Mass General Hospital

Harvard Medical School

Abuse as a Risk Factor for Perinatal Depression

Two recent reports explore the relationship between abuse and risk for perinatal depression.

The first is a study which analyzed data from 53,065 pregnant women participating in the Norwegian Mother and Child Cohort Study (MoBa).  Exposure (as an adult) to emotional, sexual, or physical abuse was based on self-report at week 30 of pregnancy, differentiating if the perpetrator was known or a stranger and whether the abuse was recent (<12 months since abuse) or more remote.  Postpartum depression was measured with a four item version of the Edinburgh Postnatal Depression Scale (EPDS) at 6 months postpartum.

Overall 19% had been exposed to some type of adult abuse. Women reporting adult abuse had an 80% increased risk of experiencing PPD (adjusted OR 1.8; 95% CI 1.7-1.9) as compared to non-abused women.   Exposure from a known perpetrator was more strongly associated with PPD than abuse from a stranger.

The timing of the abuse was also important; compared to non-abused women, women with abuse within the last year were 2.6-fold more likely to experience PPD (OR 2.6; 95% CI 2.4-2.9).  The risk for women with abuse occurring more than a year prior to pregnancy was somewhat lower (OR 1.5; 95% CI 1.5-1.7).

To our knowledge, this is the largest study assessing the relationship between abuse and risk for postpartum depression.  Other smaller studies, reviewed by Alvarez-Segura and colleagues, show a similar relationship between abuse and risk for perinatal depression.  The authors reviewed a total of 43 articles meeting criteria for inclusion. Quality of articles was evaluated with the Newcastle-Ottawa-Scale (NOS).

Despite variability in definitions of abuse and methods used to assess for depression, the reviewed studies reported a significant elevation in depressive symptoms during pregnancy and/or the postpartum period among women who had lifetime abuses histories (specifically sexual or physical abuse). This association persisted after adjusting for possible confounding factors, such as history of psychiatric illness, social support, or marital status.

When the definition of abuse was narrowed to childhood abuse, the association was strongest in women who experienced childhood sexual abuse.  The review noted that some of the effects of early adverse exposures could be buffered by important factors in adulthood, such as positive maternal relationship and social supports.  However, the reviewers also pointed out that childhood abuse creates a vulnerability to re-traumatization in adulthood with more damaging consequences. The coexistence of childhood and adult abuse resulted not only in more severe depressive symptoms but also to longer duration of the depressive symptoms.

Any form of lifetime intimate partner violence (IPV) — psychological, sexual, or physical – was associated with an increased risk of both antenatal and postpartum depressive symptoms.  The authors note that IPV is one of the strongest predictors of depressive symptoms during the perinatal period, especially when it occurs during pregnancy.

Clinicians often find it difficult to ask about childhood trauma and IPV, and there is a sense that many women with trauma histories are reluctant to reveal this information to their healthcare providers.  These studies clearly indicate that identifying women with histories of trauma may help us to identify women who are at greatest risk for perinatal depression.   In 2013, the U.S. Preventive Services Task Force (USPSTF) has updated its recommendations on screening for intimate partner violence. These guidelines, published in the Annals of Internal Medicine, recommend that all women of reproductive age be screened for intimate partner violence.  The review provides some information on which screening instruments to use and reviews interventions to reduce the risk of IPV.

This article reviewed a total of 15 studies of 13 screening instruments to identify IPV and childhood abuse in women.  The six tools that achieved the highest levels of sensitivity and specificity were:

Of the above, only the Childhood Trauma Questionnaire explores childhood experiences.  Most of the screening tools are easy to administer and consist of only a few questions.  (Copies of most of these screening tools can be found in a thorough this website on IPV from the Centers for Disease Control and Prevention.) Additional resource: Intimate Partner Violence During Pregnancy, a Guide for Clinicians.

Ruta Nonacs, MD PhD

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 Motherand Child Cohort Study.  BMC Pregnancy Childbirth. 2014 Sep 8; 14(1):316.

Alvarez-Segura M, Garcia-Esteve L, Torres A, et al.  Are women with a history of abuse more vulnerable to perinatal depressivesymptoms? A systematic review.  Arch Womens Ment Health. 2014 Oct;17(5):343-57.

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