According to the World Health Organisation (WHO), depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease. Since women are twice as likely to experience depression in their lifetime than men, it is worthwhile to explore the many risk factors that make them more susceptible.
Although depression and anxiety can have devastating effects for any individual – women have an increased chance of being affected by these common mental disorders during the perinatal period, which can have long term consequences for both mother and child.
Domestic violence (DV) and intimate partner violence (IPV) are strongly linked to depression and anxiety in the perinatal period.
Zooming in on Domestic Violence as a risk factor
Domestic violence (DV) is defined as any physical, sexual, psychological or economic abuse that takes place between people who are sharing or have recently shared a home. Intimate partner violence (IPV) relates to violence committed by a current, ex- or would-be intimate relationship that causes physical, psychological or sexual harm to either partner.
The WHO has acknowledged that all forms of interpersonal violence leads to negative health outcomes and released a global plan of action to address interpersonal violence, particularly against women, girls and children. (More in this WHO report 2016)
In Africa, there is more violence against women than on any other continent. Compared to America, twice as many women In South Africa are killed by their partners.
Violence against women during pregnancy can have negative effects for both the mother and the child. Studies have shown that negative physical effects for mother and child can include fetal death by placental rupture, premature labour, low birth weight and haemorrhage after birth.
The negative psychological effects can include lowered self-esteem, depression, anxiety, substance or alcohol misuse. These effects, in turn, render women more vulnerable to experiencing domestic violence. Furthermore, abused women are more likely to delay getting pregnancy care and to attend fewer antenatal visits.
Research on IPV from four countries
Main findings from four countries show that there is a relationship between domestic and intimate partner violence.
A recent study from Australia found that out of the 4% of pregnant women who reported a history of IPV during a routine psychosocial assessment, more than 50% were immigrants. The highest number of women reporting abuse were born in Sudan and New Zealand, while women from China and India were least likely to report IPV. It is important to note that under-reporting is very likely in many communities and this may be due to a variety of reasons such as women’s experiences of shame, stigma and lack of appropriate responses or support from others.
Those women reporting IPV were more likely to report additional psychosocial concerns including depression, thoughts of self-harm and childhood abuse.
Another study conducted in Japan showed the association between verbal and physical abuse during pregnancy and linked it to postpartum depression. The study not only offers some insights into the significant influence of both verbal and physical abuse during pregnancy on postpartum depression, but also calls for regular screening for antenatal IPV by public health nurses who could identify those women who need further support, such as referral to centres for confidential advice and support.
Similar findings were reported from Malaysia, where the exposure to IPV was significantly associated with postnatal depression. The researchers of this study are also calling for training to healthcare professional to detect and manage both problems.
A recent South African study, conducted by the Perinatal Mental Health Project, showed 15% of nearly 400 pregnant women experienced IPV. We found a substantial proportion of women were additionally experiencing violence in the home at the hands of family members other than their partners, such as brothers, in-laws and grandparents. We found that abused pregnant women are more likely to be under 30 years of age, experience a range of mental health disorders, food insecurity and are more likely to be unemployed. They are more likely to have experienced abuse in the past and be unhappy with being pregnant.
‘The atmosphere was tense in the house’ a South African mother’s story.
Further research is needed to establish the best way to identify women at risk of domestic violence or intimate partner violence. A recent systematic review showed that there is promising evidence to indicate that mental health interventions for mothers may reduce their experiences of IPV. However, further research is required to determine the mechanisms and intensity of these interventions.
- Training and supervision
Trauma-informed care, empathy training, referral-making skills and safety planning should be embedded as an integral part of the training and supervision systems for all frontline workers who engage with mothers, across different sectors.
Clinical and policy guidelines provided by the World Health Organisation are available here.
- Systems strengthening
Political will, with the attendant resource allocation, is required to develop the structures able to protect and support survivors. These structures in health (physical and mental), justice, and the non-governmental sectors should operate in a co-ordinated and mutually enhancing way.
The World Health Organisation has produced an excellent manual for health managers for systems strengthening to respond to women subjected to IPV and sexual violence. This includes building awareness, advocating, analysing and planning as well as addressing leadership and governance factors.