with special emphasis onissues related to mental health, violence and victimization. AP is a graduatestudent in the Law and Forensic Psychology Program at Simon FraserUniversity, with research interests in the co-occurrence of violence andvictimization. ELM is a graduate student in the Psychology in the Public Inter-est Program at North Carolina State University, with research interests inevaluating alternatives to incarceration for justice-involved adults with seriousmental illnesses. PAJ is Director of the MPH Program and Co-Leader of theMaternal Child Health Theme in the School of Population & Public Health atthe University of British Columbia. Her areas of research include maternal,fetal and newborn health; women’s health; and violence.AcknowledgementsFunding for this study was provided by the British Columbia Mental Healthand Addictions Research Network, the Social Sciences and HumanitiesResearch Council of Canada, and the Michael Smith Foundation for HealthResearch. The content is solely the responsibility of the authors and does notnecessarily represent the official views of the funding agencies. 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BMC Pregnancy and Childbirth 2014 14:132.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitDesmarais et al. BMC Pregnancy and Childbirth 2014, 14:132 Page 12 of 12http://www.biomedcentral.com/1471-2393/14/132

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