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.

Part One of a Three part series on Intimate Partner Violence

The women in this post have volunteered to speak for abused women who are afraid to talk or can’t talk.

Give voice to women who are facing Intimate Partner Violence. Learn more about it and what you can to do help.

There are no boundaries to intimate partner violence.

Even pregnancy does not protect the woman from abuse.

How does IPV impact the mother’s health during pregnancy, the birth process, and her recovery?  How does the abuse affect the health and well-being of her unborn child?  How does the mother provide for her newborn under the shadow of abuse?

The next post in our three part IPV series: Intimate Partner Violence during Pregnancy will address these questions.

Want to learn more now? Find out more about IPV and what you can to do help.

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