Intergenerational Impacts of Family Violence - Mothers and Children in a Large Prospective Pregnancy Cohort Study.

BACKGROUND: Violence and other adversities commonly co-occur, yet are usually investigated individually. The primary objectives of this paper are to investigate: (i) the relationship between maternal exposure to violence (including childhood abuse and intimate partner violence) and postpartum mental and physical health; and (ii) the extent to which exposure to violence and poor maternal mental and physical health are associated with children's emotional-behavioral difficulties. METHODS: Prospective pregnancy cohort (n = 1507) followed up to 4 year postpartum. Validated measures used: Composite Abuse Scale; Edinburgh Postnatal Depression Scale, SF-36, Child Maltreatment History Self Report; Strengths and Difficulties Questionnaire. Logistic regression was used to investigate associations between maternal childhood abuse, intimate partner violence (IPV), maternal health and child emotional and behavioral difficulties at age 4. OUTCOMES: Two out of five women (41%) reported abuse in childhood, and almost one in three (29%) reported IPV during the first four years of motherhood. Women reporting both physical and sexual childhood abuse had markedly raised odds of IPV and poor physical and mental health at all time points (pregnancy, first year postpartum and four year postpartum). For the index child, violence exposures (maternal childhood abuse or IPV) and poor maternal physical or mental health were associated with higher odds of emotional/behavioral difficulties at age four. In multivariable models (adjusted for child gender and maternal age), cumulative exposures (multiple violence exposures or poor maternal mental or physical health at multiple time points) each independently added to increased odds of emotional-behavioral difficulties. Children of mothers who reported a history of childhood abuse but were not exposed to IPV had odds of difficulties similar to children of mothers not reporting any violence exposure, suggesting resilient outcomes where violence experiences are not repeated in the next generation. INTERPRETATION: The clustering of risk (child and adult violence experiences) and the accumulation of risk within families (IPV, poor maternal health, child difficulties) highlight the need for effective early intervention to limit or ameliorate the impact of violence across the lifespan, and to break the intergenerational cycle of disadvantage.

Vulnerability to intimate partner violence and poor mental health in the first 4-year postpartum among mothers reporting childhood abuse: an Australian pregnancy cohort study.

The purpose of this study was to investigate intergenerational patterns of abuse and trauma and the health consequences for women in the early childbearing years. A prospective pregnancy cohort of 1507 nulliparous women (≦24 weeks gestation) were recruited in Melbourne, Australia, 2003-2005. Follow-up was scheduled in late pregnancy, 3-, 6- and 12-month and 4-year postpartum. Childhood abuse was retrospectively reported at 4-year postpartum using the Child Maltreatment History Self Report. Intimate partner violence (IPV) was assessed at 1- and 4-year postpartum with the Composite Abuse Scale. Maternal depressive symptoms were assessed in all follow-ups using the Edinburgh Postnatal Depression Scale. Multivariable logistic regression was used to examine associations between childhood abuse, maternal mental health and IPV. Childhood abuse was reported by 41.1 % of women. In the 4 years after having their first child, 28.2 % of women reported IPV, 25.2 % depression and 31.6 % anxiety. Childhood abuse was associated with odds of depression or anxiety 1.5-2.6 times greater and 1.8-3.2 times greater for IPV. Childhood physical abuse remained significantly associated with depression and anxiety in pregnancy and postpartum after adjusting for IPV and stressful life events, while sexual abuse remained significantly associated only with anxiety. Women who begin childbearing with a history of childhood abuse are more vulnerable to IPV and poor mental health. All health care services and agencies in contact with children, young people and families should have adequate training to identify trauma associated with abuse and IPV and provide first line supportive care and referral.

Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort.

OBJECTIVES: To investigate frequency, severity and risk factors for urinary incontinence and faecal incontinence 4 years after a first birth. DESIGN: Prospective pregnancy cohort study. SETTING: Melbourne, Australia. SAMPLE: A total of 1011 nulliparous women recruited in early pregnancy. METHODS: Participants were followed up at 32 weeks of gestation; then at 3, 6, 9 and 12 months and 4 years postpartum. MAIN OUTCOME MEASURES: Frequency and severity of urinary and faecal incontinence. RESULTS: At 4 years, 29.6% of women reported urinary incontinence and 7.1% reported faecal incontinence. Compared with women having only spontaneous vaginal births, women who delivered exclusively by caesarean section were less likely to have urinary incontinence at 4 years postpartum (adjusted odds ratio 0.4, 95% confidence interval 0.3-0.6). Women who reported urinary incontinence before or during the index pregnancy, and those experiencing symptoms in the first year postpartum had increased odds of incontinence at 4 years, with the highest odds (6-12 times higher) among women who had previously reported moderate or severe symptoms. The odds of reporting faecal incontinence at 4 years were two to six times higher for women experiencing symptoms in pregnancy, and around four to eight times higher for those with symptoms in the first year postpartum. CONCLUSION: Urinary and faecal incontinence are prevalent conditions 4 years after a first birth. Women reporting urinary or faecal incontinence during pregnancy had markedly higher odds of reporting symptoms at 4 years postpartum, suggesting a need for further investigation and elucidation of aetiological pathways involving nonbirth-related risk factors. TWEETABLE ABSTRACT: Moderate/severe incontinence prevalent 4 years after first birth in population cohort. Prior symptoms are biggest predictor.

Dyspareunia and childbirth: a prospective cohort study.

OBJECTIVE: To investigate the relationship between mode of delivery, perineal trauma and dyspareunia. DESIGN: Prospective cohort study. SETTING: Six maternity hospitals in Melbourne, Australia. SAMPLE: A total of 1507 nulliparous women recruited in the first and second trimesters of pregnancy. METHOD: Data from baseline and postnatal questionnaires (3, 6, 12 and 18 months) were analysed using univariable and multivariable logistic regression. MAIN OUTCOME MEASURE: Study-designed self-report measure of dyspareunia at 18 months postpartum. RESULTS: In all, 1244/1507 (83%) women completed the baseline and all four postpartum questionnaires; 1211/1237 (98%) had resumed vaginal intercourse by 18 months postpartum, with 289/1211 (24%) women reporting dyspareunia. Compared with women who had a spontaneous vaginal delivery with an intact perineum or unsutured tear, women who had an emergency caesarean section (adjusted odds ratio [aOR] 2.41, 95% confidence interval [95% CI] 1.4-4.0; P = 0.001), vacuum extraction (aOR 2.28, 95% CI 1.3-4.1; P = 0.005) or elective caesarean section (aOR 1.71, 95% CI 0.9-3.2; P = 0.087) had increased odds of reporting dyspareunia at 18 months postpartum, adjusting for maternal age and other potential confounders. CONCLUSIONS: Obstetric intervention is associated with persisting dyspareunia. Greater recognition and increased understanding of the roles of mode of delivery and perineal trauma in contributing to postpartum maternal morbidities, and ways to prevent postpartum dyspareunia where possible, are warranted.

Maternal depression from early pregnancy to 4 years postpartum in a prospective pregnancy cohort study: implications for primary health care.

OBJECTIVE: To describe the prevalence of maternal depression from pregnancy to 4 years postpartum, and the risk factors for depressive symptoms at 4 years postpartum. DESIGN: Prospective pregnancy cohort study of nulliparous women. SETTING: Melbourne, Australia. SAMPLE: In all, 1507 women completed baseline data in pregnancy (mean gestation 15 weeks). METHODS: Women were recruited from six public hospitals. Questionnaires were completed at recruitment and 3, 6, 12 and 18 months postpartum, and 4 years postpartum. MAIN OUTCOME MEASURES: Scores ≥13 on the Edinburgh Postnatal Depression Scale were used to indicate depressive symptoms. RESULTS: Almost one in three women reported depressive symptoms at least once in the first 4 years after birth. The prevalence of depressive symptoms at 4 years postpartum was 14.5%, and was higher than at any time-point in the first 12 months postpartum. Women with one child at 4 years postpartum were more likely to report depressive symptoms at this time compared with women with subsequent children (22.9 versus 11.3%), and this association remained significant in adjusted models (Adjusted odds ratio 1.71, 95% confidence interval 1.12-2.63). CONCLUSIONS: Maternal depression is more common at 4 years postpartum than at any time in the first 12 months postpartum, and women with one child at 4 years postpartum report significantly higher levels of depressive symptoms than women with subsequent children. There is a need for scaling up of current services to extend surveillance of maternal mental health to cover the early years of parenting.

Consultation about urinary and faecal incontinence in the year after childbirth: a cohort study.

OBJECTIVE: To investigate the extent to which primary-care practitioners routinely inquire about postpartum urinary and faecal incontinence, and assess the proportion of women who disclose symptoms. DESIGN: Prospective pregnancy cohort study of nulliparous women. SETTING: Melbourne, Australia. SAMPLE: A total of 1507 nulliparous women recruited in early pregnancy. METHOD: Women were recruited from six public maternity hospitals, with follow up at 3, 6, 9 and 12 months postpartum. MAIN OUTCOME MEASURES: Standardised measures of urinary and bowel symptoms, and measures of health service use. RESULTS: In the first 12 months postpartum, the period prevalence of urinary incontinence was 47%, and of faecal incontinence was 17%. In all, 86% of women visited a primary health-care practitioner at least once to discuss their own health in the first year after childbirth. However, only around a quarter were asked about urinary incontinence, and fewer than one in five women were asked about faecal incontinence. Discussion of symptoms with health professionals was most likely to occur in the first 3 months postpartum, and happened only rarely during the remainder of the first postnatal year. Over 70% of women reporting severe urinary incontinence and/or faecal incontinence had not discussed symptoms with a health professional. CONCLUSION: The findings provide robust evidence that many women experiencing postpartum urinary and faecal incontinence­including women with moderate and severe symptoms­do not receive adequate primary-care follow up in the first 12 months postpartum. Systems of maternal health surveillance need to include routine inquiry about urinary and faecal incontinence to overcome women's reluctance to seek help.

The onset, recurrence and associated obstetric risk factors for urinary incontinence in the first 18 months after a first birth: an Australian nulliparous cohort study.

OBJECTIVE: To investigate the contribution of obstetric risk factors to persistent urinary incontinence (UI) between 4 and 18 months postpartum. DESIGN: Prospective pregnancy cohort. SETTING: Six metropolitan public hospitals in Victoria, Australia. SAMPLE: A total of 1507 nulliparous women recruited to the Maternal Health Study in early pregnancy (≤24 weeks of gestation). METHODS: Data from hospital records and self-administered questionnaires/telephone interviews at ≤24 and 30-32 weeks of gestation and at 3, 6, 9, 12 and 18 months postpartum analysed using logistic regression. MAIN OUTCOME MEASURES: Persistent UI 4-18 months postpartum in women continent before pregnancy. RESULTS: Of the women who were continent before pregnancy, 44% reported UI 4-18 months postpartum, and 25% reported persistent UI (symptoms at multiple follow ups). Compared with spontaneous vaginal birth, women who had a caesarean before labour (adjusted odds ratio [aOR] 0.4, 95% confidence interval [95% CI] 0.2-0.9), in first-stage labour (aOR 0.4, 95% CI 0.2-0.6) or in second-stage labour (aOR 0.4, 95% CI 0.2-1.0) were less likely to report persistent UI 4-18 months postpartum. Prolonged second-stage labour in women who had an operative vaginal birth was associated with increased likelihood of UI (aOR 2.5, 95% CI 1.3-4.6). Compared with women who were continent in pregnancy, women reporting UI in pregnancy had a seven-fold increase in odds of persistent UI (aOR 7.4, 95% CI 5.1-10.7). CONCLUSIONS: Persistent UI is common after childbirth and is more likely following prolonged labour in combination with operative vaginal birth. The majority of women reporting persistent UI at 4-18 months postpartum also experienced symptoms in pregnancy.

Depressive symptoms and intimate partner violence in the 12 months after childbirth: a prospective pregnancy cohort study.

OBJECTIVE: To examine maternal depressive symptoms during and after pregnancy and explore their relationship with intimate partner violence in the 12 months after birth. DESIGN: Prospective pregnancy cohort study of nulliparous women. SETTING: Melbourne, Australia. POPULATION: In all, 1507 eligible women completed baseline data (mean gestation 15 weeks). Analyses are presented for 1305 women who completed all follow-up questionnaires. METHODS: Women were recruited from six public hospitals at between 6 and 24 weeks of gestation. Written questionnaires were completed at recruitment and at 3, 6 and 12 months postpartum. MAIN OUTCOME MEASURES: Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Intimate partner violence was assessed using the short version of the Composite Abuse Scale. RESULTS: Sixteen per cent of women reported depressive symptoms (EPDS ≥ 13) in the 12 months postpartum, with most women first reporting depressive symptoms in the second 6 months after birth. Around 40% of women reporting depressive symptoms at each follow up also reported intimate partner violence. Factors associated with postpartum depressive symptoms in multivariable models were: emotional abuse alone (adjusted odds ratio [OR] 2.72, 95% CI 1.72-4.13), physical abuse (adjusted OR 3.94, 95% CI 2.44-6.36), depression in pregnancy (adjusted OR 2.89, 95% CI 1.75-4.77) and unemployment in early pregnancy (adjusted OR 1.60, 95% CI 1.03-2.48). CONCLUSIONS: Screening for maternal depression at 3 months postpartum or earlier may miss over half the women with depression in the first 12 months after birth. Intimate partner violence is common among women reporting postnatal depressive symptoms and may be an important factor for health professionals to consider in their management.

Effects of prolonged second stage, method of birth, timing of caesarean section and other obstetric risk factors on postnatal urinary incontinence: an Australian nulliparous cohort study.

OBJECTIVE: To investigate the contribution of prolonged labour, method of birth, timing of caesarean section and other obstetric risk factors to postpartum urinary incontinence. DESIGN: Prospective pregnancy cohort. SETTING: Six metropolitan public hospitals in Victoria, Australia. SAMPLE: A total of 1507 nulliparous women recruited to the maternal health study in early pregnancy (≤24 weeks). METHOD: Data from hospital medical records and self-administered questionnaires/telephone interviews at ≤24 and 30-32 weeks of gestation and 3 months postpartum analysed using univariable and multivariable logistic regression. MAIN OUTCOME MEASURE: Urinary incontinence 3 months postpartum in women continent before the index pregnancy. RESULTS: Of the women continent before pregnancy, 26% reported new incontinence at 3 months postpartum. Compared with women who had a spontaneous vaginal birth, women who had a caesarean section before labour (adjusted odds ratio [OR] 0.2, 95% CI 0.1-0.5) or in the first stage of labour (adjusted OR 0.2, 95% CI 0.1-0.4) were less likely to be incontinent 3 months postpartum. Adjusted OR for incontinence after caesarean section in the second stage of labour compared with spontaneous vaginal birth was 0.5 (95% CI 0.2-1.0). Prolonged second stage labour was associated with increased likelihood of postpartum incontinence in women who had a spontaneous vaginal birth (adjusted OR 1.9, 95% CI 1.1-3.4) or operative vaginal birth (adjusted OR 1.7, 95% CI 1.0-2.8). CONCLUSIONS: In addition to pregnancy itself, physiological changes associated with the second stage of labour appear to play a role in postpartum urinary incontinence.

Intimate partner violence during pregnancy and the first year postpartum in an Australian pregnancy cohort study.

To assess intimate partner violence (IPV) in a longitudinal cohort study during and after pregnancy, and examine social and economic factors encouraging or inhibiting violence. Nulliparous women were recruited from 6 public hospitals in Melbourne, Australia. Self-administered questionnaires included standardised measures assessing fear of an intimate partner at enrolment, 6 and 12 months postpartum; and period prevalence of physical and emotional abuse in the first 12 months postpartum. 1,507 women completed baseline data (mean gestation 15 weeks). Response fractions at 3, 6 and 12 months postpartum were 95, 93 and 90%, respectively. 5.1 and 5.4% of women reported fear in pregnancy and the first year postpartum, respectively. 17% experienced physical and/or emotional abuse in the first year postpartum. Most women who reported fear of an intimate partner in the first year after the index birth reported fear before and/or during pregnancy. Women working in early pregnancy who qualified for paid maternity leave had significantly reduced odds of reporting combined physical and emotional IPV in the first 12 months postpartum compared with women not working (Adj. OR 0.21, 95% CI 0.08-0.55). Women working but not eligible for paid leave had reduced odds compared with women not working (Adj. OR 0.49, 95% CI 0.24-1.00). Models adjusted for maternal age, relationship status, income and education level. Few first time mothers reported fear for the first time after childbirth suggesting that IPV more commonly commences prior to the first birth. Paid maternity leave may have broader social benefits beyond immediate financial benefits to women and families.