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Violence against Women during Pregnancy, Postpartum, and Breastfeeding

By Kathleen Kendall-Tackett, Phd, IBCLC

From Breastfeeding Abstracts, volume 25, number 4, pp. 25-27.

Violence against women (VAW) is an unfortunate fact of life for millions of women around the world, and mothers are not immune. A recent study of 332 postpartum women in Toronto found that 14% reported a history of child sexual abuse, 7% reported child physical abuse, 13% reported adult sexual abuse, 7% reported adult physical abuse, and 30% reported adult emotional abuse.1 In the past seven years, researchers have tried to understand how both past and present violence impacts childbearing. This article summarizes these recent studies.

Pregnancy. According to a recent review, 2 high-risk sexual activity is substantially more common among sexual abuse survivors than their non-abused peers, and this dramatically increases the risk for, among other things, teen motherhood. Specifically, teens who have been sexually abused are more likely to engage in consensual sexual activity at an earlier age, have more lifetime sexual partners, and participate in high-risk sexual activity including not using condoms or contraceptives. However, at least one study of psychiatric disorders during pregnancy found that not all teen mothers have a history of maltreatment or abuse. 3 This study included 252 pregnant teens from Montreal. Among this group, 79% had no reported history of sexual or physical abuse. However, 21% reported multiple forms of past abuse. Only sexual abuse was related to depression during pregnancy.

A history of abuse also impacts women’s physical health during pregnancy. In one study, women from a community sample with a history of child sexual abuse were more likely to smoke, report more health complaints, and use more healthcare services during pregnancy than their non-abused pregnant counterparts. 4 In a nationally representative sample of mothers of children under age three (N=1220) in the US, women with a history of child sexual abuse were more likely to have had an unwanted pregnancy and late prenatal care. 5 These two symptoms may also indicate the presence of current intimate partner violence. 6 In a study of 248 married, pregnant women in Kuwait, 17% reported a lifetime history of assault. Not surprisingly, assault history was related to depressive symptoms during pregnancy, even after controlling for family stress. 7

Postpartum. Women with a history of past or current abuse are more likely to be depressed in the postpartum period. In a three-year follow-up of Australian mothers with postpartum major depressive disorder, half had a history of child sexual abuse. The women with a history of sexual abuse had significantly higher depression and anxiety scores, greater life stresses, and less improvement in their symptoms over time compared to the depressed women without a history of abuse. 8 Another study found that women with a history of abuse or depression reported more postpartum physical health symptoms. 1 Lutz conducted a qualitative study of 12 women who were survivors of intimate partner violence during at least one childbearing cycle. 9 Among these women, depression, posttraumatic stress disorder (PTSD), and anxiety were common. The study participants reported many types of violence during their lives: child physical, emotional, and sexual abuse; neglect; parental intimate partner violence and substance abuse; current intimate partner violence; adult sexual assault; and community violence. The women experienced each exposure to violence as influencing and flowing into the next. They viewed intimate partner violence in the childbearing cycle as just another part of the continuum of abusive experiences.

Unfortunately, pregnancy does not offer women protection from intimate partner violence. Three recent, large population-based studies found that many women are beaten during pregnancy and during the postpartum period. In a study from China that included 32 communities, 8.5% of women were beaten before pregnancy, 3.6% during pregnancy, and 7.4% after pregnancy. 10 In a study from North Carolina, USA (N=2648), 6.9% were beaten before pregnancy, 6.1% during pregnancy, and 3.2% postpartum. 11 Finally, in a study in Bristol Avon, UK (N=7591), 5% were beaten during pregnancy and 11% postpartum. 12 In a study of 570 teen mothers in Galveston, TX, prevalence of postpartum intimate partner violence was highest at 3 months (21%) and lowest at 24 months (13%). Seventy-five percent of mothers beaten during pregnancy were also beaten during their first 2 years postpartum. However, 78% who experienced intimate partner violence at 3 months postpartum had not reported intimate partner violence during their pregnancy. 13

Breastfeeding. The journal Pediatrics published a 2006 review of 94 studies on how exposure to parental intimate partner violence affects children. It also asked the question, “Are women who are abused by their partners less likely to breastfeed?” 14 The review authors concluded that there was insufficient evidence to draw a conclusion. They cited a study that found no difference between abused and non-abused women in initiation or duration of breastfeeding in a WIC population. 15 In this study, approximately 52% of the women had a history of abuse, and 13% had been hit in the past year. Among the women currently being abused, the number of women who breastfed (N=11) was almost identical to the number of women who bottle-fed (N=10).

Although these findings are a reason to be hopeful, they have not been replicated. Unfortunately, women involved in currently abusive relationships face significant barriers to breastfeeding. Researchers have identified several barriers to breastfeeding in the general population of women, and these barriers are more common for women in currently abusive relationships. 16 These include smoking, in general or during pregnancy, 17,18 short hospital stays (abusive partners are less likely to want their partners to remain in the hospital where there is the possibility that someone could detect abuse), 18 having a low birth weight baby or a baby admitted to the Special Care Nursery or NICU (premature delivery or other complications may come about as a result of abuse to the mother), 18,19 and husband’s lack of support for breastfeeding (an abusive husband or partner may be more likely to consider his partner’s breasts to be “his” and not for the baby). 19,20 Research on women who are survivors of past abuse is more hopeful. Women who are sexual abuse survivors are more likely than their non-abused counterparts to report an intention to breastfeed21 and to initiate breastfeeding. 5 At this point, however, we do not know how many continue, nor do we have empirical research that identifies barriers these women may face.

A recent study from Guatemala indicated that women who are highly stressed postpartum and have abnormally high cortisol levels have a delayed onset of lactogenesis II. 22 Women who are abuse survivors often have disturbed function of the hypothalamic-pituitary-adrenal (HPA) axis. This can lead to cortisol levels either being too high (in the case of depression) or too low (in the case of posttraumatic stress disorder) 23—both of which may suppress or delay lactogenesis II. This delay may make it difficult to establish successful breastfeeding without proactive lactation management.

Conclusions. Although data are limited on the impact of VAW on postpartum health, we do know that women experiencing past or current VAW are at increased risk for depression, posttraumatic stress disorder, and physical health consequences postpartum. We also know that there are significant barriers to breastfeeding for VAW survivors, and this has major health implications for women and their babies. However, there are some hopeful signs. Even in the face of significant barriers, women who have experienced violence are breastfeeding their babies. A reasonable goal for health care professionals may be to help make that happen for an even larger number of women.

Kathleen Kendall-Tackett, PhD, IBCLC, is a health psychologist, International Board Certified Lactation Consultant, Research Associate Professor of Psychology at the Family Research Lab, University of New Hampshire, and a Fellow of the American Psychological Association for the Divisions of Health Psychology and Trauma Psychology. She is also a La Leche League Leader, chair of the New Hampshire Breastfeeding Taskforce, and the Area Coordinator of Leaders for La Leche League of Maine and New Hampshire. She is the author or editor of 15 books including Intimate Partner Violence, co-edited with Sarah Giacomoni (in press, Civic Research Institute), The Hidden Feelings of Motherhood (2005, Hale Publications), Depression in New Mothers (2005, Haworth), and Breastfeeding Made Simple, co-authored with Nancy Mohrbacher (2005, New Harbinger). Dr. Kendall-Tackett would like to thank Katy Lebbing, IBCLC, at La Leche League’s Center for Breastfeeding Information, for her help in locating articles on this topic.

References:

    1. Ansara, D., M. M. Cohen, R. Gallop et al. Predictors of women’s physical health problems after childbirth. J Psychosom Obstet Gyn 2005; 26:115-25.

    2. Kendall-Tackett, K. A. Treating the Lifetime Health Effects of Childhood Victimization. Kingston, NJ: Civic Research Institute, 2003.

    3. Romano, E., M. Zoccolillo, and D. Paquette. Histories of child maltreatment and psychiatric disorder in pregnant adolescents. J Am Acad Child Adolesc Psychiatr 2006; 45:329-36.

    4. Grimstad, H., and B. Schei. Pregnancy and delivery for women with a history of child sexual abuse. Child Abuse Neglect 1999; 23:81-90.

    5. Prentice, J. C., M. C. Lu, L. Lange, and N. Halfon. The association between reported childhood sexual abuse and breastfeeding initiation. J Hum Lact 2002; 18:219-26.

    6. Campbell, J. C., and K. A. Kendall-Tackett. Intimate partner violence: Implications for women’s physical and mental health. In Handbook of Women, Stress and Trauma, ed. K. A. Kendall-Tackett. New York: Taylor & Francis, 2005, 123-40.

    7. Nayak, M. B., and M. Al-Yattama. Assault victim history as a factor in depression during pregnancy. Obstet Gynecol 1999; 94:204-8.

    8. Buist, A., and H. Janson. Childhood sexual abuse, parenting, and postpartum depression: A 3-year follow-up study. Child Abuse Neglec 2001; 25:909-21.

    9. Lutz, K. F. Abuse experiences, perceptions, and associated decisions during the childbearing cycle. West J Nurs 2005; 27:802-24.

    10. Guo, S. F., J. L. Wu, C. Y. Qu, and R. Y. Yan. Physical and sexual abuse of women before, during, and after pregnancy. Int J Gynaecol Obstet 2004; 84:281-86.

    11. Martin, S. L., L. Mackie, L. L. Kupper et al. Physical abuse of women before, during, and after pregnancy. JAMA 2001; 285:1581-84.

    12. Bowen, E., J. Heron, A. Waylen et al. Domestic violence risk during and after pregnancy: Findings from a British longitudinal study. Br J Obstet Gynaecol 2005; 112:1083-89.

    13. Harrykissoon, S. D., V. I. Rickert, and C. M. Wiemann. Prevalence and patterns of intimate partner violence among adolescent mothers during the postpartum period. Arch Pediatr Adolesc Med 2002; 156:325-30.

    14. Bair-Merritt, M. H., M. Blackstone, and C. Feudtner. Physical health outcomes of childhood exposure to intimate partner violence: A systematic review. Pediatrics 2006; 117:278-90.

    15. Bullock, L. F., M. K. Libbus, and M. R. Sable. Battering and breastfeeding in a WIC population. Can J Nurs Res 2001; 32:43-56.

    16. Kendall-Tackett, K. A., and S. Giacomoni, eds. Intimate Partner Violence. Kingston, NJ: Civic Research Institute, in press.

    17. Amir, L. H., and S. M. Donath. Does maternal smoking have a negative physiological effect on breastfeeding? The epidemiological evidence. Birth 2002; 29:112-23.

    18. Heck, K. E., K. C. Schoendorf, G. F. Chavez et al. Does postpartum length of stay affect breastfeeding duration? A population-based study. Birth 2003; 30:153-59.

    19. Scott, J. A., C. W. Binns, K. I. Graham et al. Temporal changes in the determinants of breastfeeding initiation. Birth 2006; 33:37-45.

    20. Kong, S. K., and D. T. Lee. Factors influencing decision to breastfeed. J Adv Nurs 2004; 46:369-79.

    21. Benedict, M., L. Paine, and L. Paine. Long-Term Effects of Child Sexual Abuse on Functioning in Pregnancy and Pregnancy Outcome. Final report, National Center on Child Abuse and Neglect. Washington, DC: National Center on Child Abuse and Neglect, 1994.

    22. Grajeda, R., and R. Perez-Escamilla. Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women. J Nutr 2002; 132:3055-60.

    23. Kendall-Tackett, K. A. Physiological correlates of childhood abuse: Chronic hyperarousal in PTSD, depression, and irritable bowel syndrome. Child Abuse Negl 2000; 24:799-810.

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