Monograph An-Sofie Van Parys - Intimite Partner Violence and Pregnancy, an Intervention Study in Perinatal Care

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An-Sofie Van Parys successfully defended her PhD thesis on 26/09/2016: entitled: Intimite Partner Violence and Pregnancy, an Intervention Study in Perinatal Care at Ghent University, Faculty of Medicine and Health Sciences.

Supervisors Prof. dr. Marleen Temmerman and Prof. dr. Hans Verstraelen

 

Summary
Background and objectives
Healthy women, men and children are the building blocks of a strong world. While infant and maternal mortality continues to decline, the burden of morbidity in the perinatal period remains a major concern. Psychosocial health and partner violence are two major determinants of poor perinatal outcome and have repeatedly been described as an extensive public health problem with crucial societal and health implications. However, the impact of violence related factors such as fear of childbirth and psychosocial health on the mode of delivery remains little investigated. So far, most studies have focused on the identification and consequences of abuse/violence. There is a lacuna with regards to research on interventions in the health sector to reduce the magnitude and impact of intimate partner violence (IPV). As such, this study contributes to the need to identify effective interventions and how to adopt them within the perinatal care context. Therefore, next to assessing prevalence, determinants and associated obstetric outcomes, our objective is to assess the effect of a perinatal health sector embedded intervention for IPV.

Methods
This research is based on two studies: the BIDENS-study and the MOM-study. The BIDENS-study is a longitudinal cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Sweden and Norway) aiming at assessing violence related factors that may influence pregnant women’s fear of childbirth and mode of delivery. In Belgium, we recruited in three antenatal care clinics between 2008 and 2010. Women were invited when attending antenatal care, and asked to complete a questionnaire containing items on socio-economic background, mental health, violence/abuse, negative life events, fear of childbirth and obstetric history. Birth outcome data was collected from hospital records.
The MOM-study is a Belgian multi-centre study consisting of two phases. The first phase was a cross-sectional prevalence study, and the second phase a single-blind randomized controlled trial (RCT). From June 2010 to October 2012, women seeking antenatal care in eleven Belgian hospitals were invited to participate and handed a questionnaire. The objective of the first phase was to assess the prevalence of physical, psychological and sexual partner violence 12 months before and/or during pregnancy and to provide insight into the evolution of IPV. Participants reporting IPV were randomised into the intervention study aiming at investigating the effect of handing out a referral card, on the evolution of IPV, psychosocial health, help-seeking and safety behaviour during and after pregnancy. Participants in the Intervention Group (IG) received a referral card with contact details of services providing assistance and tips to increase safety behaviour. Participants in the Control Group (CG) received a “thank you” card. Follow-up data on the evolution of IPV, psychosocial health, help-seeking and safety behaviour were obtained through telephone interview at 10-12 months and 16-18 months after receipt of the card. Both groups received the necessary care and support of antenatal caregivers, our intervention aimed at assessing the added value of handing out a referral card.

Results
Prevalence
Our results indicated that violence is a prevalent problem among pregnant women in Belgium as well as in the other five European countries. Lifetime prevalence varied across the six countries (n= 7174) and ranges from 23.2 to 45.4%, with Belgium at the lowest end of the continuum for all forms of abuse/violence. Partners or ex-partners accounted for the largest share of all violence reported and psychological abuse was the type of IPV of that is reported most frequently. In Belgium, physical partner violence before as well as during pregnancy was reported by 2.5% of the respondents (n = 1894), sexual violence by 0.9%, and psychological abuse by 14.9%. The overall percentage of IPV was 14.3% in the 12 months before pregnancy and 10.6% during pregnancy. Our data showed that both physical partner violence and psychological partner abuse are significantly lower during pregnancy.

Associated factors
First, we found a significant correlation between IPV and poor psychosocial health: lower psychosocial health scores were associated with increased odds of reporting IPV. A decrease of 10 points on the psychosocial health scale (total of 140) increased the odds of reporting IPV by 55 %. The association between overall psychosocial health and IPV remained significant after adjusting for socio-demographic status. When accounting for the 6 psychosocial health subscales (depression, anxiety, self-esteem, mastery, worry and stress) simultaneously, only depression and stress remained significantly associated with IPV.
Second, our research showed a limited correlation between a history of abuse/violence and mode of delivery. Having experienced sexual violence as an adult increases the risk of an elective Caesarean Section (CS) among primiparae, in particular for non-obstetrical reasons. Among multiparous women, a history of physical violence increases the risk of an emergency CS.

Interventions
Over a timeline of 1.5 years we observed a significant decline in the prevalence of IPV by 31.4% and a significant increase of psychosocial health (5.4/140) in both the intervention and control group. More than one fifth of all women in our study sought formal help and 70.5% sought informal help. Women reporting IPV showed significantly more formal and informal help-seeking behaviour compared to women not reporting IPV. A third of the women took at least one safety measure, and when IPV was reported, safety measures were taken significantly more frequently. The questionnaire and the interview in this study were perceived as moderately to highly helpful by more than a third of our study group which was significantly higher than the helpfulness of the referral card. Although the benefit of the referral card appeared to be more substantial in the IG, it borderline missed statistical significance. Overall, we found that being questioned about IPV has an impact on our respondents, yet were unable to attribute any of the above findings directly to handing out the referral card.

Conclusion and recommendations
Our findings demonstrate that a substantial proportion of pregnant women report a history of abuse/violence. Psychological partner abuse appears to be the most frequent type of violence reported. The IPV prevalence rates in our study are slightly lower than in other Western studies and physical partner violence and psychological partner abuse is found to be significantly lower during pregnancy. Inspired by these findings we call for a thorough methodological and scientific debate on the definitions of IPV and a corresponding added nuance in terminology, taking the complex context and mutuality into account that are particularly relevant within the perinatal period. It is also crucial to raise public awareness on abusive/violent behaviour within the context of an intimate relationship. Sensitization campaigns promoting positive and non-violent communication starting from early childhood can substantially contribute to reversing the normalization of abuse/violence and eliminating IPV.
Our research also demonstrated that IPV and psychosocial health are strongly associated. We believe that future research is necessary to deepen the understanding of the multitude of factors involved in the complex interactions between IPV and psychosocial health. Because of the important role of psychosocial health found in our study, we would like to join the growing number of authors that advocate the inclusion of IPV within a broader psychosocial health assessment as a standard part of antenatal care.
We have also shown that the correlation between a history of abuse/violence and mode of delivery is limited. However, further longitudinal and large-scale research is needed to explore the complex array of factors that are involved and shed more light on the impact of abuse/violence on obstetric outcome.
The intervention part of this research showed that the detection of even low severity mutual IPV can be a helpful tool in the battle against IPV, though combining the identification with simply the distribution of a referral card is probably not the best means of achieving that goal. Being questioned on IPV has an undeniable impact, acting upon that matter may however require the involvement of a healthcare professional rather than a list of resources. Future interventions should be multifaceted, and thus simultaneously address several factors (such as psychosocial health, substance abuse, social support, cultural norms), delineate different types of violence (intimate terrorism vs. mutual violence), involve informal networks, control for effect of the measurement as such and include a tailored intervention programme adapted to the specific needs of couples experiencing IPV.
 

Authors & affiliation: 
An-Sofie Van Parys - Doctoral Thesis submitted to the Faculty of Medicine and Health Sciences - Ghent University Supervisors Prof. dr. Marleen Temmerman - Prof. dr. Hans Verstraelen
Staff Members: 
Published In: 
Monographs UGent
Publication date: 
Monday, September 26, 2016
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