Stress During Pregnancy and Domestic Violence M Maldonado MD

Stress During Pregnancy and Domestic Violence M Maldonado MD

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

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

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

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

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

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

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

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 woman s life Particularly if stress occurs during the first trimester of pregnancy (e.g. earthquake)

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

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 (O Connor, 2002)

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

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)

What is the mechanism? Multiple factors Nutritional Stress related: CORTISOL AND ALPHA ADRENERGIC EFFECTS Hereditary Factors in the child him or herself

What is the mechanism? HYPOTHALAMUS PITUITARY GLAND ADRENAL GLAND ENDOMETRIUM, UTERINE ARTERY, OVARIES, ETC

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

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

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

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.

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

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)

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

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

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)

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

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.)

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)

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

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

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

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

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)

Injuries Physical Pregnancy Psychological

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

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

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

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

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

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

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

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