Abstract
Intimate partner violence (IPV) includes a range of activities inflicted upon a person by a current or former intimate partner. The abuse is often recurrent and patterned, intended at establishing power and control. IPV incidence rates are highest during young adulthood, the dynamics of which are made more complex during and immediately following a pregnancy (the perinatal period). This study focuses on women's perceptions of perinatal IPV. Data come from a qualitative study stemming from a community-based longitudinal project. Participants (n = 301) were screened for lifetime incidence of IPV, and those screening positive (n = 64) were asked to participate in a follow-up interview. Forty women agreed to an interview, and 25 of those described perinatal IPV. Within this subsample, the women were asked to recall the abuse they experienced during and after pregnancy, how it impacted their health and ability to parent, as well as the impacts they believed that the abuse had on their children. Their findings indicate that perinatal IPV is pervasive and consequential. A range of abuse trajectories occurred which left the women feeling demoralized as they entered parenthood. After the birth of their children, the women often shouldered disproportionate caretaking responsibilities in addition to navigating their abusers' ongoing control tactics. While they reported various forms of IPV and recognized that their children had been exposed to it, the women did not often exhibit a clear understanding of how their own victimization impacted their children, prenatally or upon birth. More recognition came in retrospect for those with older children. Understanding the nature of perinatal IPV is critical to identifying early childhood exposure, as well as effectively working with adult survivors to mitigate it.
Introduction
Intimate partner violence (IPV) involves recurrent and patterned victimization by one person against a current or former partner. An estimated 43 million women (1 in 4) experience IPV in their lifetimes (Smith et al. 2018), with the highest rates occurring in young adulthood. Forty-five percent of female victims experience their first assault between ages 18 and 24 and 19% between ages 25 and 34 (Smith et al. 2018), comprising prime childbearing years. Perinatal IPV rates range from 3.7% to 9% (Hahn et al. 2018). Upwards of 83% of abused women's children have been exposed to the violence, with 64% witnessing it by age 3 (McFarlane and Malecha 2005). The effects of IPV exposure on children are severe, with a number of studies examining its impact on birth outcomes and infant well-being (Devries et al. 2010; Donovan et al. 2016). These include increased risk of preterm birth, low birth weight, and infant mortality (Donovan et al. 2016; Hill et al. 2016). Cognitive delays through the first year of life have also been associated with elevated maternal cortisol and psychosocial stress during pregnancy (Davis and Sandman 2010).
Children exposed to IPV exhibit a range of neurophysiological effects, including anxiety, fear of parental separation, inability to bond, and emotional dysregulation (Godbout et al. 2017; Osofsky 2018). PTSD and other mental health diagnoses are common, with 30% of exposed children exhibiting symptoms by age 2 (Stover et al. 2017). That IPV is detrimental to fetuses, infants, and young children is well documented (Van den Bergh et al. 2020); however, much less is known about the perceptions of adult IPV victims. Existing research has not focused explicitly on to what extent pregnant women and new mothers acknowledge or understand the impact of IPV on their children. Examining these perceptions is critical for the development of appropriate and effective interventions that may mitigate the impacts of early IPV exposure.
While abuse dynamics do not typically begin during pregnancy, they are exacerbated by it (Gartland et al. 2011). Women may be manipulated into getting pregnant through false promises, coerced or unprotected sex, and/or sabotaged birth control (Moore et al. 2010; Smith et al. 2018). Pregnancy often increases women's social, economic, and legal ties to their abusers and may serve as an impetus for remaining in the relationship (Lutz 2005). The consequences of this are severe; beyond physical injuries, fear, safety concerns, posttraumatic stress disorder, and depression are common (Karakurt et al. 2014; Kothari et al. 2016; Smith et al. 2018). IPV has also been shown to negatively affect women's utilization of perinatal health care, which is in itself a risk factor for poor birth outcomes (Cha and Masho 2014; Gentry and Bailey 2014).
IPV exposure is detrimental regardless of age, but more so among infants due to their rapid rate of brain development (Grest et al. 2018). While young children lack the ability to protect themselves and are unable to understand the danger surrounding them, research has shown that they are able to sense and respond to conflict (Leppanen and Nelson 2012). There is also high comorbidity between IPV exposure and child maltreatment (Graham-Bermann and Edleson 2001). Thus, early recognition of IPV is critical, and the perinatal period provides an opportunity to do so given the higher likelihood that a women will have contact with health care providers (Hahn et al. 2018). A key component to mitigating the effects of perinatal IPV exposure is understanding how expectant and new mothers view their abuse.
Materials and Methods
This analysis derives from a larger project involving a community-based longitudinal study of maternal health in a midsized Midwestern city in which women were recruited from the postpartum floors of the two local delivery hospitals. A sample of 301 women were surveyed 2 days, 2 weeks, and 2 months after delivery about depression symptoms and corollary factors. At the 2 month survey, participants were screened for lifetime IPV. Sixty-four screened positive, and the authors were able to contact and interview 40 of them. The interviews were conducted by both authors equally and occurred over phone and in person (participant preference). They averaged 1 hour and were semistructured, meaning some basic questions were developed in advance but then each of the authors adjusted how and what they asked to accommodate the flow and content of each interview (Brinkmann and Kvale 2015). Their basic questions focused on living situations during and following pregnancy (most recent and any previous) and included the following:
Can you tell me a bit more about your pregnancy (pregnancies) and how things went for you? Common probes: Did you have any complications? Were you able to receive prenatal care? What was your living situation like? What type of relationship, if any, did you have with the father? How much support (emotional or financial) have you had from him, or other family and friends? What was your adjustment to parenthood like? Common probes: Did you have any postpartum problems? Did your baby have any issues? How stressful has it been? How much support (emotional or financial) did you have from family friends and/or the father? In the 2 month survey, you reported experiencing abuse by a partner or spouse. Can you tell me more about that? Common probes: When did the abuse happen? What types of abuse did you experience (emotional, physical, sexual, etc.)? How long did the abuse last? How did you cope with it? Have you had more than one abusive relationship?
Of the 40 interviewed women, 25 reported perinatal IPV. The authors explored this further, asking about the abuse as well as how it affected them and their unborn/newly born children.
Did the abuse ever occur during pregnancy? Common probes: What types of abuse did you experience (emotional, physical, sexual, etc.)? If you experienced abuse before becoming pregnant, did it change when you were pregnant (got worse, got better, or stayed the same)? Did the type of abuse change? Did you experience any physical, mental, or financial problems during your pregnancy that you think were connected to the abuse?
Did the abuse occur after pregnancy? Common probes: What types of abuse did you experience (emotional, physical, sexual, etc.)? If you experienced abuse before or during pregnancy, did it change after your baby was born (got worse, got better, or stayed the same)? Did the type of abuse change? Did you experience any physical, mental, or financial problems during this time that you think were connected to the abuse?
Did you have other children at home with you at this time? Common probes: Where were they during abuse incidents? Do you think they are aware of it? Did they ever see or hear it? Were they impacted by it? Have your other children affected how you've dealt with the situation?
The women ranged in age from 21 to 37 (average 28). Seventeen identified as white and eight as black. Three had less than a high school diploma, 8 had a diploma/General Equivalency Diploma, 13 had an associate's degree or some college, and 4 had a bachelor's degree. Nineteen reported being in a committed relationship at the time of the interviews (8 married, 11 with boyfriends); 6 were single. All had infants at the time of their interviews, with ages ranging from 2 to 9 months (average 6 months). The majority (21) had older children as well (average 2.5).
Upon transcription (identifiers removed or replaced with pseudonyms), the first author open coded the data based a phenomenological framework, which focused on the “what” and “how” of a phenomenon (i.e., what was experienced and how was it experienced) (Moustakas 1994). Sections of the transcripts were highlighted (coded) when they referenced the participants' perceptions of the abuse before, during, and after pregnancy, as well as the impact of abuse on their pregnancies, infants, and other children. These codes were then organized into broader thematic categories presented below.
Results
Abuse trajectories
Acknowledging the range of abuse, generally and during the perinatal period, provided important context. A full range of abuse was reported; however, emotional victimization was universal (100% of sample) and took a variety of forms (threats, insults, social isolation, financial control, sexual manipulation). It was often, upon reflection, the first method of abuse. As Suzie noted, “I think all of it was always there…I didn't catch on.” Candace also recalled, “I remember the first time. It was a couple months into our relationship. Out of nowhere he just slew really mean names toward me. I'm like, ‘What the heck is going on?’ He ended up apologizing and then it kind of just, I don't know, got worse from there.”
Emotional abuse caused a lot of confusion and anxiety for the women and eroded their self-concept and confidence. Later on in her interview, Candace noted, “I just remember feeling pathetic. I just felt like I couldn't move on without being with him.” This was particularly difficult when children were involved, as Clarissa explained, “It [the pregnancy] didn't do good things for me. All's it did was bring like idealization of the family and how I wished he would be. That he would change and we would be a family.” Abusers drew upon and manipulated these feelings, using pregnancy as a rationale for expressing greater control. Hillary noted, “He would say, ‘You're having my baby so you're gonna do what I say.’” By far the most common emotional abuse tactic was insulting the women's appearances during pregnancy. Sharifa explained, “It seemed like the bigger I got, the meaner he got. He would say I needed to lose weight. You know, I was fat, lazy, unattractive.” Kimberly described the incredible toll this had: “He'd always tell me that I was fat and that I was lazy. That just tore me down so bad mentally that I was physically not well. I was so depressed.”
This is not to downplay the harm of other abuse. The majority of women (22, 88%) reported an array of physical battering to their person, property, and/or pets, all of which contributed to their degradation and fear. As Hillary described, “He choked me, slapped me, punched me in the face, kicked me in the back, pushed me down stairs…I mean, everything.” Susie reported physical threats and property destruction: “Not ever actually hitting but he'd come at me and raise his fist like he was gonna hit me and he would just hit the wall. He would destroy my stuff, things that meant a lot. Clarissa reported physical abuse toward her pet: “He threw my cat up against the wall when I was about two months pregnant.”
Most of the women reported some sort of change in the nature of their abuse during and following their pregnancies (Table 1), although it is important to acknowledge that the dynamics of IPV remained present regardless of how the women perceived the nature of harm. For example, Takiyah indicated that the physical abuse became less frequent although still present: “During the pregnancy it wasn't so bad. I remember getting hit maybe twice.” Natalie also reported less severity: “He may not have tried to like physically attack me while I was pregnant…it was anything that wouldn't leave any kind of physical evidence.” However an equal share experienced just as bad or worse physical abuse. Hillary's abuse worsened during her first pregnancy and then remained at that level of severity for all subsequent pregnancies: “The first time he ever choked me was when I was pregnant. By the time my daughter's pregnancy came it was so constant. I don't know if it got worse because I was pregnant, or if it was just worse.” Choking, and other assaults on the upper body, seemed particularly common, as Clarissa described, “He hit me a lot more through the pregnancies. With my oldest daughter, he punched me in the eye. When I was pregnant with my youngest daughter, he took his steel-toed boots and started beating me in the head with them.”
Forms of Abuse and Perinatal Change
Two women ended their pregnancies through abortion due to the abuse so are not counted in postpartum tallies.
Understandably, such victimization impacted the women's ability to prepare for parenthood. Sharifa was left to attend prenatal classes alone and without transportation due to her ex-husband's emotional abuse: “He wouldn't go to any of the classes. I usually ended up walking because I wasn't allowed to have a car because ‘I was overweight’.” His financial manipulation continued after the birth of their daughter: “I didn't have an allowance. I wasn't allowed to spend money. He kept hold of the social security cards, my daughter's birth certificate, all her papers. I couldn't have control of any of that stuff.” Reports of such inadequate support and abandonment were common. As Carol put it, “I felt like I was doing everything on my own.”
The abuse continued postpartum, with emotional mistreatment figuring prominently. As Sabrina recalled, “He tells me I'm an unfit mother and that if I ever leave him he'll take my child away. It's kind of like the same tactic but he uses different words. Words that really hurt and play a lot on like my confidence.” Physical abuse also continued, often exacerbated by the demands of caring for a newborn. Jennifer explained, “With the stresses of the newborn and the bills, things started to escalate. The drinking began to get a little heavier, and then the violence…pushing, shoving, and the name calling started occurring more often.”
Perceptions of impact
Coming to terms with the impacts of IPV on an unborn or newly born child was difficult for the women in this study. While all reported being victimized during the perinatal period, only 12 (48%) believed the abuse negatively impacting their pregnancies and even fewer (5, 20%) perceived a negative impact on their infants. Indeed, several did not understand or downplayed the consequences. Kimberly's description is illustrative:
He was stalking me and he would threaten to blow up my house and kill me and my kids. He never really did anything but, well I mean he hit me a couple of times. When we were together he tried to beat the baby out of me… I started bleeding for a little while but it had no effect on the baby…
Others held out hope that having a baby would stop the abuse: “I always thought that maybe he would change if there was a kid around. I really think I thought that. That's so stupid now looking back.” [Susie]
Thankfully some started to comprehend the harm after experiencing problems that they attributed to the abuse: “Early on, in the first trimester, when we had been fighting a lot, I had a little bit of spotting. That scared me. Towards the end we got into a really big fight. That's when my contractions started. I had contractions for the last 3½ weeks.” [Andrea] While Andrea's contractions may have been Braxton-Hicks, her perspective was that they were precipitated by the abuse, which helped her link her victimization to the well-being of her child. Similar links were made postpartum, although they often came as a shock for those who believed the abuse would lesson after their babies were born. Sharifa's description is telling: “We were in the car driving and it kind of shocked me when he hit me with our daughter in the back seat… I didn't really think he would.” It was also during this time that the women were more apt to reach out for help, as many had not previously reported their abuse.
Instances of direct threats or harm to children also made a difference in the women's perspectives, as Laura shared:
The controlling got so intense… One time he said “You know the world would be a better place without [their daughter] in it.” That comment was my breaking point. That was when I packed my bags. As soon as I had to protect somebody else, I was able to walk away from it…
Furthermore, the women recognized how the abuse was impacting their ability to parent. For example, Clarissa noticed that her own mental state was deteriorating as her husband kept the focus on his needs: “I had depression bad with my girls, but nothing ever could be about me. It was always about him and his problems.” Not surprisingly, the women struggled to navigate their abusive relationships with caretaking responsibilities. Many of their partners were woefully uninvolved and hostile to the point of neglect and/or endangerment. As Sabrina shared:
He doesn't do laundry, take out the trash, watch the kid, pick up around the house. He just lays there. When I ask for money for diapers or something, he throws a fit. “You need to quit using so many diapers”…. He yelled at him when he cried when he was a newborn. Now he just hands him to me and tells me to shut the baby up.
Jane described a number of precarious situations involving her boyfriend coming to her home unannounced and intoxicated, wanting to hold their newborn: “He was notorious for just showing up… He'd come over after drinking, wanting to hold the baby, who was barely four months. He would cradle him with his face in his shirt.” On another occasion, she added: “One time I reached for him, and he ‘pushed me away’ as he called it, with his foot. I call it kicking. I ended up with a three inch bruise from hitting the crib.”
While the present analysis focuses on perinatal abuse, it is worth noting that women with older children were much more likely to recognize an impact (17, 68%), and took steps to minimize the exposure. Debbie's response was typical: “They always hear when he's yelling and screaming and stuff, but not any of the hitting or anything like that.” She was taking steps to mitigate the impact on her oldest son, who was 5: “I take him to counseling already for it. If he does something bad at school, he's like ‘Please don't tell Daddy. I don't want to get yelled at.’ We usually just deal with everything without involving him in it.” Rachelle, who perhaps had the greatest benefit of hindsight, having a teenage son in addition to her newborn, explained, “He was mostly in his bedroom, trying to hide from it, and then when he got older he jumped on his dad a couple of times, trying to get him to quit.” While she was divorced from her abuser at the time of the interview, she went on to explain “When he hears his dad, like on the answering machine, he gets a rash. I feel horrible that I kept him in that. I feel really bad for keeping him, for not being able to leave a lot sooner.”
Discussion
Our findings show that perinatal IPV is serious and consequential, with a range of emotional and physical abuse reported throughout and following pregnancy. Notable was the extent to which emotional abuse was targeted at the women's changing physicality and the specific targeting of the upper body (particularly choking) for physical assault. Such victimization increased the women's sense of worthlessness and vulnerability, demoralizing them as they entered parenthood. As a qualitative study stemming from a representative community sample, such findings add important insights to the existing body of (largely quantitative) research on the salience of maternal stress on birth outcomes and infant well-being (Davis and Sandman 2010; Devries et al. 2010; Donovan et al. 2016; Hill et al. 2016).
Infant care requires incredible flexibility, patience, and support. IPV has a direct and ongoing negative impact on the ability of abused mothers to care for their children. It was clear that the women entered parenthood with little partner support, shouldering disproportionate caretaking responsibilities while navigating their abusers' control tactics. Some recognized the deleterious impact this had on their newborns, which ranged from neglect, being placed in harm's way, and exposure to chronic conflict. As such, this study adds to the body of literature on the salience of early childhood exposure to domestic violence experience (Grest et al. 2018; Leppanen and Nelson 2012; Van den Bergh et al. 2020).
However, much less is known about the perceptions of adult victims on the impact of IPV on their unborn and newly born children. Examining these perceptions is critical for the development of appropriate interventions that could mitigate the impacts of early IPV exposure. Based on our research, women may not be fully cognizant of the deleterious impacts of IPV exposure unless or until their children are older. This is not to cast blame on the expectant and new mothers. IPV is a patterned and cyclical phenomenon predicated on eroding a victim's sense of autonomy and agency (Smith et al. 2018). The women in this study are victims in their own right, and they showed strength and resiliency by surviving the abuse. Being in survival mode likely limited their abilities to put the situation into a larger perspective. So while the women understood that abuse was occurring and that their children were exposed to it, they were not yet able to fully comprehend its impacts. To the extent they did, it was within the context of maintaining a healthy pregnancy and providing adequate infant care. However those with older children, who had verbalized or shown fear, anxiety, or other tangible reactions to the abuse, were more likely to discuss it. Given how early in life negative adaptations to abuse can occur (Godbout et al. 2017; Osofsky 2018; Stover et al. 2017), these findings highlight the need for greater identification and intervention during the perinatal period.
Within medical settings, IPV screening has remained inconsistent at best, despite long-standing recommendations for universal screening (American College of Obstetricians and Gynecologists 2012) and studies documenting the benefits thereof (McCarthy and Bianchi 2020). In many ways, and particularly within IPV, mothers are the gateway to accessing young children—addressing the adverse effects of perinatal IPV exposure starts with them. Moreover the nature of perinatal health care is well suited for intervention, as it is more likely to involve ongoing visits with a common group of providers in which rapport and trust are built over time, factors that have been shown to increase disclosure rates (Hahn et al. 2018; McCarthy and Bianchi 2020; Osofsky 2018).
Furthermore, there has been significant growth in evidence-based trauma-focused interventions over the past decade (Osofsky 2018). These have included approaching health care holistically by incorporating clinical social workers into obstetrics/gynecology (OB/GYN) practices and instituting nurse home visit programs to assist women with breastfeeding and other matters related to infant care. Both of these strategies provide opportune moments for identifying and responding to IPV victims. For such efforts to be most effective, they also ought to be culturally sensitive and strength based (Prakash et al. 2019). Studies have shown that incorporating mental health services into health care clinics is efficacious not only in itself but also for improving physical health outcomes (Osofsky et al. 2016). In other words, tending to the emotional needs of expectant and new mothers will contribute toward better physical health, which will also serve their children.
As with all research, this analysis is not without limitations. Due to the small sample size and qualitative nature, it is not statistically generalizable. Also due to the semistructured nature of the interviews, not all women were asked questions in the same way or order. As such, their responses to the role that IPV played on their perinatal health and that of their unborn and newly born children were inconsistent. Regardless, the authors obtained important insights into perinatal IPV. In this way, the current analysis may contribute to conceptual transferability—the potential to impact the development of other studies and/or policy directives in other contexts (Brinkmann and Kvale 2015). Research should continue focusing on how women see their abuse and what types of mechanisms for identifying and responding to it during the perinatal period would be most efficacious from their perspectives. Demonstration projects of trauma-informed OB/GYN interventions and/or perinatal home visiting programs would also aid understandings of the unique needs of pregnant and new mothers who have suffered IPV.
Conclusions
IPV is an insidious form of interpersonal victimization with a range of harmful impacts. When occurring during and following pregnancy, the impacts are all the more severe. As understandings of early childhood trauma increase, it is clear that perinatal exposure to IPV holds many risks. Greater prevention, identification, and intervention efforts are crucial to mitigating the impacts of early childhood exposure to IPV.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This research was supported, in part, by the Healthy Babies Healthy Start Program through Kalamazoo County Health and Community Services (Health Resources and Services Administration, 2014–2019, Grant #H49MC00047), as well as the Blue Cross Blue Shield of Michigan Foundation.