Psychological Abuse During Pregnancy Linked To Depression in Brazil

Psychological abuse by an intimate partner during pregnancy is associated with postpartum depression among Brazilian women, according to a population-based study conducted in the northeastern state of Per- nambuco.¹ Compared with women who had not been abused, those who had experienced psychological abuse had a substantially increased likelihood of being depressed (odds ratio, 1.6), as did those who had suffered psychological abuse plus either physical or sexual abuse (1.8). In analyses that controlled for these other types of abuse, women who reported the highest levels of psychological abuse had particularly elevated odds of becoming depressed after pregnancy (2.3). Neither physical nor sexual violence alone was associated with postpartum depression.

The study, conducted between July 2005 and December 2006, focused on 1,045 pregnant women who resided in a low-income section of Recife, the state's capital city, and had lived with their partner at some point during the pregnancy. Women were eligible for the study if they were 18–49 years old, in their last trimester and enrolled in the city's primary health care program (which covers three-quarters of the population). Almost all eligible women (94%) agreed to participate.

In an interview prior to delivery, women provided information about their social and demographic characteristics, history of mental illness, sources of social support (none, some or many) and relationship with their current or most recent live-in intimate male partner, including the quality of communication with this partner (categorized as good or poor) and the extent of his controlling behavior (none, moderate or very).

Women were asked if their partner had subjected them to physical abuse (e.g., choking, beating or injuring them with a weapon), sexual abuse (e.g., coercing them into having sex) or psychological abuse (e.g., threatening or insulting them) during the pregnancy. Respondents also reported how often various types of psychological abuse occurred, and their responses were converted to an abuse score. In addition, women completed questionnaires that screened for common mental illnesses (notably depression and anxiety). Postpartum depression was assessed at follow-up interviews that took place an average of eight months after delivery.

The majority of respondents were nonwhite, aged 25 or older, had at least five years of education and were currently living with a partner (78–87%). Seventy percent described their partner as being somewhat or very controlling and 34% reported that they did not have any social support. At least one type of abuse during pregnancy was reported by 31% of women—17% reported psychological abuse alone, 3% physical or sexual abuse alone and 11% all three. Some 12% had had a mental illness prior to pregnancy, 43% had been de-pressed or had an anxiety disorder while pregnant and 26% had postpartum depression.

Bivariate analyses revealed that a woman's odds of depression after delivery were elevated if she had four or fewer years of education (odds ratio, 1.6), did not currently have a live-in partner (1.8) or had a partner who communicated poorly (1.4). The odds of being depressed were also higher among women whose partner controlled them to some degree (2.0–4.3) than among those whose partner was not controlling, and higher among women who had little or no social support (2.0–5.7) than among those with many sources of support. In addition, postpartum depression was associated with mental illness that had occurred before or during pregnancy (3.2 and 5.3, respectively).

In logistic regression analyses that controlled for respondents' social and demographic background, psychological characteristics and relationship quality, women who had experienced psychological abuse, either by itself or in combination with physical or sexual violence, had elevated odds of postpartum depression relative to women whose partner had not been abusive (odds ratios, 1.6 and 1.8, respectively). An analysis that examined associations between postpartum depression and various levels of psychological abuse (adjusting for physical and sexual violence) found that the more psychologically abusive a woman's partner had been, the greater the likelihood that she suffered postpartum depression. Women with the highest psychological abuse scores were more than twice as likely as those who had not been subjected to such mistreatment to have postpartum depression (2.3); the odds were also elevated among those who had an intermediate abuse score (2.0).

Although the study used a large, population-based sample and had a high response rate, the researchers caution that cultural attitudes regarding abuse and the women's low-income status limit the generalizability of their findings. They also acknowledge that the questionnaire used in this analysis may not have accurately captured women's postpartum depression, because the ideal cut-off point for their instrument remains unclear. The investigators note, however, that this study goes beyond existing research on the relationship between abuse during pregnancy and postpartum depression by minimizing recall bias and examining the impact of psychological as well as physical violence. They note that psychological abuse may reinforce "a belief in the omnipotence of the aggressor" and lead to "feelings of defeat and loss," and suggest that interventions that address this form of abuse (as well as physical and sexual violence) could "reduce the substantial burden of postnatal depression."—S. Ramashwar

REFERENCE

1. Ludermir AB et al., Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study, Lancet, 376(9744):903–910.