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Intimate partner violence (IPV) constitutes a critical social determinant of physical and mental health during pregnancy and after delivery (Pastor-Moreno et al., 2020; Paulson, 2020). Prenatal IPV exposure confers increased risk of a wide range of pregnancy complications, such as vaginal bleeding, severe nausea, vomiting, kidney infection, and gestational diabetes (Ferdos et al., 2017; Silverman et al., 2006). In addition to pregnancy complications, IPV has adverse effects on maternal mental health in the perinatal period (Scrafford et al., 2019), such as increased risk for more severe posttraumatic stress symptoms (PTSS; Mahenge et al., 2013). Emerging evidence suggests that the type of IPV exposure (so for example, physical vs. psychological vs. sexual) may play an important role in the influence of IPV on pregnancy complications (Ferdos et al., 2017), but few studies have examined how types of IPV may uniquely relate to cumulative pregnancy complications.
Beyond the direct effects of IPV on women's health, previous work has shown that the concurrent experiences of violence and PTSS have a more severe impact on physical health than violence exposure alone (Caspi et al., 2008; Spitzer et al., 2009). Thus, we examined the unique and combined effects of PTSS with physical, sexual, and psychological IPV to better understand how these constructs may relate to pregnancy complications. We expected that PTSS would exacerbate pregnancy-related health complications associated with IPV exposure in this population. 
Participants included 137 pregnant women who reported experiencing IPV within the past year. Results showed that certain types of IPV and PTSS are uniquely associated with pregnancy complications. When examining associations among IPV, PTSS and pregnancy complications,  more frequent sexual IPV and higher PTSS were significantly associated with greater pregnancy complications.
For both psychological and sexual forms of IPV, high PTSS strengthened the relation between IPV and pregnancy complications (i.e., greater psychological and sexual IPV exposure were associated with greater pregnancy complications in the context of high PTSS). Contrary to what was expected, a significant negative relation emerged between physical IPV frequency and pregnancy complications at average to below average levels of PTSS, as well as between psychological and sexual IPV at the lowest levels of PTSS. Although unexpected, these findings may be due to differences in IPV severity for those reporting low PTSS, or the restricted range of exposure given the sample's overall high levels of violence exposure. 
This study provides insight into the variability of trauma outcomes during a key developmental period for women and it highlights critical domains that merit intervention to support women exposed to IPV during pregnancy. Study findings underscore the need for universal IPV evaluations, explicitly highlighting the necessity of assessing different types of IPV victimization at women’s prenatal appointments to better understand their risk for pregnancy complications. Further, results delineate the need for prenatal intervention efforts to address both IPV victimization and mental health functioning simultaneously rather than separately. Notably, trauma-informed, prenatal interventions remain scarce (Howell et al., 2017), highlighting the need for evidence-based treatments that successfully address IPV revictimization and PTSS severity, and thus decrease subsequent prenatal complications and risk for adverse health consequences for both women and their infants.

Future directions

  • Longitudinal designs to assess IPV exposure and PTSS over time to understand how these factors coalesce to amplify risk for pregnancy complications.
  • Concurrently examining maternal characteristics (e.g., age, weight, substance use) and medical history to understand how women’s personal and genetic backgrounds may influence their pregnancy. 
  • Identifying potential protective factors that may buffer risk for pregnancy complications. 

Target Article

Gilliam, H.C., Howell, K.H., Paulson, J.L., Napier, T.R., Miller-Graff, L.E. (In press). Pregnancy Complications and Intimate Partner Violence: The Moderating Role of Prenatal Posttraumatic Stress Symptoms. Journal of Traumatic Stress. DOI: 10.1002/jts.22855

Discussion Questions

  1. What strategies could clinicians use to support pregnant women experiencing IPV in ways that promote positive pregnancy outcomes and overall well being?
  2. How can future researchers build on our study findings to further promote the mental and physical well being of women exposed to IPV during pregnancy? What factors not captured by the current study may be important for future research to address?
  3. Given study findings, what factors might be important to consider in future research to explore the unexpected findings for those reporting low PTSS (i.e., IPV was negatively associated with pregnancy complications for women reporting very low PTSS)? Why might women who report low PTSS also be reporting lower rates of pregnancy complications despite significant violence exposure?  
  4. How could integrative care provide an optimal setting for reducing pregnancy complications among IPV-exposed pregnant women? How might the training of public health professionals and mental health providers be broadened to address the synergistic effects of PTSS and violence on health outcomes?

About the Authors

Hannah C. Gilliam, MS (she/her) is a Clinical Psychology Doctoral Student at The University of Memphis. Her research interests focus on examining the intergenerational effects of violence within a family systems framework and intervention development and evaluation aimed to address the effects of violence for marginalized groups that account for culturally specific strengths and challenges. Hannah can be contacted at hcglliam@memphis.edu
Kathryn H. Howell, PhD (she/her) is a tenured Associate Professor in the Department of Psychology at the University of Memphis. Her program of research focuses on individual, relational, and community factors that enhance resilience or reduce psychopathology following exposure to traumatic events. A common theme underlying her studies is the promotion of resilience among youth and their families exposed to adversity.
Julia L. Paulson, MA (she/her) is a Clinical Psychology Doctoral Student at the University of Notre Dame. Her research interests focus on the pathways through which trauma affects health and well-being across the lifespan, with a focus on reproductive health and key developmental transitions among women (e.g., pregnancy, menopause).
Taylor R. Napier, MS (she/her) is a Clinical Psychology Doctoral Student at The University of Memphis. Her research interests include examining strength-based factors within the family system that contribute to improved child outcomes. Specifically, her work focuses on how maternal adversity exposure impacts child development in the context of family violence and loss. 
Laura E. Miller-Graff, PhD (she/her) is an Associate Professor of Psychology and Peace Studies at the University of Notre Dame. Her program of research focuses on seeks to understand how various systems interact to promote or inhibit healthful development following violence exposure.  Dr. Miller-Graff has a particular interest in the adaptation and evaluation of brief psychological interventions for violence-exposed populations in in low- and middle-income countries and in conflict-affected settings. 

References Cited

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Ferdos, J., Rahman, M. M., Jesmin, S. S., Rahman, M. A., & Sasagawa, T. (2018). Association between intimate partner violence during pregnancy and maternal pregnancy complications among recently delivered women in Bangladesh. Aggressive Behavior, 44(3), 294–305. https://doi.org/10.1002/ab.21752
Howell, K. H., Miller-Graff, L. E., Hasselle, A. J., & Scrafford, K. E. (2017). The unique needs of pregnant, violence-exposed women: A systematic review of current interventions and directions for translational research. Aggression and Violent Behavior, 34, 128–138. https://doi.org/10.1016/j.avb.2017.01.021
Mahenge, B., Likindikoki, S., Stöckl, H., & Mbwambo, J. (2013). Intimate partner violence during pregnancy and associated mental health symptoms among pregnant women in Tanzania: A cross‐sectional study. BJOG, 120(8), 940-947. https://doi.org/10.1111/1471-0528.12185 
Paulson J. L. (2020). Intimate Partner violence and perinatal post-traumatic stress and depression symptoms: A systematic review of findings in longitudinal studies. Trauma, Violence & Abuse. Advance online publication. https://doi.org/10.1177/1524838020976098
Pastor‐Moreno, G., Ruiz‐Pérez, I., Henares‐Montiel, J., Escribà‐Agüir, V., Higueras‐Callejón, C., & Ricci‐Cabello, I. (2020). Intimate partner violence and perinatal health: A systematic review. BJOG, 127(5), 537–547. https://doi.org/10.1111/1471-0528.16084 
Scrafford, K. E., Grein, K., & Miller-Graff, L. E. (2019). Effects of intimate partner violence, mental health, and relational resilience on perinatal health. Journal of Traumatic Stress, 32(4), 506–515. https://doi.org/10.1002/jts.22414 
Silverman, J. G., Decker, M. R., Reed, E., & Raj, A. (2006). Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: Associations with maternal and neonatal health. American Journal of Obstetrics and Gynecology, 195(1), 140–148. https://doi.org/10.1016/j.ajog.2005.12.052 
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