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freestocks-ux53SGpRAHU-unsplash.jpgIntimate partner violence (IPV) includes physical, sexual or psychological abuse from a current or former partner. The prevalence of IPV is high across the globe, with an estimated one in three women experiencing this form of violence in their lifetime (Devries et al., 2013). Notably, the risk for IPV is heightened during pregnancy, which can lead to negative health effects not only for pregnant women, but also for their developing children. Given the potential for intergenerational and long-term consequences of IPV, it is critical to develop effective interventions to support pregnant women who have experienced this type of adversity (Howell et al., 2017). In response to this need, we developed the Pregnant Moms’ Empowerment Program (PMEP) to meet the unique developmental needs of pregnant women as well as the common mental health challenges associated with IPV exposure.
The PMEP was adapted from the Moms’ Empowerment Program (MEP; Graham-Bermann, 2011), which is designed for women with school-aged children. Positive effects of the MEP have been found for mental health, parenting and revictimization, but the program does not address IPV during pregnancy or the unique challenges of parenting an infant, so adaptation was necessary. The adaptation was informed by a number of different research inputs, including basic research on IPV and pregnancy, a systematic review of interventions for IPV in pregnancy and a series of focus groups with pregnant, IPV-exposed women and service providers. Together, these sources of information were synthesized to develop a clear picture of pregnant, IPV-exposed women’s unique needs, to identify a strong translational evidence basis for program components and to support a successful implementation that would be broadly accessible to women.
Focus groups identified a number of unique barriers to intervention engagement that are experienced by pregnant, IPV-exposed women, including mental health barriers (e.g., depressive symptoms), pregnancy- and health-related barriers (e.g., physical health symptoms), partner-related barriers (e.g., direct interference or demoralization from a violent partner), practical barriers (e.g., transportation, lack of compensation and childcare), cultural barriers (e.g., normalization of IPV and societal stigma) and perceived systemic barriers (e.g., fear or mistrust of helping systems and lack of available resources; Hasselle et al., 2020). These focus groups also highlighted the parenting strengths, adaptive coping strategies and aspects of resilience displayed by pregnant, IPV-exposed women (Schaefer et al., 2021; Scrafford et al., 2022). Such information was central to the successful adaptation of PMEP and was incorporated into both the program manual and the research design.
The PMEP is thus specifically designed for pregnant women who have experienced IPV. It is five sessions, delivered in a group-based format. Participation in PMEP is intended to reduce revictimization and improve mental health and parenting. Each session lasts for approximately two hours and is facilitated by two group leaders who have completed a training on the intervention as well as in work with high-risk populations. Importantly, the PMEP is a manualized intervention that is designed to be flexible for task-sharing – that is, the training materials and manual are intended to support the possibility of delivery by lay paraprofessionals who are supervised by a mental health professional. Together with its group-based design, PMEP is therefore optimized for implementation in community settings to enhance its cost effectiveness and scalability.
The PMEP is rooted in empowerment theory (Zimmerman, 2000) and the social ecological theory of resilience (Ungar, 2012). Collectively, these theoretical models suggest that promoting adaptive functioning in the context of significant adversity should be viewed as inclusive of both supporting individual-level processes (e.g., coping) as well as supporting mastery of and connectedness to existing resources in women’s environments that can facilitate positive outcomes (e.g., emotional and instrumental supports). The sessions of PMEP address the following key topics: safety planning and healthy relationships, cognitive behavioral skills for managing distress, multisystemic supports and resilience, labor/delivery and communication with prenatal care providers, early parenting (e.g., breastfeeding, maternal sensitivity) and infant health (e.g., safe sleep), and co-parenting supports. Each session includes brief psychoeducational content, which is provided by group leaders, discussion questions to facilitate knowledge exchange amongst participants, and interactive exercises and activities to enhance skill learning and retention. Women complete homework between sessions that provides out-of-session extension of skills. 
The efficacy of the PMEP was recently evaluated in the context of a quasi-randomized trial, with assessment conducted with women at pre-test [T1] and post-test [T2] and with both women and infants at three-months [T3] and 12-months [T4] post-partum (Miller-Graff et al., 2022). Results indicated sustained effects of PMEP in reducing women’s re-victimization, with those women in the treatment condition reporting lower levels of physical assault as compared to women in the control condition at all follow-up assessments. Moreover, women in the treatment condition reported lower levels of sexual coercion at T2 and T3, and lower levels of IPV-related injury at T4. When evaluating the subsample of women who were considered treatment adherent for the sessions targeting the outcomes under evaluation (i.e., completed the three sessions focused on violence and mental health), effects were further strengthened with lower levels of physical assault and sexual coercion for the treatment condition at all time points of assessment and lower rates of IPV-related injury at both T3 and T4.
Moreover, the PMEP had notable effects on maternal mental health, particularly in the domain of depression. Women in the treatment condition reported significantly lower levels of depression at post-test, an effect that was medium in size for those in the treatment condition (d= -0.50) and large for those who were considered treatment adherent (d= -0.90). The effects of PMEP on symptoms of posttraumatic stress and resilience were not significant, suggesting minimal impacts in these domains. For women who were considered treatment adherent, however, there was a medium-sized positive effect of treatment on resilience at T2 (d=0.49).
These findings suggest a high level of promise for PMEP as an evidence-based support for pregnant women who have experienced IPV, with sustained long-term effects in both re-victimization and depression. Given the dearth of available interventions for pregnant, IPV-exposed women (Howell et al., 2017), this program addresses a critically important gap in research and practice.
Based on the promising findings from the pilot quasi-randomized trial, the PMEP is currently being evaluated in a large-scale randomized controlled trial against an active control group (R01HD098092; MPIs Miller-Graff & Howell). Further, in light of the COVID pandemic, a fully online version of the PMEP was developed for remote delivery. The research team plans to assess the efficacy of this telehealth version as compared to the in-person format. If effective, this remote version of the program would be valuable for use in settings that traditionally have difficulty accessing in-person care, such as rural locations. Additionally, the team is working to conduct long-term assessments of the potential indirect effects of PMEP on child functioning in early childhood (when children are ~three years old) and is developing plans for dual-generation programming in collaboration with Dr. Kristin Valentino. Finally, the team is adapting the PMEP for Spanish-speaking participants in the United States and Mexico, in collaboration with Dr. Cecilia Martinez-Torteya.
For more information or to learn about accessing materials for the Pregnant Moms’ Empowerment Program, please contact Dr. Howell at k.howell@memphis.edu and Dr. Miller-Graff at lmiller8@nd.edu.
Keywords: pregnancy; perinatal period; intervention; IPV; domestic violence

About the Authors

Kathryn H. Howell, PhD, is a tenured Associate Professor in the Department of Psychology at the University of Memphis. Dr. Howell’s program of research centers on the health and well-being of children and their families. Across her projects, she assesses individual, relational, and community factors that enhance resilience or reduce psychopathology following exposure to traumatic events. Dr. Howell is the 2022 chair of the American Psychological Association Committee on Children, Youth and Families. She is a licensed psychologist with health service provider designation in the state of Tennessee.

Laura E. Miller-Graff, PhD, is a tenured Associate Professor of Psychology and Peace Studies at the University of Notre Dame. Dr. Miller-Graff’s program of research focuses on the development, adaptation and evaluation of brief psychological supports for violence-exposed women and children, with a particular focus on programs that can be readily brought to scale in low-resource settings. She is interested in identifying the intergenerational and indirect effects of mental health supports for parents, seeking to broaden the evidence-basis for holistic family care. She is a licensed psychologist with health service provider designation in the state of Indiana.


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Graham-Bermann, S. A. (1994, revised 2011). The Moms’ Empowerment Program (MEP): A training manual. Department of Psychology, University of Michigan, Ann Arbor, MI.
Hasselle, A. J., Howell, K. H., Bottomley, J., Sheddan, H. C., Capers, J. M., & Miller-Graff, L. E. (2020). Barriers to intervention engagement among women experiencing intimate partner violence proximal to pregnancy. Psychology of Violence10(3), 290.
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Schaefer, L.M., Howell, K.H., Sheddan, H.C., Napier, T.R., Shoemaker, H.L., & Miller-Graff, L.E. (2021). The road to resilience: Strength and coping among pregnant women exposed to intimate partner violence. Journal of Interpersonal Violence, 36(17-18), 8382-8408.
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