Intimate Partner Violence and Antenatal Depression Among Underserved Pregnant Women

Abstract

Introduction:

Few studies have examined the associations of intimate partner violence (IPV) exposure during pregnancy and types of IPV with antenatal depression among underserved pregnant women.

Methods:

Data came from participants from a Healthy Start program in South Carolina between 2015 and 2019 (n = 1,629). The first two questions in the Woman Abuse Screening Tool (WAST) were used to measure IPV exposure, that is, having a problematic relationship with their partner. Those who had IPV exposure were assessed with six additional questions of the WAST. Principal component analysis was conducted on the 8-item WAST data to identify underlying types of IPV exposure. Antenatal depression was defined as the Center for Epidemiologic Studies Depression scores ≥16.

Results:

Participants were racially diverse (71% black, 21% white) with 85% Medicaid recipients. Nearly 12% of participants reported IPV exposure and 30% reported antenatal depression. The odds of having IPV exposure were higher among unmarried women, those with less than a high school education, and those who lacked family support. The odds of having antenatal depression were 2.5 times higher (95% CI: 1.9–3.5) among women with IPV exposure. After controlling for covariates, a one-point increase in the scores for psychological IPV (Factor 1) or a problematic relationship (Factor 3) was associated with increased odds of antenatal depression.

Conclusion:

This is one of the first studies to estimate the prevalence of IPV exposure using a proxy measure (a problematic relationship) among underserved U.S. pregnant women. Its positive association with antenatal depression suggests the utility of screening for a problematic relationship using a two-item WAST and providing assistance to those with IPV exposure.

Introduction

Intimate partner violence (IPV) is domestic violence caused by an intimate partner or spouse. IPV can occur in different forms, encompassing physical violence (e.g., slapping, hitting, or beating by a partner), sexual violence (e.g., forcing sexual intercourse and other forms of coercion), and psychological violence, such as intimidation, humiliation, or threats of harm. According to the Centers for Disease Control and Prevention’s (CDC) National Intimate Partner and Sexual Violence Survey, about 2 in 5 (41.0% or 51.2 million) women in the United States have experienced IPV and reported IPV-associated consequences over their lifetime.¹ According to the U.S. national surveys, approximately 3% to 9% of pregnant individuals reported experiencing IPV during pregnancy.^2

–5 Women with IPV during pregnancy have increased risks for adverse pregnancy outcomes (i.e., low birthweight, preterm births),^6
–8 perinatal death (i.e., stillbirths, neonatal death),⁷ substance use,^9,10 and pregnancy-associated suicides and suicidal ideation.^11,12 Women with low socioeconomic status (e.g., Medicaid recipients), racial/ethnic minorities, and those who are unmarried are more likely to experience IPV,^13
–15 yet few studies have examined the prevalence of IPV and its correlates among these high-risk and underserved pregnant women using recent data.

Maternal depression is a growing public health concern in the United States and about 15.2% of U.S. women reported depression during pregnancy.¹⁶ To the best of our knowledge, the relationship between IPV exposure and maternal depression among U.S. pregnant women is inconclusive. Several clinic-based studies from the United States explored the association between distinct types of IPV, namely, physical, sexual, and psychological IPV, and depression.^17
–19 Yet these studies were likely underpowered and inconclusive due to their limited sample sizes (n < 250). Ogbonnaya et al.¹⁸ found an association between physical IPV and depressive symptoms during pregnancy. Conversely, Kastello et al.¹⁹ reported no statistically significant association between physical IPV exposure and depression. Several studies have identified that psychological IPV or emotional abuse during pregnancy, a more prevalent form of IPV than physical and sexual abuse reported in North America,²⁰ is more likely to be associated with mental health issues.^17,19,21 Thus, it is crucial to reexamine the associations between different types of IPV and depression, utilizing a relatively large sample.

Furthermore, having a problematic relationship characterized by experiencing tension, difficulties, conflicts, and possessiveness with an intimate partner is an important risk factor for IPV.^13,22 An ecologic model investigating the drivers of IPV shows that having a problematic relationship increases the risk of IPV.²² To the best of our knowledge, little is known about the association between having a problematic relationship and depression among low-income pregnant women. Screening for problematic relationships with intimate partners can be the first step in identifying and preventing IPV among pregnant women.

To address gaps in literature, this study aimed to (1) delineate the prevalence of having a problematic relationship or IPV exposure, and their correlates and (2) investigate the associations between IPV exposure, different types of IPV, and antenatal depression among pregnant women. We hypothesized that IPV exposure and experiencing any types of IPV would be positively associated with antenatal depression after adjusting for other known confounding factors.

South Carolina (SC) is ranked 44th in maternal and child health outcomes in the United States, indicating a pressing need for improvement.²³ More than 40% of SC women (42.3%) reported experiencing sexual violence, physical violence, or stalking victimization by an intimate partner at some point in their lives. Moreover, 10.6% of SC women reported such victimization in the past 12 months, ranking the state highest nationally.²⁴ Therefore, insights from a state with elevated levels of IPV and suboptimal maternal and child health outcomes are crucial for informing future interventions and prevention program planning and design.

Methods

Study population

The study focuses on participants enrolled in the Midlands Healthy Start (MHS) program at Prisma Health, a member of the National Healthy Start Initiative, which has been actively serving a predominantly African American and underserved pregnant population along with their newborns in the Midlands area of South Carolina since 1998. The MHS program recruited participants from local hospitals, obstetrician-gynecologist offices, managed care organizations, and other community programs. The mission of MHS is to improve maternal health and reduce racial/ethnic disparities in infant mortality and adverse birth outcomes.²⁵ This study used baseline data from 1831 pregnant participants who lived in the Sumter, Lexington, and Richland Counties of SC, who were served by MHS during the period spanning 2015–2019. This study included all participants being identified as pregnant women. Baseline data were collected at enrollment, which included sociodemographic characteristics, pregnancy history, mental health assessment, and screening of intimate partner relationships. All participants provided written informed consent at enrollment. This study was approved by our university’s Institutional Review Board. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were used.

IPV measures

The 8-item Women Abuse Screen Tool (WAST) was used to identify problematic intimate relationships and screen for different types of IPV.²⁶ The first two questions in the WAST, referred to the short form of the WAST (WAST-short), explore the general dynamics of the participant’s relationship status with intimate partners, assessing whether the participant was exposed to IPV.^26

–29 Participants were asked, (1) “Is there any tension in the relationship … a lot of tension, some tension, no tension and (2) how do you and your partner work out arguments … great difficulty, some difficulty, no difficulty?” Following the definition used in validation studies of the WAST-short and other assessments of intimate partner relationships,^26

–29 the participants who answered with “a lot of tension” and/or “great difficulty” to the WAST-short were considered to have a problematic intimate relationship or risk of IPV. Participants who answered “a lot of tension” and/or “great difficulty” to the first two questions in WAST proceeded to answer six additional questions to assess the frequency of three types of IPV (i.e., physical, emotional, sexual IPV) stemming from arguments with their partner and/or regardless of arguments. The WAST-short demonstrated good accuracy, with an area under receiver operating characteristic curve (AUC) of 0.73 and a reliability of Cronbach’s alpha of 0.80 in detecting IPV during pregnancy among underserved women.^30,31

Principal component analysis (PCA), a multivariate data reduction method, was used to summarize participants’ responses to the 8-item WAST. PCA facilitated the extraction of uncorrelated orthogonal factors and principal factors that explained at least a cumulative variance of 70% was retained. Factor scores, indicative of the degree of distinct IPV behaviors, were calculated using a linear composite of optimally weighted responses to the WAST. Higher scores suggested a higher likelihood of participants experiencing specific types of IPV behaviors. The interpretation of the principal factors was also considered. The factor scores from PCA were used in the remaining analyses to examine the association between IPV exposure, three types of IPV, and antenatal depression.

Antenatal depression measure

Participants with antenatal depression were identified using the 20-item validated Center for Epidemiologic Studies Depression Scale (CES-D).^32,33 The CES-D screened participants’ symptoms associated with depression in the past week, including indicators such as sadness, restless sleeping, poor appetite, loneliness, and fatigue. Responses ranged from 0 to 3 (0 = not at all, to 3 = nearly every day). The total score ranged from 0 to 60, with a higher score indicating a higher level of depressive symptoms. In this study, pregnant women with CES-D scores of 16 points or greater were categorized as having antenatal depression symptomology.³³

Statistical analysis

First, the χ ² test or Fisher’s exact test was used to assess the association between IPV exposure and its correlates. Multivariable logistic regression models were used to examine the correlates of IPV exposure. Covariates of interest included maternal age (<20 years old, 20–24 years old, 25–29 years old, and 30+ years old), race/ethnicity (non-Hispanic African American, non-Hispanic white, and other races), education (less than high school, high school or GED, high school diploma and above), marital status (unmarried and married), Medicaid status, parity (nulliparous and parous), lack of family support, current smoking, drinking alcohol, and experiencing homelessness. For the final model, participants who smoked (P = .96) and consumed alcohol (P = .60) during pregnancy were excluded based on ANOVA test. Due to the high correlations between homelessness and lack of family support (Fisher’s exact test P < .001), we did not include homelessness in our final model.

Furthermore, we used PCA to reduce dimensionality for the 8-item IPV measure. Factor scores were computed for each identified component through PCA. Multivariable logistic regression models were used to examine the association between factor scores representing IPV components and antenatal depression. The analyses were adjusted for the previously mentioned covariates, excluding homelessness. All analyses for this study were performed using SAS 9.4 (SAS Institute Inc., Cary, North Carolina).

Results

Among 1831 participants served by the Midlands Healthy Start program, 171 participants had missing values in IPV exposure and antenatal depression measures and 31 participants had missing data in the covariates (e.g., education, marital status). After deleting participants with missing data, 1629 participants with complete data were used in this study. To examine possible bias due to the deletion of participants with missing data, five multiple imputations for covariates with missing data were conducted. No qualitative differences in results were observed between the imputed sample and the sample with complete data.

The mean (SD) gestational age at enrollment for this study population was 21.65 (9.12) weeks. As shown in Table 1, our participants were on average (SD) 25.35 years old (5.87) and racially diverse (70.60% non-Hispanic black, 21.18% non-Hispanic white, 2.70% Hispanics, 5.52% other or unknown race). The majority of participants had a high school diploma or lower (76.40%), were unmarried (81.34%), and were also Medicaid recipients (84.78%).

Table 1.

Characteristics of Study Participants and the Prevalence of Intimate Partner Violence Exposure (N = 1,629)

Characteristic	Total n (%)	IPV exposure-problematic relationship n (%)	p-value
N	1,629 (100.00)	194 (11.91)
Age			0.08
<20 years old	282 (17.31)	39 (13.83)
20–24 years old	513 (31.49)	72 (14.04)
25–29 years old	449 (27.56)	48 (10.69)
30+ years old	385 (23.63)	35 (9.09)
Race/ethnicity			0.05
Non-Hispanic black	1,150 (70.60)	150 (13.04)
Non-Hispanic white	345 (21.18)	35 (10.14)
Other races^a	134 (8.23)	9 (6.72)
Education			<0.001
Less than high school	315 (19.34)	54 (17.14)
High school or G.E.D.	929 (57.03)	112 (12.06)
High school above	385 (23.63)	28 (7.27)
Marital status			<0.001
Unmarried	1,325 (81.34)	181 (13.66)
Married	304 (18.66)	13 (4.28)
Insurance type			<0.001
Medicaid	1,381 (84.78)	178 (12.89)
Non-Medicaid^b	248 (15.22)	16 (6.45)
Gravidity			0.95
Nulliparous	618 (37.94)	74 (11.97)
Parous	1,011 (62.06)	120 (11.87)
Family support			<0.001
Lack of family support	56 (3.44)	18 (32.14)
Had family support	1,573 (96.56)	176 (11.19)
Current smoking			0.15
Yes	76 (4.67)	13 (17.11)
No	1,553 (95.33)	181 (11.65)
Drinking alcohol			0.36
Yes	50 (3.07)	8 (16.00)
No	1,579 (96.93)	186 (11.78)
Experiencing homeless			<0.001
Yes	66 (4.05)	20 (30.30)
No	1,563 (95.95)	174 (11.13)

The participants with other races included 44 Hispanics (2.70%), 45 non-Hispanic others (2.76%), and 45 participants with unknown race (2.76%).

The participants with non-Medicaid included 128 participants having private health insurance (7.86%), 22 participants having other types of insurance (1.35%), 88 participants who did not have health insurance (5.40%), and 10 participants with unknown insurance information (0.61%).

IPV, intimate partner violence; G.E.D, General Education Development.

Nearly 12% (11.91%) of our study population had a problematic relationship with their intimate partner, considered exposure to IPV. Having IPV exposure was significantly associated with race/ethnicity (P = 0.05), education level (P < 0.001), Medicaid status (P < 0.001), marital status (P < 0.001), availability of family support (P < 0.001), and status of homelessness (P < 0.001).

After adjusting for covariates, the odds of having IPV exposure were higher among women with less than high school education (adjusted odds ratio [aOR], 2.01; 95% confidence interval [CI], 1.18–3.42), unmarried status (aOR, 2.64; 95% CI, 1.45–4.84), and participants who reported lack of family support (aOR, 3.41; 95% CI, 1.87–6.21) (Table 2).

Table 2.

Logistic Regression for Intimate Partner Violence Exposure and Its Covariates (N = 1,629)^a

	IPV exposure-problematic relationship
Effect	cOR (95% CI)	p value	aOR (95% CI)	p-value
Age
<20 years old	1.61 (0.99–2.61)	0.06	1.10 (0.61–2.00)	0.75
20–24 years old	1.63 (1.07–2.50)	0.02	1.37 (0.85–2.19)	0.20
25–29 years old	1.20 (0.76–1.89)	0.44	1.03 (0.64–1.66)	0.90
30+ years old	1.00 [Reference]
Race/ethnicity
Non-Hispanic black	1.33 (0.90–1.96)	0.15	1.24 (0.83–1.85)	0.30
Other races	0.64 (0.30–1.37)	0.25	0.63 (0.29–1.38)	0.25
Non-Hispanic white	1.00 [Reference]
Education
Less than high school	2.64 (1.63–4.28)	<0.001	2.01 (1.18–3.42)	0.01
High school or G.E.D.	1.75 (1.13–2.69)	0.01	1.32 (0.84–2.08)	0.23
High school above	1.00 [Reference]
Marital status
Unmarried	3.54 (1.99–6.31)	<0.001	2.64 (1.45–4.84)	<0.001
Married	1.00 [Reference]
Insurance type
Medicaid	2.15 (1.26–3.65)	0.97	1.52 (0.88–2.64)	0.14
Non-Medicaid	1.00 [Reference]
Gravidity
Nulliparous	1.01 (0.74–1.38)	0.95	0.89 (0.61–1.28)	0.52
Parous	1.00 [Reference]
Family support
Lack of family support	3.76 (2.10–6.73)	<0.001	3.41 (1.87–6.21)	<0.001
Had family support	1.00 [Reference]

The effect of age groups, race/ethnicity, education level, marital status, Medicaid recipient, gravidity, and availability of family support were adjusted for the logistic model.

IPV, intimate partner violence; cOR, crude odds ratio; aOR, adjusted odds ratio; 95% CI, 95% confidence interval.

Nearly one-third (28.91%) of pregnant women experienced antenatal depression (total CES-D score ≥ 16 points). After adjusting for covariates, the women who were exposed to IPV had a 2.54 (95% CI, 1.86–3.48) times higher odds of depression than the women who were not exposed to IPV (Table 3).

Table 3.

Association Between Intimate Partner Violence Exposure and Antenatal Depression (N = 1,629)^a

	Antenatal depression (CESD scores ≥ 16) (n = 471)
Characteristics	n (%)	cOR (95% CI)	aOR (95% CI)
Had IPV exposure-problematic relationship
Yes	97 (50.00)	2.84^* (2.09–3.85)	2.54^* (1.86–3.48)
No	374 (26.06)	1.00 [Reference]
Age
<20 years old	102 (36.17)	1.44 (1.03–1.99)	1.23 (0.81–1.89)
20–24 years old	141 (27.49)	0.96 (0.72–1.29)	0.89 (0.64–1.24)
25–29 years old	119 (26.50)	0.91 (0.67–1.24)	0.87 (0.63–1.19)
30+ years old	109 (28.31)	1.00 [Reference]
Race/ethnicity
Non-Hispanic black	326 (28.35)	0.88 (0.68–1.14)	0.81 (0.61–1.06)
Other races	107 (31.01)	0.88 (0.57–1.37)	0.86 (0.54–1.35)
Non-Hispanic white	38 (28.36)	1.00 [Reference]
Education
Less than high school	120 (38.10)	1.78^* (1.29–2.45)	1.3 (0.9–1.89)
High school or G.E.D.	252 (27.13)	1.08 (0.82–1.41)	0.93 (0.7–1.25)
High school above	99 (25.71)	1.00 [Reference]
Marital status
Unmarried	404 (30.49)	1.55^* (1.16–2.08)	1.34 (0.97–1.86)
Married	67 (22.04)	1.00 [Reference]
Insurance type
Medicaid	415 (30.05)	1.47^* (1.07–2.03)	1.31 (0.93–1.84)
Non-Medicaid	56 (22.58)	1.00 [Reference]
Gravidity
Nulliparous	176 (28.48)	0.97 (0.78–1.21)	0.85 (0.65–1.11)
Parous	295 (29.18)	1.00 [Reference]
Family support
Lack of family support	31 (55.36)	3.19^* (1.86–5.47)	2.47^* (1.41–4.32)
Had family support	440 (27.97)	1.00 [Reference]
Currently smoking
Yes	23 (30.26)	1.07 (0.65–1.77)	0.82 (0.48–1.40)
No	448 (28.85)	1.00 [Reference]
Drinking alcohol
Yes	16 (32.00)	1.16 (0.64–2.13)	1.06 (0.56–1.99)
No	455 (28.82)	1.00 [Reference]
Experiencing homeless
Yes	38 (57.58)	3.54^* (2.15–5.84)	n/a^b
No	433 (27.70)

The effect of age groups, race/ethnicity, education level, marital status, Medicaid recipient, gravidity, availability of family support, and present status of smoking and drinking alcohol were adjusted for the logistic model.

The effect of homelessness was excluded, due to a strong association with family support (P < .001).

p < 0.05.

IPV, intimate partner violence; CESD, Center for Epidemiologic Studies Depression Scale; cOR, crude odds ratio; aOR, adjusted odds ratio; 95% CI, 95% confidence interval; G.E.D., General Education Development.

Data from all participants (n = 1501) who completed the 8-item WAST were used in the PCA. The scree plot (Supplementary Fig. S1) indicated three components or factors, collectively explaining 77.77% of the total variance (Factor 1, 54.17%; Factor 2, 14.34%; and Factor 3, 9.26%). Table 4 lists the factor loadings and variances explained by each question from the PCA after varimax rotation. Factor 1 exhibited elevated loadings in the questions that screened for any psychological effects from IPV, such as feeling bad or frightened. Factor 2 displayed high loadings in the questions that screened for physical abuse, such as hitting, kicking, or pushing, and sexual abuse. Factor 3 demonstrated high loadings in questions designed to identify a problematic relationship or challenges encountered during arguments with an intimate partner.

Table 4.

Rotated Factor Pattern and Communality Estimates from the Principal Component Analysis of 8-Item Women Abuse Screen Tool (N = 1,501)^a

8-item WAST question	Factor 1	Factor 2	Factor 3	h^2b
1. In general, how would you describe your relationship?	0.25	0.14	0.80^c	0.72
2. Do you and your partner work out arguments with:	0.17	0.14	0.84^c	0.76
3. Do arguments ever result in you feeling down or bad about yourself?	0.82^c	0.09	0.30	0.78
4. Do arguments ever result in hitting, kicking, or pushing?	0.40	0.82^c	0.12	0.85
5. Do you ever feel frightened by what your partner says or does?	0.71^c	0.51	0.12	0.78
6. Has your partner ever abused you physically?	0.51	0.74^c	0.07	0.82
7. Has your partner ever abused you emotionally?	0.82^c	0.32	0.27	0.84
8. Has your partner ever abused you sexually?	0.03	0.80^c	0.20	0.67

n = 1,501participants who either completed the WAST or followed the skip patterns of WAST were included in the PCA.

h ² stands for communality estimates. The communality reflects the variance in corresponding question that is accounted for by the retained components.

This number indicated the associated question have a high influence in a certain factor. Specifically, items 3,5,7 have a high influence in Factor 1—psychological IPV, items 4,6,8 have a high influence in Factor 2—physical and sexual IPV; and items 1, 2 have a high influence in Factor 3—having a problematic intimate relationship.

WAST, Women Abuse Screen Tool.

After controlling for covariates, a one-point increase in Factor 1 (psychological IPV) was associated with increased odds of antenatal depression (aOR, 1.30; 95 CI%, 1.15–1.46), and a one-point increase in Factor 3 (a problematic relationship with their partners) was also associated with increased odds of antenatal depression (aOR, 1.62; 95% CI, 1.44–1.82) (Table 5).

Table 5.

Association Between Intimate Partner Violence Factors and Antenatal Depression (N = 1,501)^a

	Antenatal depression (CESD scores ≥ 16)
IPV factors	Mean (SD)	cOR (95% CI)	aOR (95% CI)
1. Psychological IPV	0.22 (1.53)	1.31^* (1.17–1.46)	1.30^* (1.15–1.46)
2. Physical and sexual IPV	0.03 (1.63)	1.04 (0.93–1.15)	1.02 (0.91–1.14)
3. Having a problematic relationship	0.38 (1.14)	1.65^* (1.48–1.85)	1.62^* (1.44–1.82)

p < 0.05.

IPV, intimate partner violence; CESD, Center for Epidemiologic Studies Depression Scale; cOR, crude odds ratio; aOR, adjusted odds ratio; 95% CI, 95% confidence interval.

Discussion

This study revealed that nearly 12% of pregnant women had IPV exposure, signifying problematic intimate relationships with their partners. In addition, nearly 30% of women had antenatal depressive symptoms (CESD ≥ 16). We also identified significant correlates of having IPV exposure. Moreover, our findings indicated that the women scoring higher in psychological IPV factor or in having problematic relationship factor had increased odds of antenatal depression.

Given different questions were used to screen IPV across studies,^2,4 it is difficult to directly compare our estimate of IPV exposure with the prevalence of IPV during pregnancy from published studies. For instance, the Pregnancy Risk Assessment Monitoring System (PRAMS) used a single question (During your most recent pregnancy, did your husband or partner push, hit, slap, kick, choke, or physically hurt you in any other way?) to screen for partner-related physical violence. In our study, the IPV exposure was based on the WAST-short, that is, a problematic relationship with intimate partner. In comparison with the prevalence of IPV in studies that used the WAST-short with the same categorization method to screen individuals regardless of their pregnancy status, the prevalence of IPV in our study (11.91%) was relatively higher than the prevalence reported elsewhere (range: 7–12.5%).^26,28,34 A small study (n = 166) conducted in Baltimore, Maryland, utilized a five-item Abuse Assessment Screen (AAS)-measured IPV.³⁰ Their study found that IPV prevalence can be as high as 19% among low-income urban pregnant women. The higher prevalence of IPV exposure in our study may be attributable to the low socioeconomic status of our study population.

With respect to correlates of IPV exposure, our study confirmed significant correlates of IPV as shown in previous studies.^31,35,36 Our study found that pregnant women who were unmarried (including never married, divorced, separated or widowed), did not graduate from high school, or who reported a lack of family support were more likely to have IPV exposure. Consistent with previous studies, this study also found that the odds of IPV exposure were higher among young pregnant women (<25 years old).³⁶ However, young age became an insignificant correlate after adjusting for other covariates, indicating that other factors associated with young age, such as education level and marital status, may contribute to IPV.

Importantly, this study indicated that nearly 30% of pregnant women might have antenatal depression based on the validated CES-D instrument, nearly twice the prevalence of 15.2% among general pregnant women based on a national U.S. survey, which used self-reported depression, not a validated instrument.¹⁶ The higher proportion of pregnant women experiencing depression in our study could be attributed to the disadvantaged backgrounds of our study population as indicated by their low education, being unmarried, Medicaid recipients, and unstable housing. These findings are consistent with prior studies by showing that pregnant women with low socioeconomic status were more likely to experience depression and family support being a protective factor against antenatal depression.^37
–39

Moreover, after adjusting for covariates, the odds of antenatal depression were twice as high among pregnant women who had IPV exposure. To further investigate which form of IPV was associated with depression, we conducted PCA to explore the factor structure in the responses to the WAST. Our analysis identified the following three IPV factors: psychological factor, physical and sexual abuse, and a problematic intimate relationship. Regression results utilizing three-factor scores supported previous findings.^17,19,21 Surprisingly, we did not find a significant association between physical/sexual abuse (Factor 2) and antenatal depression, which may be attributed to the low reported prevalence (1.47% and 0.53%, respectively) in our study population, with the possibility that women may be unwilling to disclose this type of abuse.

The strengths of the study include a large, racially diverse sample consisting of underserved pregnant women in the Midlands SC area and the application of an in-depth quantitative analysis with validated measurement tools (e.g., WAST and CES-D). To the best of our knowledge, our study is the first one among other published studies to apply the data-driven method, PCA, to summarize factor structure underlying the responses of IPV assessment, as well as to incorporate these factor scores into the regression model of antenatal depression.

This study had several limitations. First, due to the cross-sectional study design, our results cannot infer a causal relationship between IPV exposure (i.e., problematic relationship) during pregnancy and antenatal depression. Second, our findings can only be generalized to pregnant people with similar sociodemographic characteristics because our sample mostly included underserved pregnant women. Third, the prevalence of antenatal depression may be overestimated due to similar symptoms associated with pregnancy. For instance, the questions related to loss of appetite and poor sleep quality in CES-D might be impacted by hormonal changes in pregnancy rather than depression.⁴⁰ Prior literature considered antenatal depression as a mental consequence of a mixture of hormonal changes and psychosocial factors.⁴¹ Moreover, due to differences in IPV measure and skip pattern on the 8-item WAST, the prevalence of IPV exposure found in our study might not reflect the true prevalence of physical abuse or violence in this population. However, the literature showed that the 8-item WAST and the 3-item Partner Violence Screen,⁴² the other measure being widely used for screening IPV in health care settings, had similar sensitivities (47% versus 49.2%) and specificities (95.6% versus 93.7%).^34,43 Last but not least, our study analyzed the data collected from 2015 to 2019, before the COVID-19 pandemic. We believe that our findings are still relevant to the postpandemic era as we observe a return to prepandemic norms.

Our study provides insight on the prevalence of IPV exposure among high-risk underserved pregnant women served by a community organization. The relatively high prevalence of IPV exposure found in this study underscores the importance of implementation and execution of domestic violence policies and laws, as well as the establishment or continuation of local support programs and shelters for these pregnant women. Despite the recommendation of IPV screening by the American College of Obstetricians and Gynecologists (ACOG),⁴⁴ our national data revealed that among respondents who experienced physical violence, 58.7% and 26.9% were not screened before or during pregnancy.⁵ The positive association between IPV (proxied as a problematic relationship) and antenatal depression suggests the utility of using the 2-item WAST scale to screen for IPV in health care services, prenatal care, and other health care systems. Prior validation studies on the WAST and WAST-short have demonstrated the ease and comfort for both respondents and interviewers, which make them well-suited for use in health practice settings and community programs.^26,28 For those with a positive 2-item WAST screening, it is crucial to incorporate screening for the types of IPV. Our study emphasizes that problematic intimate relationships and psychological IPV exhibit a stronger association with antenatal depression. If any potential exposures to IPV or warning signs to depression are identified, immediate access to further services and referrals, such as consultation with social workers, utilization of domestic violence community resources, referral to supportive or mental health services, must be provided.

Conclusion

Utilizing the data from a relatively large community sample with a predominantly low-income and African American population, our study revealed elevated prevalence of having a problematic relationship with intimate partners, considered IPV exposure, and its positive association with antenatal depression. Considering the low screening rates among those with IPV exposure,⁵ our findings also suggest the need for using a brief 2-item screening for problematic relationships with intimate partners and then using the additional 6-item measure to identify the types of IPV among pregnant women in community health programs, such as the federally funded Healthy Start programs, which mostly serve underserved populations. This is particularly crucial because these women tend not to seek early prenatal care through health care systems. Home visiting programs can play a pivotal role by offering referrals to the individuals who are screened positive for IPV.²⁵ Our findings suggest that IPV screening based on a problematic relationship, additional screening of IPV types, and subsequent referrals for those with IPV exposure as a promising strategy to prevent antenatal depression among underserved pregnant women. Future studies should continue to evaluate the impact of these services on mental health and pregnancy outcomes within the underserved population.

Footnotes

Acknowledgments

The authors express their thanks to the Healthy Start participants as well as to the outreach workers at the Midlands Healthy Start program for their time and efforts in program participation and data collection. Lastly, the authors express gratitude to the reviewers and editors who have dedicated their time and expertise, providing invaluable insights and constructive suggestions that have significantly improved the quality and depth of this article.

Authors’ Contributions

X.Z.: Conceptualization, methodology, software, formal analysis, data curation, visualization, and writing—original draft. J.L.: Conceptualization, methodology, software, data curation, validation, writing—review and editing, and supervision. M.J.B.: Methodology, validation, and writing—review and editing. K.A.: Methodology, data curation, and writing—review and editing.

Author Disclosure Statement

The authors have no conflicts of interest to disclosure.

Funding Information

This study was supported by the Maternal and Child Health (MCH) Graduate Scholarship from the Maternal Child Health Catalyst Program at the University of South Carolina, which was sponsored by the U.S. Department of Health and Human Services Health Resources and Services Administration (grant number 1T1CMC35361). The Midlands Healthy Start Program was sponsored by the Health Resources and Services Administration (grant number H49-MC00072).

Supplementary Material

Supplementary Figure S1

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