REVIEW ARTICLE

VIOLENCE BY INTIMATE PARTNER IN PREGNANCY AND REPERCUSSION ON WOMEN'S AND CONCEPTUS’ HEALTH

VIOLENCIA POR PARTE DE LA PAREJA ÍNTIMA EN EL EMBARAZO Y REPERCUSIÓN EN LA SALUD DE LA MUJER Y DEL CONCEPTO

VIOLÊNCIA POR PARCEIRO ÍNTIMO NA GESTAÇÃO E REPERCUSSÃO NA SAÚDE DA MULHER E DO CONCEPTO

https://doi.org/10.31011/reaid-2023-v.97-n.1-art.1514

¹Glória Amorim de Araújo

²Hayla Nunes da Conceição

³Paula dos Santos Brito

⁴Mariana Rodrigues da Rocha

⁵Janayra Rodrigues Dantas

⁶Lucrécia Pereira Silva

¹Universidade Federal do Maranhão (UFMA), Imperatriz, Maranhão, Brasil. ORCID: https://orcid.org/0000-0001-5745-6728.

²Universidade Federal do Piauí, Teresina, Piauí, Brasil: ORCID: https://orcid.org/0000-0001-6035-8280.

³Universidade Federal do Maranhão (UFMA), Imperatriz, Maranhão, Brasil. ORCID: https://orcid.org/0000-0002-4973-8693.

⁴Universidade Federal do Piauí (UFPI), Teresina, Piauí, Brasil. ORCID: https://orcid.org/0000-0002-4745-9690.

⁵Universidade Estadual do Maranhão (UEMA), Coroatá, Maranhão, Brasil. ORCID: https://orcid.org/0000-0002-1438-1292.

⁶Universidade Federal do Maranhão (UFMA), Imperatriz, Maranhão, Brasil. ORCID: https://orcid.org/0000-0002-1507-5043.

Corresponding author

Hayla Nunes da Conceição

Gregory - Avenida Principal, 100- Residencial Dom Afonso Felipe, Imperatriz – MA. CEP:  65915-240

Telefone: +55(99) 98208-6669

E-mail: haylanunes_cx@hotmail.com

Submission: 26-09-2022

Approval: 16-03-2023

RESUMO

Objetivo: Identificar as evidências científicas sobre as repercussões da Violência do Parceiro Íntimo (VPI) na gravidez sobre a saúde da mulher e do feto.  Método: Trata-se de uma revisão integrativa da literatura. As buscas na literatura foram realizadas na Biblioteca Virtual de Saúde; Medline via Pubmed e Web of Science. Resultados: Foram incluídos 21 artigos. Os estudos demonstram que mulheres vítimas na gravidez apresentam maior vulnerabilidade a sofrimento psicológico, apresentando elevação nos níveis de estresse, tristeza, angústia, transtorno mental comum e ideação suicida. Elas são mais suscetíveis a baixa adesão ao pré-natal e a problemas ginecológicos e obstétricos, apresentando chances elevadas de infecção no trato urinário e vaginais, aumento do risco de internações pré-natais e maiores chances de evoluírem para morbidade materna aguda grave. Para a saúde do concepto, exposição a violência está relacionada a chance aumentada a ocorrência de aborto espontâneo, crescimento intrauterino restrito, parto prematuro, baixo peso ao nascer, morte perinatal, mortalidade infantil e na infância. Ainda foi demonstrado que a violência materna no período gestacional está associada a baixa adesão a imunização da criança, menor duração do aleitamento materno e com a necessidade de encaminhar a criança para o acompanhamento especializado para a triagem neonatal auditiva. Conclusão: O impacto da VPI em mulheres grávidas e em seus filhos evidencia a importância de uma maior atenção a essa problemática. No entanto, a desigualdade de gênero representa o cerne das possibilidades de romper o ciclo da VPI no período gestacional e suas consequências para saúde do binômio mãe-bebê.

Palavras-chave: Violência por Parceiro Íntimo. Maus-Tratos Conjugais. Saúde Materno-Infantil. Saúde da Mulher. Complicações na Gravidez.

ABSTRACT

Objective: To identify the scientific evidence on the repercussions of Intimate Partner Violence (IPV) in pregnancy on the health of the woman and the fetus. Method: This is an integrative literature review. Literature searches were performed in the Virtual Health Library; Medline via Pubmed and Web of Science. Results: 21 articles were included. Studies show that women victims of pregnancy are more vulnerable to psychological distress, with increased levels of stress, sadness, anguish, common mental disorder and suicidal ideation. They are more susceptible to poor adherence to prenatal care and to gynecological and obstetric problems, presenting high chances of urinary tract and vaginal infections, increased risk of prenatal hospitalizations and greater chances of progressing to severe acute maternal morbidity. For the health of the fetus, exposure to violence is related to an increased chance of spontaneous abortion, restricted intrauterine growth, premature birth, low birth weight, perinatal death, infant and childhood mortality. It has also been shown that maternal violence in the gestational period is associated with low adherence to the child's immunization, shorter duration of breastfeeding and the need to refer the child to specialized monitoring for neonatal hearing screening. Conclusion: The impact of IPV on pregnant women and their children highlights the importance of greater attention to this problem. However, gender inequality represents the core of the possibilities of breaking the cycle of IPV in the gestational period and its consequences for the health of the mother-baby binomial.

Keywords: Intimate Partner Violence. Marital Abuse. Maternal and Child Health. Women's Health. Complications in Pregnancy.

RESUMEN

Objetivo: Identificar la evidencia científica sobre las repercusiones de la Violencia de Pareja (VPI) en el embarazo sobre la salud de la mujer y el feto. Método: Esta es una revisión integradora de la literatura. Se realizaron búsquedas bibliográficas en la Biblioteca Virtual en Salud; Medline vía Pubmed y Web of Science. Resultados: se incluyeron 21 artículos. Los estudios muestran que las mujeres víctimas del embarazo son más vulnerables al malestar psicológico, con mayores niveles de estrés, tristeza, angustia, trastorno mental común e ideación suicida. Son más susceptibles a la mala adherencia al control prenatal ya los problemas ginecológicos y obstétricos, presentando altas posibilidades de infecciones urinarias y vaginales, mayor riesgo de hospitalizaciones prenatales y mayores posibilidades de progresar a morbilidad materna aguda severa. Para la salud del feto, la exposición a la violencia está relacionada con una mayor probabilidad de aborto espontáneo, crecimiento intrauterino restringido, parto prematuro, bajo peso al nacer, muerte perinatal, mortalidad infantil y en la niñez. También se ha demostrado que la violencia materna en el período gestacional está asociada con la baja adherencia a la vacunación del niño, la menor duración de la lactancia materna y la necesidad de derivar al niño a seguimiento especializado para el tamizaje auditivo neonatal. Conclusión: El impacto de la VPI en las mujeres embarazadas y sus hijos destaca la importancia de una mayor atención a este problema. Sin embargo, la desigualdad de género representa el núcleo de las posibilidades de romper el ciclo de la VPI en el período gestacional y sus consecuencias para la salud del binomio madre-bebé.

Palabras clave: La Violencia de Pareja. Abuso Marital. Salud Maternal e Infantil. La Salud de la Mujer. Complicaciones en el Embarazo.

INTRODUCTION

Violence Against Women (VAW) can be defined as any harmful act that results in physical, psychological, sexual or patrimonial damage and whose main motivation is gender, that is, committed against her expressly for being a woman⁽¹⁾. Having as scenario of greater occurrence the home environment of the victims, the VAW having been practiced in most cases by the intimate partner, which includes partners in current or previous relationships in which the woman has maintained an affective and/or sexual bond with the aggressor⁽²⁾.

Intimate Partner Violence (IPV) is one of the most extreme and perverse manifestations of gender inequality, the product of power dissymmetries, the need for submission of women in patriarchal society and male supremacy. It represents an important social phenomenon and expresses the violation of human rights that seriously affects the course of the health-disease process and the life perspective of women⁽³⁾. It is considered a global public health problem due to its incidence and impact on the individual, family, social and women’s health⁽⁴⁾.

Although IPV is a phenomenon of private life, it is an important public health problem. In this sense, it was incorporated into the health field as a new theme with a significant impact on the quality and humanity of health care⁽⁴⁾.

A worrying aspect of women’s health in the context of violence is the continuity of aggression during the pregnancy-puerperal period, although this is a stage of the vital cycle that requires more protection and care, violent episodes are a reality⁽²⁾. Worldwide, the prevalence of IPV in pregnancies was predominantly observed in three types, physical, psychological and sexual, ranging from 3.2% to 43.1%, depending on the method used for the research and the country in which the study was conducted, and differed due to cultural, socioeconomic and demographic factors^(5,6). In South Africa, in Zimbabwe, a survey conducted with 2,042 postpartum women showed that 63% had been victims of IPV during the gestational period, being one of the highest rates ever reported globally⁽⁷⁾.

In Brazil, the prevalence of IPV in pregnancy ranges from 12% to 33% and, unlike in other countries, 50% of women were victims of physical violence for the first time during pregnancy⁽¹⁾. In the Brazilian Northeast, it was observed that physical violence by intimate partner during pregnancy was present in 20.1% of women, 49.8% of which reported having suffered violence before the gestational period and 30.1% were victims both before and during pregnancy (8). In Maranhão, a study in the city of Caxias, showed the incidence of some type of violence in pregnancy was 33.0%, with isolated psychological violence being the most common (18.9%), followed by overlapping physical and psychological violence (5.2%) and (4.3%) respectively⁽⁹⁾.

Some characteristics of women are associated with a higher probability of being a victim of IPV, such as low schooling, experience of previous violence, having witnessed violence between parents and low social and economic status. In addition, the dominance of the partner, conflicts in the relationship, as well as broad social acceptance of violence can be cited^(5,10). In pregnancy, added to these characteristics, IPV occurs mainly in women with unplanned pregnancy, multiparous, those who have already suffered abortion, who started prenatal care late and with difficulty attending consultations, in addition to those who are responsible for the family⁽¹¹⁾.

In pregnancy, IPV, as a stressful and traumatic event, can trigger negative outcomes for maternal and neonatal health^(5,12,13). Thus, knowing the consequences of exposure to violence on the health of the mother and the baby becomes important so that strategies can be planned to minimize the occurrence of this disease and the impacts it generates on the health of women and the conceptus⁽²⁾. The studies that analyze the association between IPV in pregnancy and its impacts on maternal-fetal health are abundant. However, the consolidated information of these studies is still scarce. Thus, this study aims to identify the scientific evidence on the repercussions of IPV in pregnancy on women’s health and conceptus.

METHODS

This is an integrative review of the literature. The theoretical framework adopted establishes the construction of this type of study through six stages: 1- Formulation of the research question; 2 - Sampling; 3 - Data extraction; 4 - Critical evaluation; 5 - Analysis and synthesis of results and 6 - Synthesis of knowledge⁽¹⁴⁾.

Initially the guiding question was elaborated. Because it is an integrative review, a peak strategy was used to elaborate this research question, acronym for P: problem or target population; I: intervention or phenomenon of interest and Co: context⁽¹⁵⁾, based on this definition, the following guiding question was established: What is the scientific evidence on the repercussions of IPV in pregnancy on the health of women and the conceptus? (Chart 1).

Chart 1- PICo strategy for developing the guiding question

Acronym	Descriptors
P	Maternal and child health
I	Health impact assessment
Co	Intimate partner violence

Source: Authors, 2022.

To include a greater variety of studies and breadth of results, access to databases and databases was performed through the journal portal of the Coordination for the Improvement of Higher Education Personnel (CAPES), the searches were performed in the database of the Virtual Health Library (VHL) and MEDLINE (National Library of Medicine, United States) via PUBMED and in the Web of Science database (Chart 2).

The search was through the combinations between the descriptors found in the Health Descriptors (Decs) and Medical Subject Headings (MESH): "Maternal and Child Health", "Health Impact Assessment" and "Child Health", "Health Impact" and "Intimate Partner Violence" combined with the Boolean operators OR and AND (Exhibit 2).

Chart 2 - Search strategy used in the VHL Database, Imperatriz, Maranhão, 2022

VHL
Acronym	Descriptors	Descriptors combined with OR operator
P	Maternal and child health	Saúde Materno-Infantil OR Maternal and Child Health OR Salud Materno-Infantil
I	Women's health Pregnancy Complications	Saúde da Mulher OR Saúde das Mulheres OR Saúde Feminina OR Women's Health OR Salud de la Mujer OR Complicações na Gravidez OR Pregnancy Complications
Co	Intimate partner violence	Violência contra Parceiro Íntimo OR Violência contra a Parceira Íntima OR Violência entre Parceiros Íntimos OR Intimate Partner Violence OR Violencia de Pareja
Search key	Saúde Materno-Infantil OR Maternal and Child Health OR Salud Materno-Infantil AND Saúde da Mulher OR Saúde das Mulheres OR Saúde Feminina OR Women's Health OR Salud de la Mujer OR Complicações na Gravidez OR Pregnancy Complications OR Complicaciones del Embarazo AND Violência contra Parceiro Íntimo OR Violência contra a Parceira Íntima OR Violência entre Parceiros Íntimos OR Intimate Partner Violence OR Violencia de Pareja

MEDLINE/PUBMED
Acronym	Descriptors	Descriptors combined with OR operator
P	Maternal health Health, infant	Maternal Health OR Health, Maternal OR Health, Infant OR Baby Health OR Health, Baby OR Newborn Health OR Health, Newborn OR Neonatal Health OR Health, Neonatal OR Health of Newborn Infants OR Newborn Infant Health OR Health, Newborn Infant OR Infant Health, Newborn OR Health of the Newborn Infant OR Infant Health
I	Women's health Pregnancy Complications	Women's Health OR Health, Women's OR Women’s Health OR Health, Women OR Woman's Health OR Health, Woman's OR Pregnancy Complications OR OR Complication, Pregnancy OR Pregnancy Complication OR Complications, Pregnancy OR Adverse Birth Outcomes OR Adverse Birth Outcome OR Birth Outcome, Adverse OR Outcome, Adverse Birth
Co	Intimate partner violence	Intimate Partner Violence OR Partner Violence, Intimate OR Violence, Intimate Partner OR Intimate Partner Abuse OR Abuse, Intimate Partner OR Partner Abuse, Intimate OR Dating Violence OR Violence, Dating
Search key	(("Maternal Health "[MeSH Terms]) OR (Health, Infant)) OR (Baby Health)) AND ((((((("Women's Health "[MeSH Terms]) OR ("Health, Women's "[All Fields])) OR ("Womens Health "[All Fields])) OR ("Health, Womens "[All Fields])) OR ("Pregnancy Complications"[MeSH Terms])) OR ("Adverse Birth Outcomes"[All Fields])) OR ("Birth Outcome, Adverse"[All Fields])) OR ("Outcome, Adverse Birth"[All Fields])) AND ((((((("Intimate Partner Violence "[MeSH Terms]) OR ("Partner Violence, Intimate "[All Fields])) OR ("Violence, Intimate Partner "[All Fields])) OR ("Intimate Partner Abuse "[All Fields])) OR ("Abuse, Intimate Partner "[All Fields])) OR ("Partner Abuse, Intimate "[All Fields])) OR ("Dating Violence "[All Fields]))OR ("Violence, Dating"[All Fields])
WEB OF SCIENCE
Search key	((TS=(Maternal Health OR Health, Maternal OR Health, Infant OR Baby Health OR Health, Baby OR Newborn Health OR Health, Newborn OR Neonatal Health OR Health, Neonatal OR Health of Newborn Infants OR Newborn Infant Health OR Health, Newborn Infant OR Infant Health, Newborn OR Health of the Newborn Infant OR Infant Health)) AND TS=(Women's Health OR Health, Women's OR Womens Health OR Health, Womens OR Woman's Health OR Health, Woman's OR Pregnancy Complications OR Complication, Pregnancy OR Pregnancy Complication OR Complications, Pregnancy OR Adverse Birth Outcomes OR Adverse Birth Outcome OR Birth Outcome, Adverse OR Outcome, Adverse Birth)) AND TS=(Intimate Partner Violence OR Partner Violence, Intimate OR Violence, Intimate Partner OR Intimate Partner Abuse OR Abuse, Intimate Partner OR Partner Abuse, Intimate OR Dating Violence OR Violence, Dating)

Source: Authors, 2022.

Articles indexed in the databases and libraries mentioned above, published in Portuguese, English and Spanish, from 2017 to 2022 were included. We excluded works for which the full text was not provided; the central theme of the study was not related to the theme of IPV in pregnancy, publications that refer to technical manuals, pamphlets, editorials, monographs, theses and dissertations.

To help identify duplicate articles, the results for each database or data library were exported and imported into EndNote Web that detected 66 duplicates. After the removal of duplicates, the Rayyan QCRI application was used to assist in the screening and selection of studies⁽¹⁶⁾.

Data extraction from eligible studies was performed using data collection instruments and includes the following information:  year of publication, country, type of study, level of evidence, objective and main results⁽¹⁷⁾.

For the classification of methodological quality was performed using the AXIS tool for evaluation of observational studies. This tool was developed by Downes et al⁽¹⁸⁾, an evaluation tool of 20 items that allows reviewers to evaluate the methodological rigor of the studies. After this analysis, the studies were classified by level of evidence will be performed by classifying the evidence at the following levels: Level I – systematic review or meta-analysis of randomized controlled trials; Level II – well-designed randomized controlled trials; Level III – well-designed clinical trials without randomization; Level IV – well-designed cohort and case-control studies; Level V – systematic review of descriptive and qualitative studies; Level VI – descriptive or qualitative study and Level VII – opinion of authorities and/or reports⁽¹⁹⁾.

The data were analyzed descriptively, using the criterion of semantic similarity to guide the synthesis of the results. From this analysis, knowledge was synthesized into two categories: 1-repercussion of IPV on women’s health and 2-consequences of IPV on conceptus health.   

The flowchart PRISMA⁽²⁰⁾ was used to guide the articles included and excluded from the stages, and the results of the articles chosen for integrative review were presented in a table with author, year of publication, title, journal, country of study, methods and results.

RESULTS

The search returned 321 articles and, after the analysis of title, abstract and application of the inclusion and exclusion criteria, 86 articles were pre-selected for full reading. Among the 86 articles analyzed, 21 were included in the final sample of this review, as explained in the PRISMA⁽²⁰⁾  flowchart below (Figure 1):

Figure 1 - Flowchart of the selection process of articles for the integrative review. Imperatriz, MA, Brazil, 2022.

					VHL (N=4)
								WEB OF SCIENCE (N= 238)
			N. of studies included in quantitative synthesis (n = 21)

Table 3 summarizes the articles included. There was a predominance of publications in the year 2020 (n=6; 28.57%), in its entirety are in English (n=21; 100%), with most publications in Ethiopia (n=3; 14.4%) and indexing in PUBMED (n=16; 76.19%). Regarding the type of study, it was observed that most of the publications were cross-sectional studies, but the presence of cohort and case control studies was also observed. On the level of evidence, studies were concentrated at level VI.

Chart 3 - Summary of articles included according to title, authors, year, methodology, country and journal, Imperatriz, Maranhão, 2022

N.	TITLE	YEAR	METHODS	LE*	COUNTRY	DATABASE
A1 ^(21)	Utilization of maternal healthcare services in women experiencing spousal violence in Pakistan: A comparative analysis of 2012-13 and 2017-18 Pakistan Demographic Health Surveys	2020	Cross-sectional, quantitative	VI	Pakistan	Medline/PUBMED
A2^(22)	Exploring the associations between intimate partner violence victimization during pregnancy and delayed entry into prenatal care: Evidence from a population-based study in Bangladesh	2017	Cross-sectional, exploratory research.	VI	Bangladesh	Medline/PUBMED
A3^(23)	Intimate partner violence and utilization of reproductive and maternal health services in Cambodia	2019	Documentary, exploratory research.	IV	Cambodia	Medline/PUBMED
A4^(24)	Maternal outcomes associated to psychological and physical intimate partner violence during pregnancy: A cohort study and multivariate analysis	2019	Documentary research.	IV	Spain	Web of Science
A5^(25)	Intimate Partner Violence Around the Time of Pregnancy and Utilization of WIC Services	2019	Cross-sectional study of a cohort.	IV	USA	Medline/PUBMED
A6^(26)	Intimate partner violence and health outcomes experienced by women who are pregnant: a cross-sectional survey in Sanma Province, Vanuatu	2021	Qualitative, exploratory research.	V	Australia	Web of Science
A7^(27)	Emotional violence and maternal mental health: a qualitative study among women in northern Vietnam	2018	Documentary, exploratory research.	VI	Vietnam	Medline/PUBMED
A8^(28)	Married women’s experiences of intimate partner violence and utilization of antenatal health care in Togo	2020	Qualitative, exploratory research.	VI	Togo	Medline/PUBMED
A9^(29)	Pre-Pregnancy Intimate Partner Violence and Short Interbirth Interval: The Role of Insurance Status	2021	Quantitative, exploratory study.	VI	USA	Medline/PUBMED
A10^(30)	Intimate partner violence and severe acute maternal morbidity in the intensive care unit: A case-control study in Peru	2020	Case-control	IV	Peru	Medline/PUBMED
A11^(31)	Intimate partner violence during pregnancy and use of antenatal care among rural women in southern Terai of Nepal	2018	Cross-sectional, exploratory research.	VI	Nepal	Medline/PUBMED
A12^(32)	Intimate partner violence during pregnancy and risk of still birth in hospitals of Tigray region Ethiopia	2020	Cross-sectional study	VI	Ethiopia	Web of Science
A13^(33)	Verbal abuse during pregnancy increases frequency of newborn hearing screening referral: The Japan Environment and Children's Study	2019	Cohort	IV	Japan	Medline/PUBMED
A14 ^(34)	Association between intimate partner violence and child nutrition in India: Findings from recent National Family Health Survey	2020	Cross-sectional	VI	India	Web of  Science
A15^(35)	The association between intimate partner violence and low birth weight and preterm delivery in eastern Ethiopia: Findings from a facility-based study	2021	Cross-sectional	VI	Ethiopia	Medline/PUBMED
A16^(36)	Maternal Exposure to Intimate Partner Violence and Child Immunisation: Insights from a Population-based Study in India	2021	Cross-sectional	VI	India	Web of Science
A17^(37)	Association between violence during pregnancy and preterm birth and low birth weight in Colombia: Analysis of the demographic and health survey	2019	Cross-sectional	VI	Colombia	PUBMED
A18^(38)	Effect of intimate partner violence on birth outcomes	2017	Cross-sectional	VI	Ethiopia	Medline/PUBMED
A19 ^(39)	Psychologic intimate partner violence and the risk of intrauterine growth restriction in Rio de Janeiro	2018	Cross-sectional	VI	Brazil	Medline/PUBMED
A20 ^(40)	Neonatal, infant, and child mortality among women exposed to intimate partner violence in East Africa: a multi-country analysis	2020	Cross-sectional	VI	Burundi, Kenya, Rwanda, Tanzania and Uganda	Medline/PUBMED
A21^(41)	Recurrent Violence, Violence with Complications, and Intimate Partner Violence Against Pregnant Women and Breastfeeding Duration	2021	Cohort	IV	Brazil	Medline/PUBMED

Legend: *LE – Level of evidence

The objectives of the studies permeated in exploring, comparing or examining associations between IPV and impaired breastfeeding, postpartum depression, suicidal ideas, premature birth, immunization, neonatal screening tests, inadequate prenatal care and the need for supplementation of the binomial mother and children, that is, to analyze the impact of IPV in pregnancy on maternal or baby health and also the impact on the relationship of this binomial^(21-41)(Box 4). 

Chart 4 - Articles used according to purpose and results. Imperatriz, Maranhão, 2022

N.	OBJECTIVES	RESULTS
A1 ^(21)	To compare data from the last two Pakistani demographic health surveys to identify trends in the prevalence of various forms of marital violence and maternal health care utilization and to determine the predictive role of marital violence in poor maternal health.	Almost a quarter of women experienced physical and emotional violence, as revealed by both surveys. Binary analysis revealed that all forms of marital violence are significantly associated with maternal health variables.
A2^(22)	To explore the influence of experiencing IPV during pregnancy on the delay in entering prenatal care; and whether women's decision-making autonomy and support for traditional gender roles act to mediate or moderate the relationship between IPV and delay in entering prenatal care.	Almost 70% of the women surveyed reported patterns compatible with delay in entering prenatal care. Considering the influence of other covariates, women who experienced physical IPV during pregnancy were 2.61 times more likely (95% CI [1.33, 5.09]) to have delayed entry into prenatal care than their counterparts who did not report physical IPV. Neither sexual nor psychological victimization of IPV during pregnancy was associated with late entry into prenatal care. Both gender attitudes and levels of autonomy mediated the effect of prenatal IPV.
A3^(23)	To explore an association between women experiencing lifetime IPV and women's decision-making with use of reproductive and maternal health services in Cambodia.	The results show that emotional violence had a significant impact on receiving sufficient prenatal care (ANC) (OR: 0.7, 95% CI: 0.43–0.86), while physical violence had a significant association with childbirth with skilled birth attendant (SBA) (OR: 0.5, 95% CI: 0.27-0.79). In addition, women's participation in household decision-making played an important factor in enabling women to experience sufficient prenatal care (OR: 1.7, 95% CI: 1.19–2.29) and modern contraceptive method use (OR: 1.5, 95% CI: 1.09–1.97).
A4^(24)	To assess whether the experience of psychological and physical intimate partner violence negatively affects pregnancy outcomes.	The response rate was 92.2%. Psychological IPV, reported by 21.0% (n = 151), was significantly associated with urinary tract infection (127 (23%) vs 56 (37%); AOR = 1.9; 95% CI = 1.2 -3.0), vaginal infection (30 (5%) vs 20 (13%); AOR = 2.4; 95% CI = 1.2-4.7) and spontaneous preterm labor (32 (6% ) vs 19 (13%); AOR = 2.2; 95% CI = 1.1-4.5). Physical IPV, reported by 3.6% (n = 26), was associated with prenatal hospitalizations (134 (19%) vs 11 (42%); AOR = 2.6; 95% CI = 1.0- 7.1). Lack of family support was associated with spontaneous preterm labor (AOR = 4.7; 95% CI = 1.7-12.8). Mothers with IPV have a higher chance of complications, Obstetricians, gynecologists and midwives.
A5^(25)	To determine whether women, infants, and children (WIC) participants are more likely than non-WIC participants to have reported IPV before or during pregnancy in the United States.	Nearly half of the study sample received WIC (48.1%), approximately 4% of women reported physical abuse 12 months before their most recent pregnancy, and 3% reported abuse during pregnancy. After adjusting for confounders, women who reported IPV before and during pregnancy were significantly more likely to use WIC compared with women who did not report IPV.
A6^(26)	To describe the association between experiences of intimate partner violence (IPV) during pregnancy among Ni-Vanuatu women and health outcomes, including self-reported general health, prenatal care, psychological distress, and suicidal thoughts/behaviors.	192 women contributed data, among which 188 answered the questions about IPV. Of these, 80 women experienced some form of IPV during their current pregnancy.
A7^(27)	To explore Vietnamese women's experiences of emotional violence and their perceptions of the implications of such violence for their mental health.	Women described emotional partner violence as a major life stressor. Their reports pointed to three particularly significant dimensions of emotional violence: being ignored by the husband; being denied support; and being exposed to controlling behaviors. These experiences profoundly affected women's sense of well-being, causing sadness and anguish. Women's reports indicated that experiences of emotional violence were significantly shaped by dominant kinship arrangements: patrilocal residency practices and principles of patrilineal descent tended to exacerbate women's vulnerabilities to marital violence.
A8^(28)	To explore the relationship between IPV and antenatal care use in the Togolese context	At the bivariate level, women who experienced some form of IPV were less likely to meet all prenatal care utilization indicators, except that the relationship between time of first visit and sexual violence was not statistically significant. Some of these associations were attenuated when we controlled for socioeconomic variables such as education and family wealth.
A9^(29)	To examine the relationship between pre-pregnancy IPV and short IBI, and whether insurance status moderates this relationship among multiparous women who responded to the 2009-2011 Pregnancy Risk Assessment Monitoring System Survey (N=13,675).	The findings of this study reinforce the evidence that women who experience IPV before pregnancy are significantly more likely to have a short birth interval compared to women who do not experience IPV before pregnancy.
A10^(30)	To investigate the relationship between IPV and severe acute maternal morbidity in the intensive care unit (ICU) and neonatal outcomes.	There was a significantly higher rate of IPV before and during pregnancy among cases (58.7%) than controls (27.5%).
A11^(31)	To explore the impact of IPV on utilization of antenatal care services in the Southern Terai of Nepal.	Among 426 pregnant women, nearly three out of ten women (28.9%) were exposed to IPV at some point during pregnancy.
A12^(32)	To evaluate IPV during pregnancy and its association with stillbirths among postpartum women in hospitals in the Tigray region of Ethiopia.	The prevalence of stillbirths was 3.6% in the study population. There was a statistically significant association between exposure to IPV during pregnancy and childbirth. Pregnant women who were exposed to IPV during pregnancy were three times more likely to give birth to stillbirth 3,3 (95% CI: 1.1–9.7) compared to those who were not exposed. Another important factor associated with stillbirth was low birth weight 16.7 (CI 95%, 6–46).
A13^(33)	To examine the relationship between intimate partner verbal abuse during pregnancy and referral for neonatal hearing screening, which indicates immature or impaired auditory function.	Of the 79,985 pregnant women, 10,786 (13.5%) suffered verbal abuse and 978 (1.2%) suffered physical abuse. Of the 79,985 newborns, 787 (0.98%) were referred from the hearing screening service. Verbal abuse was significantly associated with referral (adjusted odds ratio: 1.44; 95% confidence interval: 1.05–1.98).
A14 ^(34)	To examine the association between maternal experience of IPV and child nutritional status in India using the latest round of the National Family Health Survey (2015–2016)	Crude analysis reveals that maternal experience of violence was associated with a greater likelihood of stunting, underweight, and wasting compared to those who did not experience marital violence. The odds of stunting, underweight, and weight loss remained significant even after controlling for maternity care and delivery outcome variables.
A15^(35)	To determine the associations between IPV during pregnancy and low birth weight and preterm delivery among women who gave birth in public hospitals in the Harari region of eastern Ethiopia.	women who experienced IPV during pregnancy were 1.62 times (AOR = 1.62, 95% CI = 1.22, 2.78) more likely to give birth prematurely and 1.37 times (AOR = 1.37 , 95% CI = 1.73), 2.57) more likely to have a baby with low birth weight compared to women who did not experience IPV during pregnancy.
A16^(36)	To examine the association between maternal exposure to IPV and childhood immunization in India	Emotional IPV was significantly associated with a lower likelihood of complete immunization (adjusted odds ratio [AOR]: 0.74, 95% confidence interval [CI]: 0.61–0.90) among children. However, physical and sexual IPV had no significant association with childhood immunization status in the adjusted analysis.
A17^(37)	To explore the association between low birth weight and premature birth with violence during pregnancy	There was no association between violence and low birth weight. However, there was an association with premature birth in women over 35 years of age (OR 1.98, 95% CI 1.23, 3.17). Prenatal care proved to be a protective factor for both outcomes.
A18^(38)	To determine the association between IPV during pregnancy and adverse birth outcomes.	An association of IPV with low birth weight of the newborn was indicated (AOR: 14.3.95% CI: (5.03, 40.7). IPV was not associated with stillbirth, premature delivery and Apgar less than 7 to 5 minutes.
A19 ^(39)	To assess whether intimate partner psychological violence during pregnancy is a risk factor for intrauterine growth restriction	Psychological IPV during pregnancy was reported by 665 women (82.1%) and 126 newborns (15.6%) had growth restriction. In the final model, each 1-unit increase in IPV psychological score during pregnancy led to a 15% increased risk of birth-restricted intrauterine growth (odds ratio 1.15; P < 0.001).
A20 ^(40)	To examine associations between IPV among East African women and risk of death among their newborns, infants, and children, as well as related variables.	Children born to women who experienced IPV were significantly more likely to die as newborns (aOR = 1.3, 95% confidence interval [CI]: 1.4-2.2) and infants (aOR = 1.9, 95% CI: 1.6-2.2), and they were more likely to die by age five (aOR = 1.5, 95% CI: 1.01-1.55).
A21^(41)	To verify whether recurrent violence, violence with complications during pregnancy and IPV against pregnant women are associated with shorter duration of exclusive breastfeeding up to the baby's 6th month and breastfeeding up to the 12th month of life.	Risk of a child not being breastfed in the first 12 months of life increased in cases of violence before/during pregnancy (95% confidence interval [CI] =1.03-1.88), recurrent psychological/physical/sexual violence during pregnancy (95% CI = 1.11-1.92), recurrent psychological violence (95% CI = 1.05-1.96) and recurrent physical/sexual violence (95% CI = 1.01-2.39 ). Violence with complications during pregnancy (95% CI = 0.94-2.22) was not associated with interruption of breastfeeding. Similar risks of breastfeeding interruption were observed for IPV (95% CI = 0.96-1.87) and violence perpetrated by other family members (95% CI = 0.83-1.89).

Source: Authors, 2022

DISCUSSION

For a better understanding of the findings were divided into 2 subtopics about IPV repercussion on women’s health and conceptus.

Repercussion of IPV on women's health

The literature shows that women exposed to IPV during pregnancy have impacts on global, gynecological and mental health^(26,27,30).

Depression, generalized anxiety disorder, post-traumatic stress, thoughts and suicide attempts and use of psychoactive substances, especially alcohol, are the most common emotional losses resulting from IPV for women’s health, when this event happens in the gestational period. In addition, emotional exhaustion and personality dissociation have been observed as a form of psychological survival in frequent violent episodes or prolonged situations, leading to "alienated" behaviors during and after aggression^(25,29).

Women who suffer IPV during pregnancy are more likely than those who did not report worse overall health (aOR: 2.97, 95% CI: 1.42-6.22), presenting 4.77 times more chances of having higher levels of psychological suffering and of presenting 3,78 times more likely to have suicidal thoughts and/or behaviors (aOR: 1.98, 95%CI:0.69-5.64)⁽²⁶⁾. In Hanoi, Vietnam, a study conducted between 2014 and 2015, with pregnant women and postpartum women, pointed out that the experiences of emotional violence deeply affected the sense of well-being of women, causing sadness and anguish⁽²⁷⁾.

The psychological impact of IPV can lead to cognitive difficulties in understanding and recognizing abusive situations, for example, when they occur throughout life. The lack of support from the partner when he is the father and aggressor of the baby is associated with high levels of stress and different types of abuse in pregnant women, including emotional problems such as grief, isolation, loneliness and weakness^(23,28,31).

Maternal gynecological and obstetric health is also affected by exposure to IPV, as evidenced by the literature^(5,24). A cohort conducted in Andalusia, Spain, in 2009, with 779 mothers, aiming to assess whether the experience of psychological and physical violence by an intimate partner negatively affects the results of pregnancy, showed that women victims of psychological IPV in pregnancy had 1,9 times more likely to have urinary tract infection, are 2.4 times more susceptible to vaginal infections and spontaneous premature birth (aOR = 2.2; 95% CI = 1.1-4.5) ⁽²⁴⁾.

On the other hand, those exposed to physical violence were 2.6 times more vulnerable to prenatal hospitalizations⁽²⁴⁾_. In addition, a study conducted in a tertiary hospital in Lima, Peru, with 218 participants, between 2015 and 2016, found that exposure to IPV increased by four times the probability of acute maternal morbidity⁽³⁰⁾.

VAW seems to be a serious social problem, considered a public health problem, with important implications for the well-being, quality of life and overall health of women and consequently their children⁽²⁶⁾. Thus, as the mitigation of episodes of violence occurs in this period of the woman’s reproductive life cycle, the quality of life of women and babies will be positively impacted⁽²¹⁾.

Intimate partner violence during pregnancy is still associated with low utilization of prenatal care services^{(21,22,28,30,31,42)}. A study that sought to analyze the association between IPV and use of maternal health care, using a data set compiling all Demographic and Health Surveys that report data on IPV. Using data from 166,685 women observed in 36 countries between 2005 and 2016, it was observed that there was a decrease in maternal health services with low percentage of prenatal visits⁽⁴²⁾.

A study conducted in Nepal with 426 pregnant women in the second trimester identified that pregnant women who were exposed to IPV were less likely to register in prenatal care (OR 0.31; 95% CI (0.08-0.50)⁽³¹⁾. Low adherence to prenatal consultations was also observed in Peru, where women victims of IPV during pregnancy were 2.78 times more likely to attend eight prenatal consultations or less⁽³⁰⁾. Convergent results were observed in Togo, West Africa⁽²⁸⁾, Bangladesh, South Asia⁽²²⁾ and Pakistan, South Asia⁽²¹⁾.  Diverging from these results, a study conducted in the Provincial of the North, Vanuatu, from May to July 2019, found that late prenatal care in women victims of IPV during pregnancy was widespread and was not related to the experience of IPV during this period⁽²⁶⁾.

On the other hand, an analysis of IPV at the time of pregnancy and use of supplementary nutrition services for women, infants and low-income children, in the United States, women who reported IPV before and during pregnancy were significantly more likely to use the supplementation service than women who did not report IPV⁽²⁵⁾.

The non-attendance of women victims of violence in prenatal consultations is related to the episodes of violence with daily events, shame of the marks of physical trauma, fear of reprisals from partners, low self-esteem, depression, which puts in a situation of greater vulnerability to problems related to maternal health and conceptus^{(8,12,25,43,44)}.

In contrast, the social support offered to women for good prenatal care is associated with a decrease in the likelihood of suffering IPV during pregnancy, possibly by providing protection and care measures to the woman and fetus, and the use of other support services for pregnant women^(8,45,46).

Consequences of IPV on the health of the conceptus

IPV in pregnancy can trigger negative outcomes for maternal and neonatal health. The main consequences of IPV for the development of the fetus are spontaneous abortion, restricted intrauterine growth, premature birth, low birth weight and perinatal death, mainly due to bruises located in the abdominal region^(32,34). 

Research conducted in Pakistan between 2012 and 2013 showed that the experience of less severe physical violence (OR = 1.26; 95% CI, 1.08-1.47), severe physical violence (OR = 1.41; 95% CI, 1.09-1.83), sexual violence (OR = 1.39; 95% CI, 1.02-1.89), physical violence during pregnancy (OR = 1.37; 95% CI, 1.07-1.76) increase the risk of termination of pregnancy. Emotional violence decreases the probability of institutional delivery (OR = 0.64; 95% CI, 0.45-0.93) and above four prenatal visits (OR = 0.54; 95% CI, 0.37-0.79)⁽²¹⁾. In Ethiopia, a study conducted between 2017 and 2018, with 648 women, showed that pregnant women exposed to IPV were three times more likely to give birth to stillbirth compared to those who were not exposed and among these, there was a 16.7 times greater risk of an association between stillbirth and low birth weight⁽³²⁾.

Similar results were observed in India and in another study also conducted in Ethiopia, where it was also found that maternal experience of violence was associated with a higher probability of growth delay and low weight compared to those who did not suffer from domestic violence^(34,35). This association of low weight with gestational IPV has also been noted in other studies^(37,38). Similarly, growth delay or restricted intrauterine growth was also observed in other national and international studies^(37-39).

In addition, a study conducted in East Africa draws attention to one of the most severe impacts of IPV on infant mortality. Conducted in 5 countries, this study showed that children born to women who suffered IPV were significantly more likely to die as newborns and infants, as well as having 1.5 times more chances of dying at the age of five⁽⁴⁰⁾.

The literature also shows that victimization in the gestational period interferes with the results of neonatal screening and immunization of the children of victimized women. Studies conducted with pregnant women living in 15 areas of Japan between 2011 and 2014 found that verbal abuse in the gestational period increased by 1,44 times the chances of babies being referred to the neonatal hearing screening service because of their immature or impaired hearing function⁽³³⁾.

In addition, women’s exposure to emotional IPV was significantly associated with a lower probability of complete immunization among children⁽³⁶⁾. Another factor that is influenced by exposure to violence is breastfeeding. A study conducted in São Luís, Maranhão, Brazil, found a shorter duration of breastfeeding until 12 months of life in cases of recurrent violence⁽⁴¹⁾.

Some limitations of this review need to be considered. First, even taking into account that there was selection of articles in different databases and without language restrictions, exclusion occurred of those with lower methodological quality and published before 2017, which may have decreased the breadth of analysis. According to analysis of the association between IPV in pregnancy and maternal health of conceptus beyond the impacts presented in this research are still scarce, which made it impossible to analyze a greater range of repercussions in this binomial. However, it is expected that the study will contribute to the understanding of these repercussions and to signal the professionals who perform prenatal care about the importance of investigating the exposure to violence in the pregnancy period and the need to monitor mothers and babies for the detection of possible health problems related to this exposure.

CONCLUSION

The results show that women victims of IPV in pregnancy have greater vulnerability to psychological suffering, presenting increased levels of stress, sadness, anguish, common mental disorder and suicidal ideation. In addition, they are more susceptible to gynecological and obstetric problems, having greater chances of presenting urinary tract infection and vaginal infections, increased risk of prenatal hospitalizations and greater chances of evolving to severe acute maternal morbidity. The evidence also shows that victimized women have low adherence to prenatal care services.

Regarding the repercussion for the conceptus, exposure to violence is related to the increased chance of miscarriage, restricted intrauterine growth, premature birth, low birth weight, perinatal death, infant and childhood mortality. Still, that maternal violence in the gestational period is associated with low adherence to child immunization, shorter duration of breastfeeding and the need to refer the child to specialized monitoring in neonatal auditory screening.

The impact of IPV in pregnant women and their children highlights the importance of greater attention to IPV, prenatal care, childbirth and puerperium.  However, gender inequality represents the core of the possibilities of breaking the cycle of IPV in pregnancy and its consequences for the health of the mother-baby binomial. The resolution of this problem depends on a set of social reformulations, intersectoral actions to empower women, availability and ease of access to safe conditions for the disruption of links with aggressors and investments in public policies to care for cases of pregnancy in situations of violence during not only the period of pre-violence the consequences of victimization will also be reflected in the periods after pregnancy.

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Scientific Editor: Francisco Mayron Morais Soares. Orcid: https://orcid.org/0000-0001-7316-2519

Rev Enferm Atual In Derme 2023;97(1):e023047