Intimate partner violence (IPV) has devastating effects on a pregnant woman and her unborn child.

Intimate partner violence may be more severe and more frequent during pregnancy which poses health risks to the mother and her baby. The effects on a woman’s health due to IPV during pregnancy may extend long after the pregnancy and post-partum period. One in four women are victims of IPV and 324,000 pregnant women experience IPV each year and 1600 maternal deaths each year are the result of intimate partner violence.

This blog post is part of our IPV series and covers the effects on mother-infant bonding, maternal and fetal outcomes, and our role as nurses.

The last in our blog series coming out in winter 2015 will cover screening details for nurses.

Mother-Infant Bonding

The mother-infant bond is the first social tie an infant will experience. This bond is essential as failure for a mother and infant to bond may have long term effects on the infant and affect child functioning making it more difficult to form meaningful relationships.

The moments and days following birth are necessary to establish a positive bond. Women who are abused during pregnancy may be emotionally and physically unavailable to their infants and unable to take advantage of the first moments after birth which may jeopardize initiating bonding with their infant.

“I was supposed to enjoy her infancy and I had to worry about abuse. I took no pictures. I did not capture the experience of being a mother”

After birth a mother is drawn to her infant and when she begins to respond to the infant’s behaviors, at that moment a reciprocal relationship has begun.

“I don’t feel connected to my baby”

Infant behaviors such as crying, eye contact, and facial expressions are strong social elicitors of the mother’s response and facilitate the mother’s emotional connection.  These infant behaviors encourage the mother to hold, rock, kiss and gaze at her infant while keeping the infant at close proximity.

The reciprocal relationship between the mother and her infant is necessary for the establishment of the mother-infant bond. Many abused women cannot or do not experience these necessary connections.

“I had to remind myself every day to tell my baby I love him, I did this because I know babies need to hear that”

“When I look at my baby I see him (the abuser)”

“I felt insecure with my baby, more fear”

“[The abuse] kept us distant, but not really, I loved him but was distraught over life.”

” I still feel guilty”

“I resent my baby”

Maternal and Fetal Outcomes of Women Abused During Pregnancy

Pregnant women typically have between twelve to thirteen prenatal visits with 96% of women receiving prenatal care (CDC). It is not uncommon for abused women to have a late entry into prenatal care[2] which may compound the health risk to both mother and fetus.

Physical violence during pregnancy has been associated with increased maternal risk of:

• antepartum hemorrhage
• intrauterine growth restriction
• prenatal death
• depression and PTSD in the postpartum period

Poor fetal outcomes have been associated with increase risk of:

• low birth weight
• preterm births
• stillbirths

Our Role as Nurses

As nurses and midwives we are often the main and most trusted contact our pregnant women have during and after their pregnancy.

We must ask ourselves how we can intervene early and offer supportive care that will enhance the bonding experience between the mother and her infant especially if she has experience IPV during her pregnancy.

The nurse’s role is three-fold:

1. Assess: create a safe environment that allows for assessment and screening for partner abuse in private setting; use a validated IPV assessment tool that ask questions targeting abuse, safety, and especially abuse during pregnancy.
2. Refer: be knowledgeable of community resources and make referrals to community agencies that support women who are experiencing IPV.

3. Treat: be prepared to treat the physical or psychological consequences of IPV.

Intervening in these ways offers opportunities for the new mother to receive support and services she needs while attending to her immediate physical and psychological needs.

Maternity nurses must be mindful that some routine assessments and exams during labor may be threatening to a woman who has been abused. The routine procedure of vaginal exams may trigger negative experiences causing anxiety which can affect labor progression.

Explaining and talking through the assessment or exam allows a woman to be apart of her care and shows sensitivity towards her past experiences. This approach  may decrease a woman’s fear. Epidurals can also trigger memories of past negative experiences especially for women who have been raped or approached from behind and sexually assaulted. With a disclosure of abuse and a better understanding of IPV and its affects on pregnancy, labor, and birth nurses are better prepared to offer care that meets the woman’s needs and allows the woman to maintain control over her own birth experience. This may be the moment she feels empowered to take on the role of motherhood.

Nothing is more satisfying than watching the first moments when the mother and her newborn meet face-to-face for the first time. Maternity nurses get to experience this moment everyday. Maternity nurses are in an ideal position to advocate for abused women and their infants so all new mothers can begin motherhood with a positive bonding experience.

Ann Bianchi, PhD, RN
Ann L. Bianchi is an Associate Professor, College of Nursing , The University of Alabama in Huntsville, Huntsville Alabama.

Additional Information

This year AWHONN released a position statement titled: Intimate Partner Violence and recommended women should be universally screened in a safe and private setting. This position statement also supports refining existing screening tools, regular IPV training and competency validation, and enhancing documentation of IPV screening.

Helpful resources on intimate partner violence

• The National Domestic Violence Hotline
  1-800-799-7233
  http://www.thehotline.org/
• National Resource Center on Domestic Violence
• Types of Violence against Women from the Office on Women’s Health at the U.S. Department of Health and Human Services
• Centers for Disease Control and Prevention’s Intimate Partner Violence: Definitions
• Futures Without Violence
• Break the Cycle (Empowering Youth to End Domestic Violence)

AWHONN’s Position

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) opposes laws and other policies that require nurses to report the results of screening for intimate partner violence (IPV) to law enforcement or other regulatory agencies without the consent of the woman who experiences the IPV. Nurses and other health care professionals, however, should become familiar with laws on mandatory reporting in their states and comply as applicable.

Women should be universally screened for IPV in private, safe settings where health care is provided. Nurses are ideally positioned to screen for IPV for the purpose of initiating a referral for services and support when applicable. To protect the woman’s safety, AWHONN supports policies that require a woman’s consent before reporting occurs.

Read our Position Statement on IPV.

References

Center for Disease Control. Intimate partner violence during pregnancy: A guide for clinicians. 2006. Available at:  http://www.cdc.gov/reproductivehealth/violence/intimatepartnerviolence/sld001.htm#2 Retrieved June 4, 2015 .

Figueiredo, B., Costa, R., Pacheco, A., & Pais, A. (2009). Mother-to-infant emotional involvement at birth. Journal of Maternal Child Health Nursing,13, 539-549.

Flach, C., Leese, M., Heron, J., Evans, J., Feder, G., Sharp, D., & Howard, L.M. (2011). Antenatal domestic violence, maternal mental health and subsequent child behaviour: a cohort study. British Journal of Obstetrics and Gynaecology.118, 1383-1391.

Huth-Brooks AC, Levendosky AA, Bogat GA. (2002). The effects of domestic violence during pregnancy on maternal and infant health. Violence and Victims,17:69-85.

Klaus, M, H. & Kennel, J. H. (1976). Maternal-infant bonding. Saint Louis: The C. V. Mosby Company.

Spinner, M. R. (1978). Maternal-infant bonding. Canadian Family Physician, 24, 1151-1153.

Taylor, A., Atkins, R., Kumar, R. Adams, D., & Glover, V. (2005). A new mother-to-infant bonding scale: links with early maternal mood. Archives of Women’s Mental Health, 8, 45-51.

Tjaden, P. & Thoennes, N. (2000). Extent , nature, and consequences of intimate partner violence: findings from the National Violence Against Women Survey. Washington D.C.: Department of Justice (US); 2000. Publication No. NCJ 181867.

Tjaden, P. & Thoennes, N. (2006). Extent , nature, and consequences of rape victimization: findings from the National Violence Against Women Survey. Washington D.C.: Department of Justice (US):  Publication No. NCJ 210346.

An open letter to all the moms, soon to be moms or family supporting moms!

On December 31st, 2011 I gave birth to a beautiful baby girl! It was something I had dreamed about for so long. I remember the day after she was born crying on the phone with my midwife because I was so overwhelmed. She was so little and I didn’t really know what to do.

Being a little overwhelmed is common, medical specialists call it the baby blues. Post-birth, most moms (as many as 85%!) experience some form of the baby blues. This could be feeling irritable, exhausted, needing to cry for no reason or worrying that you won’t be a good mom.

I did not have that. I had something that damn near sucked the life out of me.

Once we returned home from the hospital, I rarely got off of the couch for 30 days. I got up to feed the baby and change her…I didn’t even eat. I remember just feeling so weird. Everything was robotic. Must feed baby, must change baby…I don’t even remember enjoying any of it.

I remember my husband picking me off of the couch giving me a hug and saying babe, you do not smell good…I am going to take you to the shower. He literally stripped me down and put me in the shower and helped wash me. Many times with post-partum depression (PPD) the mom is too tired to notice the symptoms, and it is a husband, partner, a family member or friend that shares that something just isn’t quite right.  I am thankful for my supportive system every day.

One night I was so tired that I actually Googled how many sleeping pills I could take without dying. I didn’t want to die, but I did want to be pretty close so that at least I would sleep for a few days. I literally had a bunch of pills laid out on the ottoman. I started to down them and then I thought. What if I am unconscious and she starts crying?! Nobody will hear her. I didn’t want her to cry and not have help. So I begged God to let me fall asleep and I threw the pills away. She saved my life.

Then the paranoia set in. I started to think that something very terrible was going to happen. So I started to place emergency items around the house. Things I would need to run away with. I made sure not to be too obvious because I didn’t want my husband to be on to me. One day he left to go to the store. I remember it so clearly, “babe I’m running to the store be back in a few.”

He stepped out of the house and I threw all of my emergency items in a bag, grabbed the baby and ran.

My grandpa was staying in a nursing home at the time and I knew nobody would look for me there so I went to his house and I hid out. I had NO contact with the outside world for days. Yes, I kidnapped my own child because at this point I was pretty unstable.

My husband and best friend were texting like crazy. Finally about ten days in I received a message from best friend which said, “I love you, but right now I have to love your baby more and I will call the police because I know you need help.” I finally told her where I was but begged her not to come. She sent a family friend who is a nurse to see me.

The nurse showed up and told me I had postpartum depression. I had no idea that 15% of new moms experience PPD which is way more intense than the blues, and encompassed so many of the things I was feeling and thinking. But at the time I didn’t know any of that, all I knew is that I just wanted to disappear. I hated everything, I couldn’t function and I was mad that I wasn’t connecting with such a precious little baby.

I never wanted to hurt my baby but I know many women who suffer from PPD do, and I would be lying if I said that I never wanted to hurt myself.

I don’t even remember when I started feeling better. There is so much about that time that scares me, so much more that I could share, but even writing about it makes me feel horrible. It’s a place I NEVER want to return to, and I would NEVER wish it upon anyone.

There were periods of time where I felt that I was bordering on insanity.

Follow the rest of my story in my Part 2 post publishing October 9th – National Depression Screening Day. Take care of yourself!
Danni Starr
Danni Starr works daily as co-host of the nationally syndicated “The Kane Show.” Danni fell in love with radio at 19 and 11 years later, she still considers it her first true love. As a Mother and wife Danni is the “Den Mom” to the show & offers open, honest, opinions and advice.

The above story is adapted from Danni’s original post: https://www.facebook.com/notes/danni-starr/take-a-walk-in-my-postpartum-shoes/572481839449596

Get Support

Postpartum Support International: 1-800-994-4773 or postpartum.net
National Postpartum Depression Hotline: 1-800-PPD-MOMS

References and Learn More at

AWHONN’s Mood and Anxiety Disorders in Pregnant and Postpartum Women Position Statement