Physical and Emotional Intimate Partner Violence and Women’s Health in the First Year After Childbirth: An Australian Pregnancy Cohort Study

Abstract

Intimate partner violence (IPV) can comprise physical, sexual, and emotional abuse, and is a widespread public health concern. Despite increasing recognition that women experience different types of IPV, the majority of research has focused on physical IPV. The present study aims to examine associations between different types of IPV (physical, emotional, physical, and emotional) and women’s mental, physical, and sexual health by analyzing longitudinal data from a prospective pregnancy cohort of 1,507 first-time mothers in Melbourne, Australia. Questionnaires included validated measures of physical and mental health (Short Form Health Survey, Edinburgh Postnatal Depression Scale) and IPV (Composite Abuse Scale). Emotional IPV alone was the most commonly reported type of IPV (n = 128, 9.5%), followed by both physical and emotional IPV (n = 76, 5.7%), and then physical IPV alone (n = 30, 2.2%). Women reporting emotional IPV or physical and emotional IPV had increased odds of poor health compared with women reporting no IPV. Experience of physical and emotional IPV was most strongly associated with mental health issues, including depressive symptoms (adjusted odds ratio [OR] 4.6, 95% confidence interval [CI] = [2.9, 7.1]) and self-reported anxiety (adjusted OR 2.9, 95% CI = [1.9, 4.4]). Experience of emotional IPV alone was associated with poor mental health as well as physical factors, including poor general physical health (adjusted OR 1.9, 95% CI = [1.2, 3.1]), and pain during sex (adjusted OR 1.8, 95% CI = [1.2, 2.7]). Increased odds of poor body image were also observed for women reporting emotional IPV alone and physical and emotional IPV. These findings highlight the need for greater awareness of the diversity in women’s experiences of IPV among health care providers. This includes understanding the prevalence of emotional IPV among new mothers, and the range of health problems that are more common for women experiencing IPV.

Keywords

domestic violence mental health and violence perceptions of domestic violence

Early motherhood is a time of significant transition for women and their families, often accompanied by both psychological and physical health issues. It is common for women to experience chronic exhaustion, back pain, incontinence, dyspareunia, loss of interest in sex, issues with body image, and mental health issues such as depressive and anxiety symptoms (Brown & Lumley, 1998; Gartland et al., 2010; Gartland, MacArthur, et al., 2016; Leeman & Rogers, 2012; Rallis et al., 2007; Woolhouse et al., 2014).

Intimate partner violence (IPV) is also common during the perinatal period (Cox, 2015; Devries et al., 2010; Finnbogadottir & Dykes, 2016; Gartland et al., 2011). IPV broadly refers to any behavior within an intimate relationship that causes physical, emotional, or sexual harm (García-Moreno et al., 2013). Women who have experienced IPV report worse health across a number of health domains both in the immediate period after childbirth (Bauleni et al., 2018; Brownridge et al., 2011; Faisal-Cury et al., 2013; Mandal et al., 2018; McDonald et al., 2015) and across the lifespan (García-Moreno et al., 2013; Loxton et al., 2017). These include an increased risk of depression, anxiety, posttraumatic stress disorder (PTSD), and suicide (Bonomi et al., 2009; Devries, Mak, Bacchus, et al., 2013); back pain, abdominal or pelvic pain (Campbell, 2002), and poor sexual and reproductive health including dyspareunia, vaginal bleeding, unintended pregnancy, pregnancy termination, and irregular use of contraception (Bauleni et al., 2018; Coker, 2007; Hall et al., 2014; Maxwell et al., 2015). There is some evidence that IPV may be associated with greater body mass index (BMI), although findings have been inconsistent (Bosch et al., 2015; Mason et al., 2017; Simmons et al., 2018). Associations have also been reported between IPV and body shame and objectification (Gervais & Davidson, 2013) as well as altered eating behaviors (Bundock et al., 2013; Wong & Chang, 2016).

IPV is not a uniform experience, and can include physical and sexual violence as well as emotional abuse. Women may experience different types of IPV singularly or concurrently, with varying frequency and severity (Hegarty et al., 2013; Smith et al., 2002). It has long been understood that these experiences can be highly correlated, for example, sexual IPV with physical IPV (Finkelhor & Yllö, 1985); or physical IPV with emotional IPV (Walker, 1984). Furthermore, incidents of physical and sexual IPV typically occur within a broader pattern of coercive and controlling behaviors that constitute emotional IPV (Hegarty et al., 1999; Johnson, 2011; Stark, 2007). In contrast, emotional IPV is often reported in the absence of other types of IPV, and is the most common type of IPV reported in the general population (Australian Institute of Health and Welfare, 2018; Gartland, Woolhouse, et al., 2016; Thompson, Bonomi, et al., 2006). Despite evidence of women’s experiences of multiple types of partner violence, most quantitative measures assess a single type of IPV (Thompson, Basile, Hertz, & Sitterle, 2006). Quantitative research has overwhelmingly focused on physical IPV alone, followed by physical and sexual IPV (Australian Institute of Health and Welfare, 2018; Devries, Mak, Garcia-Moreno, et al., 2013; On et al., 2016). Acts of physical and sexual violence can be infrequent or may be threatened rather than enacted. This makes assessment of these types of IPV in isolation problematic (DeKeserady, 2000; Devries, Mak, Bacchus, et al., 2013). Where emotional IPV has been measured, women’s concurrent experiences of other types of IPV are rarely examined. Furthermore, even when data are available, different types of IPV are often analyzed in isolation from one another (Australian Bureau of Statistics, 2016; Bonomi et al., 2009; Loxton et al., 2017; Martin-de-las-Heras et al., 2019; Smith et al., 2002; Smith et al., 2017). Consequently, little is known about the health impacts of the different types and combinations of IPV (On et al., 2016).

There is some evidence suggesting that women who experience multiple types of IPV may have poorer health compared with those experiencing emotional IPV alone. Several studies of women reporting co-occurring emotional and physical and/or sexual IPV show higher odds of chronic mental or physical health conditions (Coker et al., 2002), worsened quality of life, and increased risk of anxiety and depressive symptoms (Hegarty et al., 2004, 2013), including postnatal depressive symptoms (Woolhouse, Gartland, et al., 2012) than women reporting a single type of IPV. However, other studies found the risk of depression and anxiety to be comparable for women experiencing physical and emotional IPV and emotional IPV alone (Coker et al., 2002; Pico-Alfonso et al., 2006).

In summary, there is clear evidence that experiences of IPV are associated with poorer health; however, women’s experiences of different types of IPV and associated health impacts are not well understood. Furthermore, studies investigating postpartum IPV have largely focused on associations with depressive symptoms. There is limited understanding of other health concerns of new mothers experiencing IPV. Drawing on data from an Australian longitudinal cohort study of first-time mothers, this study aims to address this gap in the literature by examining women’s experiences of different types of IPV in the postnatal period. The aims of the paper are to (a) estimate the period prevalence of different types of IPV (physical IPV, emotional IPV, and co-occurring physical and emotional IPV) in the first 12 months postpartum; and (b) examine associations between different types of IPV and women’s mental, physical, and sexual health in the first 12 months postpartum.

Method

Sample

Data were drawn from the Maternal Health Study, a prospective pregnancy cohort study designed to assess women’s health during and after pregnancy. Women registered to give birth were recruited through six Melbourne public hospitals between April 2003 and December 2005. Eligible women were nulliparous, ≥18 years, able to complete questionnaires in English, and ≤24 weeks gestation at enrolment. Women completed a questionnaire in early pregnancy and were followed up in late pregnancy and at 3, 6, 9, and 12 months postpartum. Participants completed self-administered questionnaires and two computer-assisted telephone interviews (at 32 weeks’ gestation and 9 months postpartum). Due to Australian privacy laws, recruitment was conducted by hospital staff who identified and mailed questionnaires to eligible participants, with no incentive for participation. In two hospitals, study information was also provided to women attending booking clinics and in a third, information was given to women attending prenatal classes. This meant that some women received more than one invitation to take part in the study. The study was approved by human research ethics committees at La Trobe University (2002/38); Royal Women’s Hospital, Melbourne (2002/23); Southern Health, Melbourne (2002-099B); Angliss Hospital, Melbourne (2002); and the Royal Children’s Hospital, Melbourne (27,056A). Participants provided informed consent at enrolment with the opportunity to withdraw at any stage.

The measure of IPV (Composite Abuse Scale [CAS]) was not included at enrolment as per ethical approval conditions designed to address safety concerns associated with questionnaires being mailed to participants’ homes. The same concerns for women’s safety applied to telephone interviews; however, these did provide an opportunity to ask women privately whether they would prefer questionnaires to be sent to a different mailing address.

Measures

IPV

Questions regarding experiences of IPV were included in the questionnaire completed at 12-months postpartum. The research team deliberately chose not to include detailed questions of IPV in earlier questionnaires completed during pregnancy and early postpartum for reasons to do with women’s safety. By the time of the 12-month follow-up, women had had several contacts with the research team, and had been invited on several occasions to nominate an alternate mailing address if they wished. A number of women requested alternate arrangements (e.g., posting questionnaires care of another family member), which increased our confidence to include detailed questions asking about IPV in the 12-month postpartum follow-up.

The 12-month period prevalence and types of IPV experienced in the first year after childbirth were measured using the 18-item version of the CAS (Hegarty et al., 2005). The CAS is a validated self-report measure inquiring about the actions of a current or former partner of 1 month or more that constitute physical or emotional abuse. Participants report the frequency of each behavior during the previous 12 months (never, only once, several times, once per month, once per week, and daily). A score of three or more on the emotional abuse scale (e.g., tried to keep me from seeing or talking to my family), or one or more on the physical abuse scale (e.g., pushed, grabbed, or shoved me) was used to indicate IPV. Type of IPV was categorized as emotional IPV alone, physical IPV alone, and both physical and emotional IPV.

Mental health

Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS; J. L. Cox et al., 1987) at enrolment and in follow-up questionnaires at 3, 6, and 12 months postpartum. Participants report the frequency of 10 items relating to their thoughts and feelings over the past week on a four-point scale. A score of ≥13 was used to indicate depressive symptoms as recommended in the original validation of this measure (Cox et al., 1987). This cut-point has been validated in the Australian sample of postpartum women, demonstrating high sensitivity and specificity: 100% and 95.7%, respectively (Boyce et al., 1993). A single item was used to assess anxiety symptoms, asking about experiences of intense anxiety or panic attacks in the past 3 months (never, rarely, occasionally, or often). The item was included in questionnaires at 3, 6, 9, and 12 months. Responses were grouped dichotomously as never or rarely and occasionally or often.

General health

The Short Form 36 questionnaire (SF-36; Jenkinson et al., 1993) was administered at 6 months postpartum. This 36-item measure asks participants about their physical and emotional functioning over the past 4 weeks across eight subscales, from which two continuous summary scores can be calculated: the Mental Health Component Score and the Physical Health Component Score. Lower values are indicative of poorer health. Summary scores were dichotomized with scores that were more than a standard deviation less than the mean component score categorized as poor health, and all other scores categorized as good health.

Physical health

A checklist of physical health problems in the past 3 months was included at 3, 6, 9, and 12 months postpartum. Items included exhaustion, coughs or colds, migraines, lower back pain, upper back pain, painful perineum, pain from cesarean, pain passing urine, urinary tract infection, painful bowel motion, bleeding when passing bowel motion, constipation, hemorrhoids, breast problems, pelvic pain, and heavy vaginal bleeding. Participants reported the frequency of each symptom (never, rarely, occasionally, or often). Health problems reported occasionally or often were summed for each participant, and grouped as a tally (0–4 and 5–16) as per previous papers reporting on study findings (Perlen et al., 2013). Incontinence was assessed using standardized measures based on instruments previously validated in the Australian, Scandinavian, and U.K. populations (Sandvik et al., 1993; Talley et al., 1995). Urinary incontinence was identified as any leakage that occurred at least once a month and fecal incontinence as any stool leakage in the preceding 3 months. See earlier publications for further details of incontinence measurement (Gartland, MacArthur, et al., 2016).

Sexual health

At each follow-up women were asked a series of questions about sex following childbirth, drawing on measures developed by Barrett and colleagues (2000). Women who had recently resumed vaginal sex were asked if it happened “too soon,” “about the right time,” or “would have liked to start sooner.” At each time point, for the women who had resumed sex, a dichotomous variable was created to distinguish between women who said that they had resumed sex “too soon” versus the other responses. At 12 months postpartum, women were also asked if they were experiencing pain or tenderness during vaginal sex. Women who had not resumed vaginal sex by 12 months postpartum were excluded from all analyses regarding sexual health.

Body weight and image

BMI was calculated using weight at 12-months postpartum and height at enrolment (weight in kilograms/height in metres²). Scores were classified as underweight (<18.5), normal weight (18.5–24.9), overweight (25.0–29.9), and obese (≥30). Three dichotomous variables were created: normal weight versus underweight, normal weight versus overweight, and normal weight versus obese. Body image was assessed using two items adapted from the Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994): “In the past month how dissatisfied have you felt about: a) Your weight? b) Your shape?” Participants responded from 0 (not at all) to 6 (markedly). Due to strong correlation a threshold of 6 on either item was used to indicate poor body image. This is in line with previous research using the highest cut-point for self-report measures to prevent the overestimation of body image issues including body dissatisfaction (Mond & Hay, 2011).

Maternal sociodemographic information was gathered at enrolment and throughout the follow-up period. Maternal age, country of birth, highest education, and annual income were collected in early pregnancy; maternity leave status at 3 months postpartum; and relationship status, employment status, and holding a government health care concession card at 12 months postpartum.

All women participating in the study received a wallet-sized card with information about services to contact if in need of support. This included telephone support lines for women experiencing mental health issues and/or domestic violence. In addition, each returned questionnaire was scanned individually to check responses to the EPDS, CAS, and comments/queries from women. Women requesting information or support were contacted as soon as possible after receipt of the questionnaire. We also contacted women with high scores on the EPDS and/or the CAS when their responses to questions about contact with health professionals indicated that they lacked support. Research staff making these calls were trained and supported to provide appropriate guidance regarding avenues for local support.

Analysis

Data were analyzed using STATA version 15.1 (StataCorp, 2017). Participant characteristics were compared with routinely collected Victorian perinatal data for nulliparous women giving birth as public patients during the study period as a means of assessing the representativeness of the sample. The 12-month period prevalence of emotional IPV alone, physical IPV alone, and both physical and emotional IPV was estimated based on the proportion of women reporting each type of IPV divided by the total sample with data for these variables. Women with missing data on the CAS were excluded from further analysis. With the exception of incontinence, maternal health outcomes measured at multiple time points were combined to give a period prevalence over the first 12 months postpartum. Due to the high prevalence of urinary and fecal incontinence in the first few months after childbirth (Gartland, MacArthur, et al., 2016), we restricted analyses assessing the association between IPV and incontinence to women with symptoms of urinary and/or fecal incontinence at 12 months postpartum.

First bivariable and then multivariable logistic regression was used to assess associations between different types of IPV and women’s mental, physical, and sexual health in the first 12 months postpartum. Maternal age and mode of birth were defined as potential confounders a priori due to known associations with women’s postnatal health (Gartland, MacArthur, et al., 2016; McDonald & Brown, 2013; Woolhouse, Perlen, et al., 2012). Estimates for the association between women’s experiences of different types of IPV and physical, mental, and sexual health adjusted for these factors using multivariable models. The reference category for all regression analyses was women who reported no IPV in the 12 first months postpartum, and estimates are presented as odds ratios (ORs) and 95% confidence intervals. Results from the multivariable model were used to estimate the population attributable fraction of maternal depressive symptoms for emotional IPV and physical and emotional IPV compared with no IPV. This was calculated using the punaf command in STATA (Newson, 2013).

Results

Sample Characteristics

A total of 1,507 eligible women enrolled in the study. The precise response fraction is unknown as some women are likely to have received multiple invitations via different pathways. We estimate that around one in three eligible women giving birth at the six participating hospitals enrolled in the study, but this may be an underestimate. A total cohort of 1,507 eligible women completed the enrolment questionnaire in early pregnancy. Sample retention was 95.0% at 3 months postpartum, 98.6% at 6 months, 92.0% at 9 months, and 90.0% at 12 months postpartum. Participant age at the time of birth of their first child ranged from 18.9 to 49.9 years (M = 31.0 years). Most women were born in Australia (76.2%), were tertiary educated (74.1%), and in a relationship (95.9%). Cohort characteristics were compared with routinely collected state-wide data for all nulliparous women who gave birth at the participating hospitals during the recruitment period. This showed the sample to be representative in terms of key obstetric characteristics, including method of birth, infant birth weight, and gestation. The sample has fewer women aged 18–24 in early pregnancy (15.5% vs. 29.9%) and fewer women born overseas of non-English-speaking background (16.2% vs. 21.0%) (Brown et al., 2008).

The sample for this paper comprises women who completed the questionnaire at enrolment and follow-up questionnaires at 3, 6, 9, and 12 months postpartum (n = 1,353). Women with missing data on the key exposure variable (IPV) were excluded (n = 7, 0.5%) leaving a final sample of 1,346. Some missing data was observed for outcome variables ranging from 0 to 94 cases, which represents 0.0%–6.9% of the sample.

Selective attrition was apparent at 12 months postpartum with a reduced proportion of women completing follow-up questionnaires who were aged 18–24 years in early pregnancy (13.3% vs. 15.5%), born outside of Australia (25.6% vs. 23.7%), high school rather than tertiary educated (27.9% vs. 26.2%), not working or studying during pregnancy (14.5% vs. 12.6%), and had an annual income of AUD$30,000 or less (31.2% vs. 29.3%).

Period Prevalence of IPV

Approximately one in six women (n = 234, 17.4%) reported physical IPV and/or emotional IPV in the 12 months following the birth of their first child. Emotional IPV without physical IPV was most prevalent, reported by 9.5% of women (n = 128), followed by both physical and emotional IPV (n = 76, 5.6%). Physical IPV without emotional IPV was reported by just 2.2% of women (n = 30). Women reporting physical IPV alone were grouped with women reporting both physical and emotional IPV, creating three exposure groups for all further analyses: no IPV, emotional IPV, and physical and emotional IPV.

IPV and Maternal Sociodemographic Characteristics

Table 1 shows the demographic characteristics of the sample by type of IPV reported in the first 12 months postpartum. Compared with women reporting no IPV, women reporting physical and emotional IPV were more likely to be under 25 years at the time of having their first baby, to have a low income during pregnancy, not be working or studying during pregnancy, not be eligible for paid maternity leave, and not have completed any post-school qualifications. At 12 months postpartum, they were also markedly more likely not to have a current partner and to be eligible for a government health care concession card available to low-income families. A similar pattern is apparent for women reporting emotional IPV; however, the effect sizes were, in the main, not as large. For example, compared with women not reporting IPV, women reporting physical and emotional IPV had odds of not having a partner at 12 months postpartum that were nine times higher, whereas for women reporting emotional IPV, the odds were five times higher.

Table 1.

Maternal Sociodemographic Characteristics and Women’s Experiences of Different Types of IPV in the First 12 Months Postpartum.

Maternal Sociodemographic Characteristics	Samplen=1,346	Women’s Experiences of IPV in the First 12 Months Postpartum
	Samplen=1,346	No IPVn=1,112	Emotional IPV^an=128, 9.5%			Physical and emotional IPV^bn=106, 7.9%
	n (col %)	n (%)	n (%)	Unadj.OR	95% CI	n (%)	Unadj.OR	95% CI
Early pregnancy
Age
25 years and older	1,167 (86.7)	982 (84.1)	104 (8.9)	1.0	Ref	81 (6.9)	1.0	Ref
18–24 years	179 (13.3)	130 (72.6)	24 (13.4)	1.7*	[1.1, 2.8]	25 (14.0)	2.3***	[1.4, 3.8]
Country of birth
Australia	1,021 (76.2)	848 (83.1)	92 (9.0)	1.0	Ref	81 (7.5)	1.0	Ref
Overseas	319 (23.8)	259 (81.2)	35 (11.0)	1.2	[0.8, 1.9]	25 (7.8)	1.0	[0.6, 1.6]
Highest qualification
Tertiary educated	991 (74.1)	839 (84.7)	88 (8.9)	1.0	Ref	64 (6.5)	1.0	Ref
Year 12 or below	347 (25.9)	266 (76.7)	39 (11.2)	1.4	[0.9, 2.1]	42 (12.1)	2.1***	[1.4, 3.1]
Annual income
AUD$ 30,001 and above	881 (70.8)	751 (85.2)	76 (8.6)	1.0	Ref	54 (6.1)	1.0	Ref
AUD$ 30,000 and below	364 (29.2)	287 (78.8)	37 (10.2)	1.3	[0.8, 1.9]	40 (11.0)	1.9**	[1.3, 3.0]
Employment status
Working or studying	1,156 (87.5)	976 (84.4)	100 (8.7)	1.0	Ref	80 (6.9)	1.0	Ref
Not working or studying	165 (12.5)	115 (69.7)	24 (14.5)	2.0**	[1.3, 3.3]	26 (15.8)	2.8***	[1.7, 4.5]
3 months postpartum
Paid maternity leave
Yes	464 (36.0)	401 (86.4)	41 (8.8)	1.0	Ref	22 (4.7)	1.0	Ref
No	824 (64.0)	675 (81.9)	69 (8.4)	1.0	[0.7, 1.5]	80 (9.7)	2.2**	[1.3, 3.5]
12 months postpartum
Current partner
Yes	1,290 (95.9)	1,086 (84.2)	117 (9.1)	1.0	Ref	87 (6.7)	1.0	Ref
No	55 (4.1)	25 (45.5)	11 (20.0)	4.1***	[2.0, 8.5]	19 (34.5)	9.5***	[5.0, 17.9]
Health care card
No	980 (73.2)	842 (85.9)	77 (7.9)	1.0	Ref	61 (6.2)	1.0	Ref
Yes	359 (26.8)	265 (73.8)	49 (13.6)	2.0***	[1.4, 3.0]	45 (12.5)	2.3***	[1.6, 3.5]

Note. IPV: intimate partner violence; OR = odds ratio; 95% confidence intervals (CI) in brackets.

Emotional IPV = women reporting emotional IPV and not physical IPV in the previous 12 months (Composite Abuse Scale).

Physical and emotional IPV = women reporting physical IPV with or without emotional IPV in the previous 12 months (Composite Abuse Scale).

p < .05. ^**p < .01. ^***p < .001.

IPV and Maternal Health

Bivariable and multivariable analyses (adjusting for maternal age and mode of birth) revealed the same pattern of association, with minimal shifts in effect sizes, and therefore adjusted ORs are presented below (see the appendix for results from bivariable models). Figure 1 provides a graphical representation of the overall pattern of association between (a) emotional IPV and separately (b) physical and emotional IPV and a broad range of common maternal health issues, adjusting for maternal age and mode of birth. Results are displayed as adjusted ORs and 95% confidence intervals (CIs). The odds of reporting mental health problems were elevated three to four times for women reporting physical and emotional IPV, and two to three times for women reporting emotional IPV, compared to women reporting no IPV. Associations were also observed for poor physical health as well as sexual health and body image, with largely comparable effect sizes observed for women reporting emotional IPV and emotional and physical IPV. These findings are discussed in greater detail below.

Figure 1.

Odds ratios for mental, physical, and sexual health outcomes for women reporting emotional IPV and physical and emotional IPV compared with women reporting no IPV. Multivariable regression models were adjusted for maternal age and mode of birth. Confidence intervals (95%) are represented by error bars.

Mental Health and IPV

Maternal mental health issues were common in the 12 months following childbirth with approximately one in four women (25.0%) reporting anxiety or panic attacks and one in six (16.2%) reporting depressive symptoms (EPDS ≥13). One in six women (16.6%) also reported poor general mental health at 6 months postpartum (SF-36 MCS). Women reporting IPV were more likely to report all mental health issues compared to those reporting no IPV (Table 2). The biggest effect sizes were observed for depressive symptoms. Strong associations were observed for emotional IPV (OR = 2.97, 95% CI = [1.92, 4.59]), with even greater effects for physical and emotional IPV (OR = 4.57, 95% CI = [2.94, 7.12]). These estimates reflect a population attributable fraction for depressive symptoms of 9.9% for emotional IPV (95% CI = [5.0, 14.6%]) and 13.0% for physical and emotional IPV (95% CI = [8.2, 17.5%]). Taken together this reflects approximately one fifth of the attribution for depressive symptoms.

Table 2.

Associations Between Maternal Mental, Physical, and Sexual Health and Women’s Experiences of Different Types of IPV in the First 12 Months Postpartum.

Maternal Health		Samplen = 1,346	Women’s Experiences of IPV in the First 12 Months Postpartum
		Samplen = 1,346	No IPV n = 1,112, 82.6%	Emotional IPV^an = 128, 9.5%			Physical and emotional IPV^bn = 106, 7.9%
	Data collected^c	n (col %)	n (%)	n (%)	Adj.OR^d	[95% CI]	n (%)	Adj.OR^d	[95% CI]
Mental health
Anxiety	3, 6, 9, 12
Never/rarely		1,009 (75.0)	868 (86.0)	82 (8.1)	1.0	Ref	59 (5.8)	1.0	Ref
Occasionally/often		337 (25.0)	244 (72.4)	46 (13.6)	1.9**	[1.3,2.9]	47 (13.9)	2.9***	[1.9,4.4]
Depressive symptoms (EPDS)	3, 6, 12
No		1,125 (83.8)	972 (86.4)	88 (7.8)	1.0	Ref	65 (5.8)	1.0	Ref
Yes ( ≥13)		217 (16.2)	137 (63.1)	39 (18.0)	3.0***	[1.9,4.6]	41 (18.9)	4.6***	[2.9,7.1]
General mental health (SF36)^e	6
Average—good		1,083 (83.4)	933 (86.1)	85 (7.8)	1.0	Ref	65 (6.0)	1.0	Ref
Poor		216 (16.6)	149 (69.0)	33 (15.3)	2.5***	[1.6,3.9]	34 (15.7)	3.5***	[2.2,5.6]
Physical health
general Physical health (SF36)^e	6
Average—good		1,125 (86.6)	952 (84.6)	93 (8.3)	1.0	Ref	80 (7.1)	1.0	Ref
Poor		174 (13.4)	130 (74.7)	25 (14.4)	1.9**	[1.2,3.1]	19 (10.9)	1.6	[0.9,2.7]
Physical health issues	3, 6, 9, 12
0–4		644 (47.8)	549 (85.2)	49 (7.6)	1.0	Ref	46 (7.1)	1.0	Ref
5 or more		702 (52.2)	563 (80.2)	79 (11.3)	1.7*	[1.1,2.4]	60 (8.5)	1.3	[0.9,1.9]
Urinary incontinence	12
No		989 (73.8)	830 (83.9)	88 (8.9)	1.0	Ref	71 (7.2)	1.0	Ref
Any		352 (26.2)	280 (79.5)	38 (10.8)	1.3	[0.8,2.0]	34 (9.7)	1.5	[1.0,2.4]
Fecal incontinence	12
None		1,260 (93.8)	1,049 (83.3)	119 (9.4)	NC	NC	92 (7.3)	NC	NC
Any		84 (6.3)	62 (73.8)	8 (9.5)	NC	NC	14 (16.7)	NC	NC
Resumption of vaginal sex^f
Too soon after childbirth	3, 6, 9, 12
No		1,072 (84.3)	913 (85.2)	86 (8.0)	1.0	Ref	73 (6.8)	1.0	Ref
Yes^g		200 (15.7)	148 (74.0)	26 (13.0)	1.9**	[1.2,3.1]	26 (13.0)	2.1**	[1.3,3.4]
Vaginal sex painful	12
No		917 (71.6)	780 (85.1)	71 (7.7)	1.0	Ref	66 (7.2)	1.0	Ref
Yes		363 (28.4)	284 (78.2)	44 (12.1)	1.8**	[1.2,2.7]	35 (9.6)	1.5	[0.9,2.3]
Weight and body image
Body mass index	12
Underweight		55 (4.5)	44 (80.0)	6 (10.9)	NC	NC	5 (9.0)	NC	NC
Normal weight		649 (52.5)	545 (83.9)	60 (9.2)	1.0	Ref	44 (6.8)	1.0	Ref
Overweight		327 (26.5)	271 (82.9)	27 (8.3)	0.9	[0.5,1.5]	29 (8.9)	1.3	[0.8,2.2]
Obese		204 (16.5)	162 (79.4)	24 (11.8)	1.3	[0.7,2.1]	18 (8.8)	1.3	[0.7,2.4]
Poor body image	12
No		1,010 (77.1)	860 (85.1)	83 (8.2)	1.0	Ref	68 (6.7)	1.0	Ref
Yes		301 (22.9)	223 (74.1)	45 (15.0)	2.1***	[1.4,3.1]	33 (11.0)	1.7*	[1.1,2.8]

Notes. IPV: intimate partner violence; OR = odds ratio, 95% confidence intervals (CI) in brackets. NC = not calculated.

Emotional IPV = women reporting emotional IPV and not physical IPV in the previous 12 months (Composite Abuse Scale).

Physical and emotional IPV = women reporting physical IPV with or without emotional IPV in the previous 12 months (Composite Abuse Scale).

Months postpartum.

Multivariable regression model adjusted for maternal age and mode of birth (cesarean vs. vaginal delivery).

Poor health categorized as SF36 component score <1 SD below mean component score.

Women who had resumed vaginal sex at 12 months (n = 1,297).

Women reporting vaginal sex too soon at the time they reported resumption of vaginal sex.

p < .05. ^**p < .01. ^***p < .001.

Physical Health and IPV

More than half of the sample reported five or more physical health issues in the 12 months following childbirth (52.2%), and just over a quarter reported urinary incontinence at 12 months postpartum (26.2%). Women reporting emotional IPV were more likely to report five or more physical health issues and poor general physical health (SF36–PCS) compared to women reporting no IPV (Table 2). Raised odds of poor physical health were also observed for women reporting both physical and emotional IPV. However the confidence intervals for these estimates included one suggesting the odds for women reporting both physical and emotional IPV are equal to those for women reporting no IPV (see Figure 1). No associations were observed between different types of IPV and urinary incontinence at 12 months postpartum. We were unable to calculate ORs for fecal incontinence due to small numbers. However, women reporting physical and emotional IPV were overrepresented in this group, with 13.2% (14/106) reporting fecal incontinence compared with 5.6% (62/1,112) of women reporting no IPV.

Sexual Health and IPV

Almost all women had resumed vaginal sex by 12 months postpartum (n = 1,297, 96.4%). Of these, close to one in six said that vaginal sex had resumed too soon after childbirth (15.7%), and more than one in four reported experiencing pain during vaginal sex at 12 months postpartum (28.4%). Women reporting emotional IPV and women reporting both physical and emotional IPV were approximately twice as likely to feel that the resumption of vaginal sex was too soon after childbirth, compared to women reporting no IPV (see Table 2). Increased odds of experiencing pain during vaginal sex at 12 months postpartum were also observed for women reporting emotional IPV.

Weight, Body Image, and IPV

Women experiencing IPV were also more likely to report poor body image 12 months after childbirth. The strongest effect size was observed for women reporting emotional IPV, who were approximately twice as likely to report marked dissatisfaction with their body weight or shape compared to women reporting no IPV (see Table 2). No associations were observed between emotional IPV or emotional and physical IPV and having a BMI categorized as overweight or obese at 12 months postpartum. The very small number of women with a BMI categorized as underweight prevented meaningful interpretation of regression analysis.

Discussion

Emotional IPV was more prevalent than physical IPV in the 12 months following childbirth. Emotional IPV without physical IPV was reported most frequently, while physical IPV was almost always reported in combination with emotional IPV. These findings support the theory that women tend to experience emotional IPV in greater frequency and regularity than other types of IPV (Hegarty et al., 2013; Henning & Klesges, 2003), and physical IPV most typically occurs in the context of emotional IPV (Hegarty et al., 1999; Stark, 2007).

Both emotional IPV alone and physical and emotional IPV were associated with a range of health problems for women. In line with previous research (Coker et al., 2002; Pico-Alfonso et al., 2006), associations with women’s health were generally comparable for women reporting both physical and emotional IPV and women reporting emotional IPV alone, with overlapping confidence intervals observed for all estimates. Considerably stronger associations with mental health problems were observed for women reporting physical and emotional IPV, with depressive symptoms displaying the most extreme effect. However, the population attributable fractions of depressive symptoms that we observed suggest that at a population level a reduction in emotional IPV and a reduction in physical and emotional IPV would provide comparable benefits for women’s mental health. These are important findings as reviews of IPV and health have highlighted the widespread prioritization of physical IPV in the literature (Devries, Mak, Garcia-Moreno, et al., 2013; On et al., 2016). Furthermore, recent survey data suggest that awareness of emotional IPV among young people is waning. Between 2009 and 2013 there was a drop in the proportion of young people, particularly young men, who endorsed items pertaining to financial control and social isolation as aspects of IPV (Australian Institute of Health and Welfare, 2018). Our study findings suggest that there should be increased attention given to emotional IPV and the associated health burden for women.

Despite the wealth of literature regarding IPV and mental health problems such as depression and anxiety, to the best of our knowledge this is the first prospective pregnancy cohort study investigating associations with body image. Women reporting physical and emotional IPV and women reporting emotional IPV alone had elevated odds of body dissatisfaction. This is perhaps not surprising, as it has long been understood that targeting a woman’s self-worth is an aspect of emotional abuse (Walker, 1984). Furthermore, associations have been reported between IPV and altered eating behaviors (Bundock et al., 2013; Wong & Chang, 2016). Altered eating is highly related to body dissatisfaction, with both considered to be part of the symptomology of an eating disorder (Mitchison et al., 2017). The findings in this study relate to the period of recovery after pregnancy and childbirth, which is known to be a time of increased sensitivity with regard to body image for some women (Rallis et al., 2007). It remains unclear whether there is any association between IPV and body dissatisfaction for women at other stages of life. This is worthy of investigation as body dissatisfaction has been shown to be associated with eating disorder psychopathology and psychological distress (Mitchison et al., 2017; Mond & Hay, 2011).

Studies investigating the relationship between IPV and BMI have produced mixed results. Associations have been reported between lifetime history of IPV and a BMI score in the obese range compared to the normal range (Bosch et al., 2015), as well as an increase in BMI over time when depressive symptoms are also present (Mason et al., 2017). Contrasting longitudinal research reported that prior IPV was not associated with a higher BMI in later waves of the study (Simmons et al., 2018). Similarly, the present study did not observe significant associations between BMI and IPV, however the two constructs were measured concurrently (i.e., at 12 months postpartum). Taken together, the findings suggest that any relationship between IPV and BMI is complex and could be influenced by the timing of exposure as well as the presence of other health problems.

Women experiencing emotional IPV alone and physical and emotional IPV were more likely to say that they had resumed vaginal sex too soon after childbirth. Previous papers examining sexual health in this cohort have not found an association between IPV and the timing of resumption of sex after first or subsequent childbirth (McDonald & Brown, 2013). The association identified in this paper therefore likely reflects how women felt about resuming sex after childbirth and not the timing itself. An association was also observed between women reporting sex to be painful 12 months after childbirth and report of emotional IPV. These findings suggest that emotional IPV may be associated with negative experiences of sex, an important finding that requires further investigation. The study did not include a standardized measure of sexual IPV so the potential confounding effects of sexual IPV are unknown. However, as sexual IPV tends to be reported in conjunction with emotional and/or physical IPV (Coker et al., 2000; P. H. Smith et al., 2002) it is likely that the majority of women experiencing sexual IPV during the first 12 months postpartum were included in the group of women identified as experiencing IPV by the CAS.

The key strengths of this study are the recruitment of women in early pregnancy; frequent follow-up throughout the first 12 months postpartum; relatively low attrition; and the inclusion of measures of maternal mental, physical and sexual health including standardized measures for assessing maternal depressive symptoms, general health status and experiences of IPV. Importantly, the study included a robust measure of IPV that identified both physical and emotional IPV and allowed for the examination of different types and combinations of IPV reported by women.

There are also a number of limitations to be considered. First, while the study included a multidimensional measure of IPV, the 18-item CAS does not assess sexual IPV. This could lead to under-identification or misclassification of IPV exposure although, as discussed earlier, such behaviors are likely to co-occur with physical and/or emotional IPV and therefore be captured in the group of women identified as experiencing IPV. The study also did not capture the broader context of coercive control in women’s lives, which is likely to have contributed to the observed associations between IPV and women’s health. Younger women and women of non-English-speaking background were underrepresented in the cohort. Selective attrition was observed among women with fewer years of formal education and lower income. Each of these factors is likely to have biased estimates of IPV prevalence downwards. Social adversity is also associated with postnatal depressive symptoms (Woolhouse, Gartland, et al., 2012) and poorer physical health following childbirth (Gartland et al., 2010). It is likely that the true prevalence of IPV and poor mental and physical health in the first 12 months postpartum is higher in the general population. The study did not include a measure of IPV during pregnancy. Exposure to IPV and outcomes were measured over the same period precluding causal inference. Finally, there has been a time-lag between data collection (2003–2007) and the analyses reported in this paper. However, few studies have examined associations between experiences of different types and combinations of IPV and women’s health, and to the best of our knowledge no comparable examination of IPV and body image has been reported previously. Therefore, this paper provides an important addition to the available evidence.

Emotional IPV without physical IPV was the most common experience of IPV reported by women in the first year after childbirth, followed by both physical and emotional IPV. Physical IPV alone was uncommon. Women are also at risk of a range of health problems in the period following childbirth, and this risk is even greater for women who are exposed to emotional IPV alone, as well as for women who are also experiencing physical IPV. In this general population cohort, of the women who reported depressive symptoms in the first-year postpartum, 18.0% were experiencing emotional IPV and a further 18.9% were experiencing physical and emotional IPV. Women’s frequent contact with primary health care during this period provides a unique window of opportunity to better support women experiencing IPV. In particular, our research shows that the identification of postpartum mental health problems should prompt health care workers to consider women’s exposure to physical and/or emotional IPV. This is key for clinicians, as the clinical support required and effective therapeutic treatment approaches will differ for women experiencing mental health issues in the context of IPV. A greater understanding among perinatal health care workers of the complexity and heterogeneity of women’s experiences of emotional and physical IPV, and the association with poorer health, will ensure the most appropriate and effective care is provided to all women after childbirth.

Footnotes

Appendix

Bivariable Associations Between Maternal Mental, Physical, and Sexual Health and Women’s Experiences of Different Types of IPV in the First 12 months Postpartum.

Maternal Health		Women’s Experiences of IPV in the First 12 Months Postpartum
		No IPVn = 1,112, 82.6%	Emotional IPV^an = 128, 9.5%			Physical and emotional IPV^bn = 106, 7.9%
	Data collected^c	n (%)	n (%)	Unadj. OR	[95% CI]	n (%)	Unadj. OR	[95% CI]
Mental health
Anxiety	3, 6, 9, 12
Never/rarely	3, 6, 9, 12	868 (86.0)	82 (8.1)	1.0	Ref	59 (5.8)	1.0	Ref
Occasionally/often		244 (72.4)	46 (13.6)	2.0***	[1.4, 2.9]	47 (13.9)	2.8***	[1.9, 4.3]
Depressive symptoms (EPDS)	3, 6, 12
No	3, 6, 12	972 (86.4)	88 (7.8)	1.0	Ref	65 (5.8)	1.0	Ref
Yes ( ≥13)		137 (63.1)	39 (18.0)	3.1***	[2.1, 4.8]	41 (18.9)	4.5***	[2.9, 6.9]
General mental health (SF36)^d	6
Average—good		933 (86.1)	85 (7.8)	1.0	Ref	65 (6.0)	1.0	Ref
Poor		149 (69.0)	33 (15.3)	2.4***	[1.6, 3.8]	34 (15.7)	3.3***	[2.1, 5.1]
Physical health
General physical health (SF36)^d	6
Average—good		952 (84.6)	93 (8.3)	1.0	Ref	80 (7.1)	1.0	Ref
Poor		130 (74.7)	25 (14.4)	2.0**	[1.2, 3.2]	19 (10.9)	1.7*	[1.0, 3.0]
Physical health issues	3, 6, 9, 12
0–4	3, 6, 9, 12	549 (85.2)	49 (7.6)	1.0	Ref	46 (7.1)	1.0	Ref
5 or more		563 (80.2)	79 (11.3)	1.6*	[1.1, 2.3]	60 (8.5)	1.3	[0.9, 1.9]
Urinary incontinence	12
None		830 (83.9)	88 (8.9)	1.0	Ref	71 (7.2)	1.0	Ref
Any		280 (79.5)	38 (10.8)	1.3	[0.9,1.9]	34 (9.7)	1.4	[0.9,2.2]
Fecal incontinence	12
None		1,049 (83.3)	119 (9.4)	NC	NC	92 (7.3)	NC	NC
Any		62 (73.8)	8 (9.5)	NC	NC	14 (16.7)	NC	NC
Resumption of vaginal sex^e
Too soon after childbirth	3, 6, 9, 12
No		913 (85.2)	86 (8.0)	1.0	Ref	73 (6.8)	1.0	Ref
Yes^f		148 (74.0)	26 (13.0)	1.9**	[1.2, 3.0]	26 (13.0)	2.2**	[1.4, 3.6]
Vaginal sex painful	12
No		780 (85.1)	71 (7.7)	1.0	Ref	66 (7.2)	1.0	Ref
Yes		284 (78.2)	44 (12.1)	1.7**	[1.1, 2.5]	35 (9.6)	1.5	[0.9, 2.2]
Weight and body image
Body mass index	12
Underweight		44 (80.0)	6 (10.9)	NC	NC	5 (9.0)	NC	NC
Normal weight		545 (83.9)	60 (9.2)	1.0	Ref	44 (6.8)	1.0	Ref
Overweight		271 (82.9)	27 (8.3)	0.9	[0.6, 1.5]	29 (8.9)	1.3	[0.8, 2.2]
Obese		162 (79.4)	24 (11.8)	1.3	[0.8, 2.2]	18 (8.8)	1.4	[0.8, 2.4]
Body image	12
Average—good		860 (85.1)	83 (8.2)	1.0	Ref	68 (6.7)	1.0	Ref
Poor		223 (74.1)	45 (15.0)	2.1***	[1.4, 3.1]	33 (11.0)	1.9**	[1.2, 2.9]

Note. Denominators vary due to missing values. IPV = intimate partner violence; OR = odds ratio, 95% confidence intervals (CI) in brackets. NC = not calculated.

Emotional IPV = women reporting emotional IPV and not physical IPV in the previous 12 months (Composite Abuse Scale).

Physical and emotional IPV = women reporting physical IPV with or without emotional IPV in the previous 12 months (Composite Abuse Scale).

Months postpartum.

Poor health categorized as SF36 component score <1 SD below mean component score.

Women who had resumed vaginal sex at 12 months (n = 1,297).

Women reporting vaginal sex too soon at the time they reported resumption of vaginal sex.^*p < .05, ^**p < .01, ^***p < .001.

Acknowledgements

The authors are extremely grateful to all of the women taking part in the study; to members of the Maternal Health Study Collaborative Group (including Harriet Hiscock, Helen Hermann, Sheena Reilly, George Patton) who contributed to the design of study instruments and data collection procedures for 10-year follow-up of mothers and children in the cohort; and to members of the Maternal Health Study research team who have contributed to data collection and data management (Liesje Brice, Melissa Dunning, Maggie Flood, Ali Fogarty, Ann Krastev, Ellie McDonald, Kay Paton, Sandra Papadopoullos, Renee Paxton, Pam Pilkington, Sue Perlen, Monique Seymour, Lorraine Skinner, Martine Spaull, and Marion Tate).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Maternal Health Study was supported by project grants from the Australian National Health and Medical Research Council (NHMRC) (#199222, #433006, and #491205) and Australian Rotary Health. S.B. holds an NHMRC Senior Research Fellowship (#1103976); F.M. holds an NHMRC Career Development Fellowship (#1111160); and D.G. is supported by the NHMRC Safer Families Center (#1116690). K.F. receives a scholarship from the Murdoch Children’s Research Institute in association with the NHMRC Safer Families CRE. Research at the Murdoch Children’s Research Institute is supported by the Victorian Government Operational Infrastructure Support Program.

ORCID iD

Kelly M. FitzPatrick

Author Biographies

Kelly M. FitzPatrick is a PhD candidate at the Murdoch Children’s Research Institute, University of Melbourne, and is a scholar for the Center of Research Excellence for Safer Families. The focus of her research is women’s experiences of family violence.

Stephanie Brown is a social epidemiologist and head of the Intergenerational Health Group at the Murdoch Children’s Research Institute. A major focus of her work is improving the health and wellbeing of Aboriginal children and families, women, and children of refugee background and women and children experiencing family violence.

Kelsey Hegarty is an academic general practitioner and her research program includes the evidence base for early interventions; educational and complex interventions around identification of and response to family violence online and in health care settings. This evidence is needed to transform the health system to address family violence.

Fiona Mensah is a senior research fellow in medical statistics and social policy. Her research focuses on promoting health and healthy development for children and families who are experiencing social adversities, including family violence.

Deirdre Gartland is a senior research officer at the Murdoch Children’s Research Institute. Her research focus is maternal and child health, particularly in the context of social adversity and family violence. She is currently leading a project to define and measure child resilience, working collaboratively with Aboriginal and refugee background communities.

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