Postpartum depression is a common psychosocial health problem seen in the first year after birth. Depression in mothers, postpartum, causes significant problems for mothers, children, and families. It may affect the relationship between a mother and her child along with decreasing mothers’ learning aboutinfant care and the parenting role . Postpartum depression affects 10-15% of mothers in the first year after a birth . In developing countries this rate is even higher. Studies in Turkey have shown rates of violence perpetrated by intimate male partners that vary between 6.3 and 50.7% [4,5]. While postpartum depression most often begins during the first 4 weeks after a birth, the first year of a child’s life is recognized as a high-risk period and that risk period can extend for as long as two years .
Many factors are responsible for postpartum depression. According to research, some significant factors include a family history of depression, younger age, stressful situations during pregnancy, early puberty, anxiety, low social support during the pregnancy, marital conflict, ambivalance about the pregnancy, insufficient weight gain for the mother, smoking, and alcohol and drug use. All of these factors increase the risk of postpartum depression [7,8]. Recently, it has been reported that violence against a woman by her husband physically, emotionally, sexually, or economically can trigger depression.
The World Health Organization(WHO) defines violence or abuse as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” . The first thing that comes to mind when considering violence is usually physical abuse. However, other non-physical types of abuse are also very common, and when perpetrated in a systematic way, these types of abuses create short and long-term effects at least as serious as physical violence.
Community health studies should be undertaken to identify factors that lead to depression, with the goal of decreasing the risk of postpartum depression. Some studies have shown a relationship between postpartum depression and abuse in women exposed to domestic violence postpartum [7, 11-15]. However, we do not have adequate knowledge about the effects of past or current domestic violence on postpartum depression. The relationship between exposure to different types of abuse and postpartum depression are also important.
The aim of this study was to examine the effect of exposure to intimate partner violence on women who experience postpartum depression as compared with postpartum women without depression. We wanted to investigate the relationship between all forms of violence and abuse and postpartum depression.
Material and Method
128 postpartum women whose pregnancy follow up and postpartum monitoring were conducted in a Family Practice clinic were involved in the study. A psychiatric assessment was administered to these participants in a psychiatry clinic. The Edinburgh Postpartum Depression Scale (EPDS) and a sociodemographic form prepared for this study were administered to the participants in the 4th week postpartum. Participants who scored as depressed and those who did not were compared in relation to their exposure to violence. Their scores on the EPDS, along with sociodemographic characteristics, were compared using appropriate statistical methods.
This study was approved by the Dışkapı Yıldırım Beyazıt Teaching and ResearchHospital local ethics committee. After the study procedure was fully explained, all subjects provided written informed consent for participation.
Sociodemographic Questionnaire: This form was prepared by us for this study. It identified each participant’s age, length of marriage, type of marriage, number of pregnancies, and exposure to physical, emotional, sexual, and economic abuse.
The Edinburgh Postpartum Depression Scale (EPDS): This scale was developed by Holden and Cox to determine risk for depression and to measure levels and types of abuseduring the postpartum period. It is a self-assesment tool and includes a total of 10 questions. The cutoff score for the scalehas been calculated as 12/13. The validity and reliability of the Turkish version was established by Engindeniz et al..
All statistical analyses were performed using SPSS software version 22.0 (SPSS, Chicago, IL). Descriptive analyses are presented here as frequencies, percentages, mean, and standard deviations. Continuous variables were investigated using the Kolmogorov–Smirnov test to determine normal distribution. A chi-square and Fisher’s exact test were used to compare categorical variables in different groups. Mann-Whitney U test was used to compare continuous variables between the study groups. A p value of <0.05 was considered statistically significant.
We recruited 128 women for this study. Their average age was 28.62±5.94 years, the average length of marriage was 7.10±6.18 years, and their average number of pregnancies was 1.96±0.97. Their types of marriage included: arranged marriages 28.1%(n=36), elopement 14.1% (n=18), and mutual agreement between the spouses 57.8% (n=74). 48.4 % (n=62) of the women had been exposed to emotional abuse, 14.1 % (n=18) of them to physical abuse, 3.1%(n=4) of them to sexual abuse, and 3.1% (n=4) of them to economic abuse.
The group with EPDS scores of 12 or more were identified as depressed. In 56 women ( 43.7%), we found no depression. 72 women (56.3%) were determined to have postpartum depression.
The average age and the length of marriage for depressed partipicants was found to be statistically significantly higher than for those who were not depressed (p=0.035 and p=0.003 respectively). There was a statistically significant difference between the type of marriage for women who were depressed and those who were not. The rates of exposure to emotional abuse for women who were depressed was statistically significantly higher when compared to women who were not depressed (p<0.001). The rate of exposure to physical abuse for women who were depressed was statistically significantly higher when compared to women who were not depressed (p=0.047). We did not find any significant differences between the groups in terms of their exposure to economic and sexual abuse. The sociodemographic and clinical characteristics of the women whowere depressed and those who were not are shown in Table 1.
The main finding of our study was that the rates of exposure to emotional abuse and physical abuse for the women with postpartum depression were statistically significantly higher when compared with rates for women who did not have postpartum depression. We did not find any significant difference between the groups with and without postpartum depression in terms of their exposure to economic and sexual abuse. One of our other findings was that the average age and length of marriage for women depressed postpartum was statistically significantly higher than for women who were not depressed.
Postpartum depression is a disorder that negatively affects the mental health and quality of life of both mothers and children. Depressed mothers experience mood fluctuations, anxiety, guilt, low self confidence, and have difficulty functioning in their parenting role. Depressed mothers are less sensitive to their infants’ needs and demonstrate negative attitudes toward their babies. These attitudes negatively affect children’s physical and emotional development . In a meta-analysis of studies of the relationship between abuse and postpartum depression, a positive correlation between violence and postpartum depression has been reported . In addition, it has been reported that exposure to abuse is a predictor for depression . The most frequent type of violence against women is abuse committed by an intimate partner. Abuse causes chronic stress in women. Exposure to abuse along with depression creates a serious risk for chronic and significant health problems in both mothers and babies .
Research by the WHO across 10 countries showed that the lifetime prevalance of exposure to physical violence and sexual abuse varies between 15% and 71% . This study reported that women’s rate of exposure to physical violence by their partners throughout their lives varies between 10% and 56%,while 30% of women are exposed to sexual abuse. In a study done in Brazil, 50.7% of women aged 15-49 were exposed to domestic violence. According to a survey of approximately 5,000 people across Turkey, conducted by theTurkish Institute of Family Research, 53% of the violence against women committed by their husbands involved emotional abuse . Violence rates obtained in our sample group were similar to other results obtained in Turkey.
A study in Canada reported that emotional abuse is correlated with postpartum depression while sexual and physical abuse show no relationship with postpartum depression . In contrast with these results obtained by Cohen et al. , Sorbo et al. report that women most often report exposure to emotional abuse, but that all forms of abuse increase their risk for postpartum depression. Another recent study reported that exposure to emotional abuse during pregnancy is more correlated with the development of postpartum depression than is exposure to physical abuse. In our study, when women with depression and without depression were compared, women with depression showed a statistically significant relationship between exposure to emotional and physical abuse and depression but no correlation between economic, and sexual abuse and depression. Our findings support the findings of Ludermir et al. and Sorbo et al.
Our study found that patients with postpartum depression were married younger than women without postpartum depression, and the length of their marriages was longer. The fact that emotional abuse rates were higher for women with depression suggests that the duration of exposure to violence and abuse may be an important risk factor.
A longitudinal prospective study reported that when abuse by a partner ends, the woman shows a decrease in her depression score . A study by Agrawal et al. obtained similar results . Because we made a cross-sectional examination in our study, we could not observe changes that occured in depression rates after the abuse and violenceceased. This may be viewed as one of the limitations of our study. There are very few studies on this specific topic. In the future, longitudinal studies with more varied and larger sample sizes are needed. Recent studies have also examined the person who perpetrates the violence. One study reports that while there is a strong correlation between abuse perpetrated by an intimate partner and postpartum depression, there is no relationship between exposure to violence perpetrated by other people and postpartum depression . Our study examined only exposure to violence and abuse by an intimate partner. Violence perpetrated by other people (known or not known) was not considered. This is another limitation of our study. A study by Sorbo et al.reported that exposure to multiple types of violence or abuse increases the risk of postpartum depression by 2-3 times; in addition, postpartum depression is also correlated with the frequency ofabuse. Our study did not examine how often and how frequently women were exposed to violence, another limitation of our study. Our study also considered only women who had live births. Women who experienced still births and lost their childrenwere not included in this study. This could also be considered a limitation of our study.
In conclusion emotional abuse, which is often considered less important than other forms of abuse, is an important risk factor in the development of postpartum depression. Greater length of marriage and exposure to emotional abuse increase the risk of postpartum depression. Future support for this evidence will depend upon larger sample sizes and longitudinal studies. These results need clarification. There is a need for rapid diagnostic methods to facilitate early identification of depression in high-risk individuals. Rates of illness in mothers, children, and families related to postpartum depression could be decreased with early diagnoses and psychotherapeutic interventions. Emergency helplines offering psychological support for women exposed to violence and abuse and providing legal and medical services could help protect women from violence and abuse. Future studies should examine high-risk populations exposed to abuse and consider the ways that they might be provided with early diagnoses. Preventing the development of postpartum depression would support healthier mothers and better child development.
The authors declare that they have no competing interests.
1. Weinberg MK, Tronick EZ. Maternal depression and infant maladjustment: a failure of mutual regulation. In: Nospitz JD, editors. Handbook of Child and Adolescent Psychiatry. New York: John Wiley &Sons Inc; 1997.p.243-57.
2. Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 2006;91(2–3):97–111.
3. Faisal-Cury A, Menezes PR. Prevalence of anxiety and depression during pregnancy in a private setting sample. Arch Womens Ment Health 2007;10(1):25–32.
4. Ayvaz S, Hocaoğlu Ç, Tiryaki A, Ak İ. Incidence of postpartum depression in Trabzon province and risk factors at gestation. Turk Psikiyatri Derg 2006;17(4): 243-51.
5. Atasoy N, Bayar Ü, Sade H, Konuk N, Atik L, Barut A, Tanrıverdi A ve ark. Clinical and sociodemographic risk factors effecting level of postpartum depressive symptoms during postpartum period. Türkiye Klinikleri J Gynecol Obst 2004;14:252-7.
6. Manfredi G, Lazanio S, Kotzalidis GD, Ruberto A, Girardi P, Tatarelli R. Postpartum depression without delivering a child? Acta Psychiatr Scand 2005;112:233-7.
7. Wu Q, Chen HL, Xu XJ. Violence as a risk factor for postpartum depression in mothers: A meta-analysis. Arch Womens Ment Health 2012;15(2):107–14.
8. Melo EF, Cecatti JG, Pacagnella RC, Leite DF, Vul- cani DE, Makuch MY. The prevalence of perinatal depression and its associated factors in two different settings in Brazil. J Affect Disord 2012;136(3):1204–8.
9. Chambliss LR. Intimate partner violence and its implication for pregnancy. Clin Obstet Gynecol 2008;51(2):385–97.
10. World Health Organization, World Report On Violence And Health: In: Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. Geneva: World Health Organization; 2002.P.3-22.
11. Valentine JM, Rodriguez MA, Lapeyrouse LM, Zhang M. Recent intimate partner violence as a prenatal predictor of maternal depression in the first year postpartum among Latinas. Arch Womens Ment Health 2011;14(2):135-43.
12. Cohen MM, Schei B, Ansara D, Gallop R, Stuckless N, Stewart DE. A history of personal violence and postpartum depression: is there a link? Arch Womens Ment Health 2002;4(3):83-92.
13. Ludermir AB, Lewis G, Valongueiro SA, de Arau ́jo TV, Araya R. Violence against women by their intimate partner during pregnancy and postnatal depression: A prospective cohort study. Lancet 2010; 376(9744): 903–10.
14. Urquia ML, O’Campo PJ, Heaman MI, Janssen PA, Thiessen KR. Experiences of violence before and during pregnancy and adverse pregnancy outcomes: an analysis of the Canadian Maternity Experiences Survey. BMC Pregnancy Childbirth 2011;11(1):42.
15. Sørbø MF, Grimstad H, Bjørngaard JH, Lukasse M, Schei B. Adult physical, sexual, and emotional abuse and postpartum depression, a population based, prospective study of 53,065 women in the Norwegian Mother and Child Cohort Study. BMC Pregnancy and Child Birth 2014;14(1):1.
16. Engindeniz AN, Kuey L, Kultur S. Validity and reliability of Turkish version of Edinburgh Postnatal Depression Scale. In Book of Annual Meeting of Psychiatric Association of Turkey. Turkish Psychiatric Association Press, Ankara; 1996.p.51-2.
17. Dennis CL, McQueen K. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics 2009;123(4):736-51.
18. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. Lancet 2008; 371(9619):1165-72.
19. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet 2006; 368(9543):1260-9.
20. Ludermir AB, Schraiber LB, D’Oliveira AF, França-Junior I, Jansen HA. Violence against women by their intimate partner and common mental disorders. Soc Sci Med 2008; 66(4):1008–18.
21. Aile ve Sosyal Araştırmalar Genel Müdürlüğü. Aile İçi Şiddetin Sebep ve Sonuçları. Ankara: T.C. Başbakanlık Aile ve SosyalAraştırmalar Genel Müdürlüğü; Ankara, 1994.
22. Bassuk E, Dawson R, Huntington N. Intimate partner violence in extremely poor women: Longitudinal patterns and risk markers. J Fam Violence 2006;21(6):387-99.
23. Kothari CL, Liepman MR, Tareen RS, Florian P, Charoth RM, Haas SS et al. Intimate partner violence associated with postpartum depression, regardless of socioeconomic status. Matern Child Health J 2016;20:1237-46.
24. Campbell JC, Soeken KL. Women’s Responses to Battering Over Time An Analysis of Change. J Interpers Violence 1999;14(1):21-40.
25. Agrawal A, Ickovics J, Lewis JB, Magriples U, Kershaw TS. Postpartum intimate partner violence and health risks among young mothers in the United States: A prospective study. Matern Child Health J 2014;18(8):1985-92.