Stress During Pregnancy and Domestic Violence

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Stress During Pregnancy and Domestic Violence

• M Maldonado MD

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Stress and violence

• Effects of Stress on the future mother
• Effect of stress on the baby in utero
• Scenarios of violence and their effects,
  phenomena, epidemiology and interventions

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EFFECTS OF STRESS DURING PREGNANCY

• Some degree of stress is universal
• Normal concerns and worries during pregnancy
• Psychological/emotional adjustments
• Transition to parenthood
• Changes in body, hormones, emotions
• Emotional field of the pregnancy

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Excessive stress in pregnancy

• Higher risk of miscarriage i.e. premature
  spontaneous termination of pregnancy
• Eg. If victim of a crime
• If stress at work place
• If death of a relative

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Excessive stress in pregnancy

• INCREASED RISK OF PREECLAMPSIA
• Some changes from the first trimester of
  pregnancy (Increase CRH. Corticotropin releasing
  hormone)
• Elevation of blood pressure
• Risks of higher fetal suffering
• Placenta more likely insufficient
• Risk of Eclampsia

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Excessive stress in pregnancy

• INCREASED RISK OF PREMATURITY AND PREMATURE LABOR
• Higher frequency in adolescents
• Higher frequency in Afro American girls?
• Higher frequency of growth retardation and
  possibly lower head circumference

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Risk of prematurity

• Copper et al. 1996. Multicenter study
• 2593 women in ten centers
• Ages 25-29
• Higher psychosocial stress is associated with
• HIGHER INCIDENCE OF PREMATURITIY
• LOWER GESTATIONAL WEIGHT
• Growth restriction of fetus

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Higher risks if stress

• Rauchfus and Gauger, 2003
• Study with 508 women
• Higher rates of stress are associated with higher
  risk of prematurity
• Higher risk if Lower access to female network
• Lower support from Partner
• Higher preoccupation with somatic problems

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Excessive stress in pregnancy

• Higher incidence of low birth weight, even if at
  term
• Chronic lower perfussion toward placenta and
  fetus? ( Xiao et al, 2003)
• Associated with daily hassles in womans life
• Particularly if stress occurs during the first
  trimester of pregnancy (e.g. earthquake)

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Long term effects on the child?

• Prematurity is known to be associated with
  emotional and behavioral disturbances later on
• Learning difficulties
• Attention deficit hyperactivity disorder
• Disruptive behavior
• Increased aggression

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Long term effects of in utero stress on the child?

• Higher risk of self-regulation difficulties
• Higher risk of attention deficit hyperactivity
  disorder ( Linnet et al, 2003. Laucht et al,
  2000. War time stress , Meijer 1985)
• More temperamental difficulties, more difficult
  children at age 4 (OConnor, 2002)

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Long term effects of in utero stress on the child?

• Avon Longitudinal Study ( O Connor et al, 2003)
• High anxiety during pregnancy
• PROGRAMMING EFFECT on fetus
• Higher rate of behavioral and emotional problems
  at ages 47 months and 81 months

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Long term effects of in utero stress on the child?

• Huizink et al, 2003
• Higher anxiety during pregnancy
• Follow up 170 women
• LOWER performance in developmental scores in the
  babies at 8 months (cognitive and motor
  performance)

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What is the mechanism?

• Multiple factors
• Nutritional
• Stress related CORTISOL AND ALPHA ADRENERGIC
  EFFECTS
• Hereditary
• Factors in the child him or herself

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What is the mechanism?

• HYPOTHALAMUS
• PITUITARY GLAND
• ADRENAL GLAND
• ENDOMETRIUM, UTERINE ARTERY, OVARIES, ETC

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What is the mechanism?
STRESS
PERCEPTION BY BRAIN HYPOTHALAMUS
PITUITARY GLAND STIMULATING HORMONES
CORTISOL
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Mechanism

• High level cortisol in the mother due to stress
• Associated with High levels of cortisol in the
  fetus
• This causes higher levels of activity in the
  fetus
• Lower capacity for habituation, higher reactivity
  in the baby
• Worse effect of chronic

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Mechanism

• Teixera et al, (1999)
• Demonstrated CONTRACTION OF THE UTERINE ARTERY
• Less irrigation/oxygenation for the placenta and
  the baby
• (doppler, resistance index of the uterine artery)
  Higher resistance in women under stress or more
  anxious

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Need to reduce stress

• Awareness of negative effects
• Avoidance of stressful situations
• Creating a protective of buffering environment
• Mothering of the mother
• Need for peace of mind, absence of daily hassles
  and a supportive network.

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Domestic Violence

• Interest in the field is relatively recent
• Little available evidence of the causes and
  phenomena associated with it
• Less information about what is effective in terms
  of prevention and treatment
• Cultural and psychosocial factors are very
  important

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Epidemiology

• Domestic violence exists in most societies
• Often it consists of males maltreating their
  spouse or partner
• Intimate violence
• Position of women in most societies
• (subordinate, dependency, power relationships,
  cultural and societal attitudes toward the
  position of women)

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Epidemiology

• One of every five productive days is lost due to
  domestic violence (Panamerican Health
  Organization)
• Difficult to estimate prevalence due to social
  stigma and to fears of making revelations
• No adequate interventions for the women (long
  term) or for the family in many cases, e.g. the
  children

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Epidemiology

• Teenagers in the US.. 20 experience intimate
  partner violence (Nat. Longitudinal Study of
  Adolescent Health)
• Risk factors depression, substance use
• History of violence in their own home or
  childhood
• Multiple partners, early initiation

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Epidemiology

• Rhode Island, 1998. McGrath et al.
• 397 women attending a clinic
• 46 remembered a history of physical or sexual
  abuse
• 38 had experienced recent abuse
• Risks lower SES (economic), young age
• (Only 18 women had ever been asked)

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Epidemiology

• Latinamerica ( estimated between 20 and 40)
• Castro et al (2003)- 914 pregnant women in
  Guerrero, Mexico
• Third trimester of pregnancy
• Prevalence of 25 of domestic violence
• Brazil (Schreiber et al, 2002), 322 women,
• 40 reported domestic violence

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Epidemiology

• Bangla Desh, women in microenterprises
• (Bhuiya et al, 2003)
• 50 reported physical battering by their spouse
• If pregnant, 20 beaten during pregnancy
• (questioning husband, not doing chores, etc.)

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Epidemiology

• South Africa (Pelzer et al, 2003)
• 60 of women reported verbally abused
• 20 of women beaten
• Uganda (Kampala), of 379 pregnant women
• (Kaye et al, 2002) 57 report moderate to severe
  beating by husband
• (being maltreated as child and witnessing
  violence were risk factors)

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Epidemiology Epidemiology

• IMMIGRANT STATUS may be a risk factor
• (lack of psychosocial support, isolation,
• Lack of familiarity with services or rights
• Boston (Raj and Silverman, 2003)
• 160 South Asian women
• 40 reported intimate partner violence

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Epidemiology

• In Turkey (Sahin and Sahin, 2003)
• 455 women screened during pregnancy
• 33 reported physical or sexual abuse during the
  pregnancy
• Even higher prevalence of verbal abuse

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Risk factors

• Transgenerational transmission
• Adult beliefs and values
• History of violence during childhood
• Low socioeconomic status and access to education,
  services, self-esteem
• Cultural attitudes and values

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Adult beliefs

• Survey of women in Zimbabwe (Hindin, 2003) 50
  of women
• Perceived that hitting was justified if
• Arguing with their husband
• Burning the food
• Refuses to have sex with husband
• Not cleaning house adequately
• Going out without husband permission

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Why women endure?

• (Study In Bangla Desh)
• Concern about the children and their future
• Not having where to go
• Stigma associated with the separation (failure on
  her part)

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Injuries

• Physical
• Pregnancy
• Psychological

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Injuries

• In the US it is estimated that between
• 20 and 33 of visits by women to
• The EMERGENCY ROOM of a hospital
• Are RELATED TO DOMESTIC VIOLENCE INJURIES
  (Corrigan et al, 2003)
• Blows to head, face
• Or perpetrator tries not to leave marks ( ribs,
  chest ,etc.) 3-21 significant injury

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Health care establishment

• Ignoring the problem
• If one does not think about it , it does not
  exist
• It would be better if problem went away
• Not ask, do not tell
• Even if told, not much action after the revelation

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Health Care response

• Most physicians do not receive training in
  recognizing or screening for domestic violence
• One should ask privately
• Ask several times yields higher admissions.
• A proportion of physicians may think violence is
  always a private matter where no intervention is
  necessary

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intervention

• Preventive
• Remedy
• Long term support and assistance
• Who should do it?

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Intervention

• Prevention
• Conflict resolution
• Power relationships
• Self esteem and beliefs of the woman
• Education of young people
• Education, media, institutions
• Detection and early intervention

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Intervention

• Emergency situation
• First SAFETY of the woman affected
• Providing a safe place may be necessary
• Relative, safe house, etc.
• Cooling down
• Psychosocial Evaluation of the woman and if
  possible the spouse

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intervention

• Careful and detailed assessment of the situation
• Spouses as individuals ( substance use,
  psychopathology, attention deficit)
• Evaluation of psychosocial stress
• Evaluation of the couples relationship and
  dynamic
• Evaluation of the whole family, effect on the
  children

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Intervention

• Multimodal
• Help to the spouses
• E.g. anger management, conflict resolution,
  rehabilitation, pharmacotherapy, etc.
• Support to the woman to develop options
• Separation is not always the answer
• Health care staff frustration