Curr Psychiatry Rep (2017) 19: 26 DOI 10.1007/s11920-017-0778-6

COMPLEX MEDICAL-PSYCHIATRIC ISSUES (MB RIBA, SECTION EDITOR)

Current Reports on Perinatal Intimate Partner Violence Donna E. Stewart 1 & Simone N. Vigod 2 & Harriet L. MacMillan 3 & Prabha S. Chandra 4 & Alice Han 5 & Marta B. Rondon 6 & Jennifer C. D. MacGregor 7 & Ekaterina Riazantseva 8

Published online: 17 April 2017 # Springer Science+Business Media New York 2017

Abstract Purpose of Review The purpose of this study was to review the literature on perinatal intimate partner violence, focusing on recent knowledge to guide mental health professionals on the best approaches to identify and treat women exposed to perinatal intimate partner violence. Recent Findings Risk factors have been broadened from individual victim and perpetrator factors to include relationship, community, and societal factors which interact together. Better information is now available on how to identify, document,

This article is part of the Topical Collection on Complex MedicalPsychiatric Issues * Donna E. Stewart [email protected]

1

University Health Network Centre for Mental Health, University of Toronto, 200 Elizabeth Street, EN-7-229, Toronto, ON M5G2C4, Canada

2

Women’s College Hospital and Research Institute and University of Toronto, Toronto, Canada

3

Departments of Psychiatry and Behavioural Sciences, and of Pediatrics, McMaster University, Hamilton, Canada

4

National Institute of Mental Health and Neuroscience, Bengaluru, India

5

Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA

6

Psychiatry and Mental Health Unit, Universidad Peruana Cayetano Heredia, Lima, Peru

7

Faculty of Information and Media Studies, Western University, London, Canada

8

University Health Network Women’s Health Program, Toronto, Canada

and treat women exposed to violence around the time of conception, pregnancy, and the postpartum period. Summary Recent information helps psychiatrists and other mental health professionals assist women exposed to violence related to the perinatal period; however, further research is needed to provide improved evidence for optimal interventions for better patient outcomes. Keywords Intimate partner violence . Perinatal . Mental health . Interventions

Introduction Intimate partner violence (IPV) is a global public health and human rights problem that affects millions of women regardless of country, age, economic status, race, ethnicity, religion, education, or sexual orientation [1••]. Although it can occur at any time of life, the highest prevalence of IPV is during a woman’s reproductive years [2••]. When it occurs associated with pregnancy, it is described as “perinatal.” “Perinatal IPV” (P-IPV) in this paper will include IPV occurring in the year before conception, throughout pregnancy, to during and up to 1 year after giving birth. IPV is defined by the World Health Organization as “behaviours by an intimate partner that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse or controlling behaviours” [3]. It may be perpetrated by a current or past intimate partner, occur in heterosexual or same-sex relationships, and include stalking. At its core, it is a means to control and dominate the abused partner [3, 4]. While conception, pregnancy, childbirth, and early transition to parenthood are usually happy events, they also present new challenges to each parent and their relationship. In addition to the physical changes in pregnancy, emotional, social,

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and economic adjustments may cause stresses that affect individual’s and couple’s coping strategies leading to the initiation, continuation, or increased frequency or severity of psychological and physical aggression [2••]. These stresses may be magnified if the partners are no longer together and suffer from mental illness or substance abuse or if the pregnancy is coerced or unwanted. Evidence shows that IPV is one of the most common health risks in the perinatal period [5]. Perinatal IPV is a risk factor for adverse health outcomes to the mother, fetus, and infant [6••, 7]. Maternal mental health problems associated with P-IPV include depression, anxiety, post-traumatic stress disorder (PTSD), psychosis, inability to trust others, self-harm, risky behaviors, and multiple psychosomatic conditions including chronic pain, all of which may be referred to psychiatrists [4]. There is evidence of varying quality of P-IPV being associated with miscarriage, placental abruption, preterm birth, low birth weight, fetal death, and other sequelae discussed later [1••]. It is essential that psychiatrists and other mental health professionals, as well as reproductive healthcare providers, are aware of P-IPV, how to facilitate disclosure, respond safely, and provide evidence-based care to women who experience IPV during this period. As 60% of mental health professionals report that they lack adequate knowledge and want more education on IPV [8], the purpose of this article is to discuss the latest information on P-IPV prevalence, risk factors, adverse effects to mother and fetus/infant during the perinatal period, how to identify, document, and intervene in PIPV cases and draw some conclusions from this information.

IPV Prevalence in Pregnancy and Postpartum Period in North America and Elsewhere There is wide variation in P-IPV prevalence, depending on the definition and the setting, the population studied, and instruments used. Hospital and clinic-based prevalence studies show that some populations may be at increased risk of IPV during pregnancy, but most community-based samples show a prevalence similar to non-pregnant women or that pregnancy may be protective [9]. In general, IPV and P-IPV are greatly underreported in all jurisdictions. P-IPV rates in the American continent vary widely. In the USA, using data from 27 states, 5.3% of postpartum women reported physical abuse from an intimate partner in the year prior to becoming pregnant, compared to 3.6% during pregnancy. Higher rates were reported in women who were unmarried, young, separated, nonwhite, poorly educated, and those whose partner or themselves had been incarcerated [10]. Canada has reported a 3.3% [11] to 6.6% [12] prevalence of IPV (physical abuse only) during pregnancy. In Latin America and the Caribbean, the rates vary by type of violence, ranging from 3.0 to 34.5% for sexual, 2.5 to 38.7% for physical, and

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13 to 44% for emotional/psychological violence [13••]. Subpopulations in all countries may have greatly increased rates. Physical violence is easier to define than emotional or psychological abuse, some examples of which are shown in Table 1. The WHO Multi Country Study on Violence against Women reported that between 1 (Japan) and 28% (Peru, province) of surveyed women suffered IPV during pregnancy, with the majority of the 14 sites reporting between 4 and 12% [15]. Similarly, a secondary analysis of Demographic and Health Surveys and International Violence against Women Surveys (24 surveys, 19 countries) showed rates ranging from 2% in Australia, Cambodia, and the Philippines and 13.5% in Uganda among ever-pregnant, ever-partnered women. Latin America and Africa had higher rates of violence in comparison to Europe and Asia [5]. In general, countries with high patriarchy and conservative cultures, where abusive behaviors may be more normalized, have higher rates of P-IPV. In a meta-analysis of 92 studies, James et al. reported an average prevalence of IPV during pregnancy: 28.4% for emotional abuse, 13.8% for physical abuse, and 8.0% for sexual abuse [16]. Developed countries had a significantly lower prevalence rate compared to developing countries.

Risk Factors Risk factors for P-IPV are similar to these for IPV in general. The World Health Organization has espoused a public health approach using an ecological framework which views IPV as resulting from the interaction of many factors at four levels: individual, relationship, community, and societal (see Fig. 1) [17]. Table 1

Some examples of psychological aggression [14]

• Control of reproductive or sexual health (e.g., refusal to use birth control; coerced abortion) • Questioning the paternity of the fetus without justification • Expressive aggression (e.g., name-calling, humiliating, degrading) • Coercive control (e.g., limiting access to money, friends, and family; excessive monitoring of a person’s whereabouts and communications; monitoring or interfering with electronic communication; threats to harm self; threats to harm a loved one or possession) • Threat of physical or sexual violence (e.g., use of words, gestures, or weapons when victim is either unwilling or unable to consent) • Exploitation of victim’s vulnerability (e.g., immigration status, disability, undisclosed sexual orientation) • Exploitation of perpetrator’s vulnerability (e.g., perpetrator’s use of real or perceived disability, immigration status to control victim’s choices, or limit victim’s options) • Gaslighting (i.e., “mind games”)—presenting false information to victim to cause them doubts about their memory and perception

Curr Psychiatry Rep (2017) 19: 26 Fig. 1 The World Health Organization Ecological Framework for Intimate Partner Violence. Some examples of risk factors (which may apply to both the victim and perpetrator) at each level. Adapted from Ref [17]

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Poor parenting practices Marital discord Violent parental conflict Low socioeconomic status Violent friends

INDIVIDUAL

RELATIONSHIP

A meta-analysis identified factors for the victim (abuse before pregnancy, lower educational level, low socioeconomic status (SES), being single or living apart, alcohol abuse, unintended/unwanted pregnancy, and lifetime adversity/ exposure to violence) and for the perpetrator (alcohol abuse and unintended/unwanted pregnancy, both weak predictors of risk) [16]. In developing countries (IPV during pregnancy; rate 27.7%), the greatest risk factor was a previous history of IPV, which raises the risk of violence during pregnancy as much as 14 times. In developed countries (IPV during pregnancy; rate 13.3%), risk factors also include low SES, low educational level, unintended/unwanted pregnancy, being single, and having a partner that abuses alcohol, all of which increased the risk at least twice [16]. A recent study showed P-IPV increased in the postpartum period with the strongest risk factors being a history of violence, living apart, and depressive symptoms [18•].

Adverse Effects of IPV in Pregnancy Intimate partner violence is of particular concern during pregnancy, with risks towards maternal, fetal, and newborn health [19]. Maternal Effects IPV during pregnancy is associated with high-severity violence [20] and hospitalization. A wide range of physical health sequelae can be associated with P-IPV including fractures, contusions, burns, lacerations, and dental injuries among others [21]. There is an increased risk of death [22•], with 54% of pregnancy-related homicides associated with IPV [23]. IPV is also associated with maternal infections including hepatitis B, sexually transmitted infections (STIs), and HIV [24–27]. P-IPV is associated with depression [11, 28] during pregnancy and the postpartum period. Almost 40% of women experiencing IPV reported maternal depressive symptoms [29, 30], followed by 19–84% experiencing PTSD [31, 32]. Others suffer from anxiety, low self-esteem, functional

SOCIETAL

COMMUNITY

Gender, social and economic inequalities Poverty Weak economic safety nets Poor rule of law Cultural norms that support violence

Poverty/unemployment High crime levels Illicit drug trade Situational factors

disorders, self-harm, and suicidality [21]. More research is needed on mental health problems associated with P-IPVother than postpartum depression [32] and on the association with abuse other than the physical type. Research is also needed to elucidate differences in health outcomes between women reporting chronic IPV (i.e., before and during pregnancy) versus women reporting IPV either before or during pregnancy [33•]. For example, higher rates of postpartum depression may be associated with abuse experienced during compared to before pregnancy [33•]. IPV during pregnancy is associated with negative health behaviors, such as higher smoking rates [34], alcohol use, substance use [35], poor nutrition causing inadequate gestational weight gain [36, 37], and inadequate antenatal care [38], including being twice as likely to miss prenatal care appointments or initiating prenatal care later than recommended [38, 39]. Unintended Pregnancy Reproductive coercion (behavior that interferes with contraception use and pregnancy in ways that reduce women’s control over reproductive decisions, including pregnancy coercion and contraceptive sabotage) [23, 40–42] resulting in either nonconsensual sexual intercourse, unwanted pregnancy, or forced abortions does not necessarily entail physical violence. Subtle forms of manipulative behavior, such as threat of abandonment or benefit withholding, or reminders of the woman’s duty to have sex as “a proof of love,” may also be used [41]. Data about the relationship between IPV and contraceptive use is inconsistent: some studies report lower use of contraceptives among abused women [43•, 44, 45, 46••] while others report the opposite [47]. Fear of violent consequences by the abuser is a barrier to negotiating condom use [48] and other contraceptives [49]. Emergency contraception may be used after unprotected intercourse within 5 days for hormonal methods (levonorgestrel or ulipristal) or a copper-bearing IUD inserted within 5 days [3]. No data was found for the prevalence of use of emergency contraception following IPV.

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Abortion P-IPV is also associated with greater rates of pregnancy termination [23, 50, 51], with or without the abuser’s knowledge [52]. Women in abusive relationships are twice as likely to have induced abortions and three times as likely to have had multiple abortions than women partnered to nonabusive men. IPV interacts with reproductive coercion to result in higher rates of unintended pregnancy and coerced unsafe abortion, independently of the direct consequences of physical violence itself. Abusive men disclosed that they were more likely to coerce abortion (often in unsafe settings) than non-abusive peers, increasing the likelihood for severe morbidity or abortion-related death for women subject to P-IPV [53]. Attempts to control reproductive outcomes are reported by abusive partners, ranging from physically assaulting a pregnant woman with intent of causing miscarriage to sabotaging contraception [54].

[65] also show a strong association between P-IPV and increased risk of postpartum depression which may be “bi-directional” [63, 64•]. In addition to the effects of P-IPV on birth outcomes, it is increasingly recognized that P-IPV exposure may reduce maternal postpartum responsiveness to one’s infant; however, the specific pathways are uncertain. It may be mediated by postpartum mental health problems, including depressive or anxiety disorders. Negative effects on breast-feeding have also been reported [59]. There is evidence that mothers who have experienced P-IPV have ways of thinking about themselves and their infants that are more negative [66], which may lead to problems in attachment. Future research is needed to understand the specific vulnerabilities that exist for women exposed to P-IPV in parenting both during and beyond the postpartum period.

Fetal Effects Offspring of abused women during pregnancy have increased risk of intrauterine growth restriction [55•], low birth weight [56], small for gestational age [57], and prematurity [6••, 43•, 55•, 56–59, 60••], with premature birth rate ranging from 14 to 25% [43•, 59]. Three recent systematic reviews found an association between IPV during pregnancy and both low birth weight and preterm birth [6••, 56, 60••]. Two of these reviews found no increased risk of intrauterine growth retardation (small-for-gestational age at birth) [56, 60••], while one identified a weak association with smallfor-gestational age infants [6••]. Among the most severe risks is perinatal death (i.e., fetal loss after 20 weeks gestational up to neonatal death occurring <=28 days after delivery) [19, 55•] which has also been documented in low- and middle-income countries [61, 62].

Case Identification, Documentation, and Reporting

Postpartum Effects of Perinatal IPV As outlined above, P-IPV is associated with increased risk of a broad range of maternal and infant health concerns during the postpartum period. Any of the physical and/or mental health problems associated with women’s IPV exposure generally, including injuries and death, can occur during this time. Maternal mental health symptoms are among the most common problems associated with P-IPV. A recent systematic review and meta-analysis of the relationship between IPV and perinatal mental disorders showed a three-fold increase in “probable depression” experienced in the postpartum period following IPV during pregnancy. Less is known about postpartum anxiety disorders and PTSD in relation to perinatal IPV, although there appears to be an association [63]. Much of the research examining perinatal IPV and mental health problems has been conducted in high-income countries, but recent prospective studies from sub-Saharan Africa [64•] and Brazil

Possibly, one of the most debated issues in the area of intimate partner violence is the role of screening every patient versus case finding (asking tailored questions when appropriate). There is enough evidence to suggest that routine screening for partner violence is of little benefit to women. Most policies recommend a case identification method with facilities and services for safety planning and referrals for interventions [3, 67]. However, women who present with mental health issues or conditions or physical injuries commonly seen after IPV warrant specific queries about violence and abuse. The situation in P-IPV is no different. Studies exploring women’s acceptance of enquiry about partner violence in the perinatal period have indicated that the majority of pregnant women are accepting of enquiry regarding IPV provided there is enough privacy and confidentiality and the enquiry and disclosure leads to positive consequences [68]. An overarching theme women request is that the clinician offer referrals or direct services for support, treatment, and safety. Women prefer a caring and nonjudgmental attitude when being asked about IPV and feel that being told about the relevance of IPV in pregnancy would facilitate disclosure [69••]. Women should not be blamed or pressed to leave the partner [4]. A systematic review on acceptability of enquiry for IPV found that women are more likely to accept routine or casebased enquiry during antenatal care than general care. The frequency of contact with the health system, the trust between the family doctor, midwife or obstetrician and the patient during pregnancy and the women’s desire to have a healthy baby may be factors that facilitate case identification [70]. Programs with institutional support, effective protocols, thorough ongoing staff training, and immediate access or referrals to onsite and/or offsite support services are most successful in increasing P-IPV identification [71]. Patient self-administered or

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computerized approaches have been shown to be as effective as clinician-led interviewing in terms of disclosure, comfort, and time spent [72]. Staff may feel apprehensive especially if proper systems are not in place for supporting women and if protocols for case identification and referral of P-IPV are not clear. There is no consensus on how often women should be asked about P-IPV. However, checking with the woman during each of her antenatal and postpartum visits and setting the stage to explore any relationship stress may be helpful. Questions should be tailored to the situation, but a possible opening question is “What happens when you and your partner disagree about things?” Among others, follow-up questions as appropriate might include “Has the violence gotten worse?”, or “Does he have a weapon?” [73••]. All questions about P-IPV should be conducted in a private, safe, and confidential environment. If recent or serious violence is reported, the woman should be helped to assess if it is safe to return home. If danger exists, she should be immediately referred to an appropriate agency/shelter for safety [3, 4]. Documentation of the clinical details and verbatim statements of the woman may provide important evidence for any future legal proceedings. It is essential that they be accurate and complete. Details of the history, circumstances, chronology, signs, symptoms, evidence, and names of witnesses (if any) should be recorded. Separation of facts and opinions should be clear. Mental health signs and symptoms and their relationship to the violence/abuse should be documented. The health professional may want to include the woman’s own quotes and also use dated body maps or photographs (with patient permission) in case of injuries for better recording [4, 74]. While IPV is a crime in most jurisdictions, reporting (without child exposure) is usually not required and should be the woman’s choice if not mandated, as it may increase the woman’s risk of danger. Mental health providers should know and follow local legal requirements. However, all women should be asked about safety and helped to arrange practical supports, services, and follow-up [4].

Interventions to Reduce Exposure to P-IPV and Manage Mental Health Sequelae. Randomized Controlled Trial Evidence Summary There are limited randomized controlled trials (RCTs) on effective interventions for P-IPV. A recent Cochrane systematic review [75••] examined interventions for pregnant women exposed to IPV. We are aware of two further papers that report additional findings from a study included in this Cochrane review [76, 77•]. Each RCT examined a different intervention; all interventions began during pregnancy and some continued

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into the postnatal period or beyond. The overall quality of the RCTs is mixed, with only one study considered to have ‘low’ risk of bias overall [78]. Characteristics of the nine studies are summarized in Table 2. Results regarding the effectiveness of the interventions for reducing IPV exposure are inconsistent within and across the six studies examining this outcome, with two studies showing no improvements [79, 80], one showing improvement [77•], and three showing significant improvement on some IPV outcomes and not others [78, 81, 82]. One study [78] reported a positive effect on depression for women receiving a brief prenatal intervention, whereas three other studies found no group differences [77•, 79, 82]. Two studies examined birth outcomes and found benefits as a result of intervention (e.g., reduction in preterm birth, birth weight, etc.) [81, 82]. Other outcomes examined in single studies showed significant improvement—PTSD symptoms (at some timepoints) [80], provider-patient IPV discussions (which might increase disclosure, safety, and interventions) [83, 84], workforce participation, sense of mastery, general mental health, and mother-child interaction [82]—whereas others did not, including use of safety behaviors (i.e., having things in place that will increase safety in crisis situations such as having clothing and money hidden in case the victim needs to suddenly leave home), P-IPV resource use [85], stress (various domains, including abuse) [86], children’s externalizing behaviors, welfare use, and substance use [82]. In general, there is heterogeneity among RCTs in the types of interventions and outcomes examined, as well as inconsistent findings and mixed study quality, which preclude drawing strong conclusions regarding the best intervention for pregnant women exposed to IPV. Nevertheless, there is some indication that interventions including advocacy components (i.e., empowerment and support) from a trained advocate including supportive counseling, safety planning advice, and assistance to access community resources may be particularly promising [77•, 78, 81]. Consistent with this perspective, a recent review of advocacy interventions for IPV tentatively concluded, partly based on evidence from these studies, that “brief advocacy may provide small short-term mental health benefits and reduce abuse, particularly in pregnant women and for less severe abuse” [87••]. Clearly, more research is needed to examine the best intervention approaches for pregnant women exposed to IPV in both developed and developing countries. Rigorous designs examining key outcomes are needed, particularly studies that examine mothers’ long-term IPVexposure, and maternal mental health and pregnancy outcomes such as maternal mortality, miscarriage, antepartum hemorrhage, placental abruption, and the health of newborn babies [75••]. Meanwhile, less robust forms of evidence must inform the care of women exposed to P-IPV.

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Summary characteristics of randomized controlled trials of interventions for intimate partner violence

Author, year Population

Intervention(s)

Comparator

Outcomes measured

Humphreys Women <26 weeks 2011 pregnant with positive USA screen for IPV; intervention group, n = 25; control group, n = 25 Cripe 2010 Low-income pregnant Peru women with physical/sexual IPV; experimental group, n = 110; control group, n = 110 Curry 2006 Pregnant women at risk of USA abuse with high stress levels; intervention group, n = 106; control group, n = 101 Kiely 2010 Pregnant women from USA minority groups who reported IPV; experimental group, n = 169; control group, n = 167

Interactive multimedia ‘Video Doctor’ about discussing IPV. Providers received ‘cueing sheets’ alerting them to patient IPV exposure and suggesting counseling statements. 30-min empowerment intervention (supportive counseling and education, safety advice, community resources, empathic listening)

Usual care (not described)

IPV discussions with provider

Nagle 2002 USA

Olds 2004 USA

Sharps 2016 USA

Tiwari 2005 Hong Kong

Zlotnick 2011 USA

Standard care (referral card Safety behaviors, resource use, health-related quality of life only; intervention provided at conclusion of study)

Standard care plus video about abuse Standard care (written information on local and 24/7 access to nurse case resources for IPV) management during pregnancy

Several 30-min. Sessions: cognitive-behavioral intervention focused on individual risk factors (smoking, passive smoking, depression and IPV) and emphasizing safety planning; local resources provided Medicaid-eligible pregnant Treatment 1:Nurse home visits about every other week until child age 2; women; 2 treatment Treatment 2: As above but team groups, n = 241; control included mental health professional group, n = 116 Low-income pregnant Treatment 2: Treatment 1 + paraprof. women; Treatment 1 Home visits during pregnancy/first (control), n = 255; 2 years; Treatment 3: Treatment Treatment 2, n = 245; 1 + nurse home visiting during Treatment 3, n = 235 pregnancy/first 2 years DOVE: 6 times within regularly Low-income pregnant scheduled home visits (3 during women experiencing IPV; pregnancy, 3 postpartum) - IPV DOVE group, n = 124; education, danger assessment, control group, n = 115 safety planning, local resources info., and decision-making support (all tailored to women’s needs). Pregnant women 30-min interview with midwife experiencing IPV; researcher (safety advice and experimental group, problem-solving; intervention n = 55; control group, based on empowerment and n = 55 empathic understanding), plus brochure reinforcing information provided Pregnant women with 4 60-min. Sessions + booster within past-year IPV; 2 weeks of birth (principles of experimental group, interpersonal psychotherapy; n = 28; control group, enhance social support to improve n = 26 depression, service use, IPV)

Stress (various domains)

Standard care according to IPV, adverse pregnancy/neonatal protocols at each clinic outcomes

Usual care (not clearly described)

IPV, depression

IPV, subsequent pregnancies/birth outcomes, workforce participation, welfare use, mental health, substance use, sense of mastery, child outcomes Usual care (standard home IPV, depression visiting protocol, discussion of IPV only if suspected or if woman raised concern) Treatment 1: free developmental screening/referral for children

Standard care (written information about local IPV resources)

IPV, health-related quality of life, depression

IPV, depression, PTSD Usual medical care (educational material and list of IPV resources)

Notes: n per group may vary by analysis IPV intimate partner violence, DOVE Domestic Violence Enhanced Home Visiting Program, PTSD post-traumatic stress disorder, RCT randomized controlled trial

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Management of Mental Health Sequelae of Perinatal IPV Mental health sequelae of perinatal IPV include perinatal depression, anxiety, and PTSD, as well as substance use and somatization disorders, although the stress of IPV could precipitate or perpetuate any type of mental illness [88]. General principles of managing these conditions in the perinatal period are applicable in the IPV context. These include preferential use of non-drug or psychotherapeutic techniques for illnesses of mild and moderate severity and consideration of the risks and benefits of psychotropic medication in pregnancy and lactation in women with more severe symptomatology [89, 90]. Management of any perinatal mental illness in the context of IPV can benefit from a trauma-informed care framework, even when specific criteria for PTSD are not met. Traumainformed interventions pay attention to difficulties that trauma survivors often have with trust and interpersonal relationships. Considering a trauma survivor’s need to be respected, informed, and empowered can reduce the chance that a mental health intervention will be experienced as a form of revictimization [91•]. Psychotherapeutic challenges include promoting safety and recognizing that symptoms may not resolve until after ongoing abuse ends, while also attending to readiness of a victim of IPV to leave an abusive situation. Specific psychotherapeutic interventions may be useful when symptoms of PTSD are present. Although no trials have been conducted among perinatal women, both trauma-focused cognitive behavior therapy (TF-CBT) and eye-movement desensitization and reprocessing (EMDR) have been shown to be more effective than usual care (and possibly more effective than nontrauma focused CBT and other non-specific psychotherapies) in RCTs for reducing symptoms of PTSD outside of the perinatal period [92•]. When pharmacological management of PTSD in pregnancy or postpartum is required due to severity of symptoms and/ or non-response to psychotherapy, both the risk for continued mental health symptoms and the safety profile of medications in pregnancy and lactation must be considered. Untreated mental illness in pregnancy has been linked to increased rates of poor antenatal care, suboptimal nutrition, smoking, and substance use, as well as high rates of postpartum mental illness. Infants exposed to untreated (or incompletely treated) mental illness in pregnancy are at increased risk for complications such as prematurity and poor fetal growth. Postpartum mental illness is associated with poor maternal-infant attachment and has been linked to a range of child problems including delayed development and child psychiatric illnesses [93]. When pharmacotherapy is required in pregnancy, selective serotonin reuptake inhibitors (SSRIs) fluoxetine and sertraline are preferred due to combined evidence of efficacy in PTSD and reasonable safety profile for the fetus and infant [89]. SSRI exposure in pregnancy does not appear to be associated

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with increased risk for major congenital malformations. It has been associated with small absolute increased risks for specific cardiac malformations, preterm birth, low birth weight, and respiratory complications in the newborn. More commonly, a poor neonatal adaptation syndrome occurs with exposure late in pregnancy, affecting about 30% of infants; this condition is self-limited and serious adverse events such as seizures are extremely rare. While it is difficult to separate the effects of SSRI exposure in pregnancy from postpartum environmental impacts or shared genetic susceptibility to psychiatric conditions, and some studies have reported weak associations between SSRIs and child developmental delay, there is no clear indication of long-term behavioral teratogenicity associated with these drugs [89]. The serotonin-norepinephrine reuptake inhibitor venlafaxine may be considered a second-line option as there is also evidence for its efficacy in PTSD, but reproductive safety data are more limited than for fluoxetine and sertraline [89, 90, 94]. Overall, the risks of SSRI’s/SNRI’s need to be weighed against the risks to mother and fetus/ infant of untreated mental illness. Decision-making about use of psychotropic medication is less complicated in lactation. SSRIs and SNRIs are generally considered compatible with breastfeeding in healthy full-term infants as the relative infant dose in breastmilk is generally lower than 10% of the maternal dose, so most women can continue to breastfeed while using these medications [95••]. When there are severe psychiatric symptoms, additional medications may be indicated. Benzodiazepines may be used while awaiting effects of antidepressant medication for acute symptom relief of severe anxiety and/or insomnia. Although some clinical studies suggested a possible benefit from risperidone, antipsychotic medication is not likely to be effective in treating PTSD except in the presence of comorbid psychotic symptoms [94]. Hospitalization may be required in severe cases where there is active suicidal intent or another safety concern.

Conclusions Perinatal IPV continues to be a common global public health and human rights problem that adversely affects the physical and mental health and well-being of women and their offspring. Fortunately, the World Health Organization and many countries and organizations are now attempting to educate, raise awareness, track reported cases, train health and social service providers, and develop interventions to prevent and ameliorate the negative sequelae of P-IPV. The recent World Psychiatric Association Competency-Based Curriculum on IPV and Sexual Violence against Women is an important tool to improve mental health services to affected women [96••]. Psychiatrists and other mental health providers must play a vital role in educating, identifying, and providing mental

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health care to women (and their children) who have experienced P-IPV. The implementation of what we now know must be augmented by rigorous research to improve the evidence for optimal treatments and outcomes.

Curr Psychiatry Rep (2017) 19: 26 9. 10.

11. Compliance with Ethical Standards Conflict of Interest Simone N. Vigod, Prabha S. Chandra, Alice Han, Marta B. Rondon, Jennifer C. D. MacGregor, and Ekaterina Riazantseva declare that they have no conflict of interest. Donna E. Stewart has received a grant on Family Violence from Public Health Agency of Canada. Dr. Stewart has also received fees from Eli Lilly for membership on the Scientific Advisory Board of the Duloxetine Pregnancy Registry. Harriet L. MacMillan was involved as a member of the WHO Guideline Development Group on Responding to Intimate Partner Violence and Sexual Violence Against Women. Dr. MacMillan has received grants from the Public Health Agency of Canada (PHAC) and from the Centers for Disease Control and Prevention. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

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References

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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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1.•• Stewart DE, Vigod S, Riazantseva E. New developments in intimate partner violence and management of its mental health sequelae. Curr Psychiatry Rep. 2016;18:4. A recent review of IPV in general. 2.•• Van Parys A-S, Verhamme A, Temmerman M, Verstraelen H. Intimate partner violence and pregnancy: a systematic review of interventions. In: Vermund SH, editor. PLoS One. 2014;9:e85084. An excellent review of IPV during pregnancy. 3. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines [Internet]. Geneva: WHO; 2013 [cited 2017 Jan 3]. Available from: http://apps.who.int/iris/bitstream/10665/85240/1/ 9789241548595_eng.pdf?ua=1. 4. Stewart DE, MacMillan H, Wathen N. Intimate partner violence. Can J Psychiatr. 2013;58:1–15. 5. Devries KM, Kishor S, Johnson H, Stöckl H, Bacchus LJ, GarciaMoreno C, et al. Intimate partner violence during pregnancy: analysis of prevalence data from 19 countries. Reprod Health Matters. 2010;18:158–70. 6.•• Donovan B, Spracklen C, Schweizer M, Ryckman K, Saftlas A. Intimate partner violence during pregnancy and the risk for adverse infant outcomes: a systematic review and meta-analysis. BJOG. 2016;123:1289–99. An excellent review of infant outcomes after IPV in pregnancy. 7. Campbell JC. Health consequences of intimate partner violence. Lancet. 2002;359:1331–6. 8. Nyame S, Howard LM, Feder G, Trevillion K. A survey of mental health professionals’ knowledge, attitudes and preparedness to respond to domestic violence. J Ment Health. 2013;22:536–43.

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Zlotnick C, Capezza NM, Parker D. An interpersonally based intervention for low-income pregnant women with intimate partner violence: a pilot study. Arch Womens Ment Heal. 2011;14:55–65. 81. Kiely M, El-Mohandes AAE, El-Khorazaty MN, Gantz MG, Gantz MG. An integrated intervention to reduce intimate partner violence in pregnancy. Obstet Gynecol. 2010;115:273–83. 82. Olds DL, Robinson J, Pettitt L, Luckey DW, Holmberg J, Ng RK, et al. Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial. Pediatrics. 2004;114:1560–8. 83. Calderón SH, Gilbert P, Jackson R, Kohn MA, Gerbert B. Cueing prenatal providers effects on discussions of intimate partner violence. Am J Prev Med. 2008;34:134–7. 84. Humphreys J, Tsoh JY, Kohn MA, Gerbert B. Increasing discussions of intimate partner violence in prenatal care using video doctor plus provider cueing: a randomized, controlled trial. Womens Heal Issues. 2011;21:136–44. 85. Cripe SM, Sanchez SE, Sanchez E, Ayala Quintanilla B, Hernández Alarcon C, Gelaye B, et al. Intimate partner violence during pregnancy: a pilot intervention program in lima, Peru. J Interpers Violence. 2010;25:2054–76. 86. Curry MA, Durham L, Bullock L, Bloom T, Davis J. Nurse case management for pregnant women experiencing or at risk for abuse. J Obs Gynecol Neonatal Nurs. 2006;35:181–92. 87.•• Rivas C, Ramsay J, Sadowski L, Davidson LL, Dunne D, Eldridge S, et al. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. In: Feder G, editor. Cochrane Database Syst Rev. Chichester: John Wiley & Sons, Ltd; 2015;CD005043. A good review of advocacy interventions after IPV. 88. de Oliveira Fonseca-Machado M, Camargo Alves L, Scotini Freitas P, Dos Santos Monteiro JC, Gomes-Sponholz F. Mental health of women who suffer intimate partner violence during pregnancy. Investig y Educ en Enferm. 2014;32:291–305. 89. Vigod SN, Wilson CA, Howard LM. Depression in pregnancy. BMJ. 2016;352:i1547. 90. Stewart DE, Vigod S. Postpartum depression. N Engl J Med. 2016;375:2177–86. 91.• Substance Abuse and Mental Health Services Administration. Trauma-informed approach and trauma-specific interventions | SAMHSA [Internet]. [cited 2017 Jan 31]. Available from: https:// www.samhsa.gov/nctic/trauma-interventions. A good review of trauma informed care. 92.• Bisson JI, Roberts NP, Andrew M, Cooper R, Lewis C. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. In: Bisson JI, editor. Cochrane Database Syst Rev. Chichester: John Wiley & Sons, Ltd; 2013;CD003388. This is an updated systematic review around best practice in psychological treatment for PTSD. 93. Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384:1800–19. 94. Jonas D, Cusack K, Forneris C, Wilkins T, Sonis J, Middleton J, et al. Psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD). Comp Eff Rev. 2013;92 95.•• Orsolini L, Bellantuono C. Serotonin reuptake inhibitors and breastfeeding: a systematic review. Hum Psychopharmacol. 2015;30:4–20. A good review of SSRIs in breast–feeding. 96.•• Stewart D, Chandra P. The World Psychiatric Association (WPA) international competency-based curriculum for mental health care providers on intimate partner violence and sexual violence against women [Internet]. 2016. Available from: http://www.wpanet.org/ uploads/Latest_News/News_from_WPA_Sections/WPA_IPV_ SV_Curriculam.pdf. Teaching slides, references and case vignettes used to teach about intimate partner violence.