| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Department of Psychiatry and Department of Obstetrics and Gynaecology, Faculty of Medicine, Kuwait University, Safat, Kuwait.
Address reprint requests to: Madhabika B. Nayak, PhD 92 Charak Sadan, Vikaspuri New Delhi 110018 India E-mail: nayakmb{at}ndf.vsnl.net.in
 |
Abstract |
|---|
Top
 Abstract Materials and MethodsResultsDiscussionReferences |
|---|
Methods: Two hundred forty-eight pregnant, married women, aged 15–46 years presenting to obstetric clinics in Kuwait were assessed for lifetime history of assault victimization and other stressful events, marital conflict, family stress, and depressive symptoms using various self-report measures. An analysis of covariance was used to examine the effect of assault victim history on depression scores, using assault victim history and marital conflict as independent variables, and family stress and other stressful event scores as covariates.
Results: Assault victim history, but not marital conflict, was significant in self-reported severity of depressive symptoms, even after controlling for effects of family stress and other stressful events (F = 11.58; P < .001). Specifically, regardless of marital conflict, women with assault victim histories (mean ± standard deviation, 1.27 ± 0.15) had significantly higher depression scores than those with no assault histories (0.78 ± 0.14). Lack of statistical power might have limited detection of independent effects of marital conflict, and possible interactions between marital conflict and assault victim history.
Conclusion: Assault victim history has a significant influence on depressive symptoms in pregnant women. Routine assessment of detailed assault victim history and marital problems in obstetric patients is strongly recommended.
Depression is a critical issue in women’s health. Research in several countries has shown that depression is more common in women than men, and that its onset peaks in the childbearing years. Although pregnancy itself does not increase the risk of depression,1 studying depression during pregnancy is very important. Depressive symptoms are quite common in pregnancy. Up to 70% of pregnant women report depressive symptoms and 10–16% of pregnant women fulfill diagnostic criteria for major depressive episodes during pregnancy.2 Depression during pregnancy often marks the onset of depressive illnesses in women and is associated with increased risk for postpartum depression.1,3 Some evidence suggests a link between depression during pregnancy and negative pregnancy outcomes such as low birth weight and preterm delivery.4
Women worldwide are most likely to present for obstetric care than any other health service over the course of their lives, so pregnancy is a unique opportunity for physicians to detect and manage depression in women. Studies that examined depression during pregnancy concur that it is maintained by psychosocial factors and not medical conditions.5 Psychosocial factors identified in depression during pregnancy include distinct event stressors such as stressful life events during the pregnancy and chronic stressors such as marital problems and other daily stressors, eg, parental worries, financial and other resource concerns, and conflicting relations with members of one’s social network.
Despite increasing support in the literature that associates interpersonal violence victimization with poor physical health and depression in women,6 violence against women continues to be a neglected health issue, particularly in developing countries. Physical abuse was noted as an issue for pregnant women,7 and a review of the literature suggested an association between physical and sexual violence and depression during pregnancy and postpartum8; yet few studies simultaneously assessed quality of marital life, history of interpersonal assault victimization, traumatic life events, and other types of family stress in the study of depression in pregnant women. Some studies assessed stressful events such as accidents, moving, and loss of a loved one, but not violence-related events such as physical or sexual assault. Possible interactions between a history of physical or sexual assault victimization, marital conflict, and other life stressors have yet to be examined.
The present study examined the effects of assault victim history with other stressors on depressive symptomatology in women who presented for obstetric care at two large hospitals in Kuwait. Besides examining interpersonal violence victimization and depression in pregnancy, we also addressed the relative lack of research on violence against women and on mental health of pregnant women in the Middle East.
|
Materials and Methods |
|---|
|
Top
AbstractMaterials and MethodsResultsDiscussionReferences |
|---|
) with yearly hospital records of women who presented for obstetric care found no significant differences and suggested that our sample was representative. To ensure that subjects comprehended study measures, exclusion criteria included mental retardation, psychotic disorders, drug or alcohol intoxication at presentation, or serious medical conditions. All study procedures and measures were approved by the Faculty of Medicine research committee and subjects provided written informed consent.
|
The introduction of the questionnaire assessed recent events (occurring in the past 3 months) including serious injury or death of a loved one, loss of job or large part of family income, separation or divorce, accident, witnessing someone being killed or seriously injured, and being the victim of physical assault in which injuries were received. In the second section, stressful events were assessed as happening anytime in your life. Traumatic events were defined as involving perceived threats to individual physical safety, including accidents, serious natural disaster or fire, witnessing death or violence, witnessing children or family members being physically hurt by someone, and being repeatedly physically threatened by someone. For each lifetime event reported, respondents were asked if they feared being killed or seriously injured during the event, and if they received injuries from it. Summary scores of recent and lifetime events, with associated injury and fear of death or injury, were computed as an index of other lifetime stressful events scores.
To minimize the influence of cultural variations in definitions of interpersonal assault (eg, domestic violence), assault was assessed in the questionnaire in terms of criminal or aggravated assault,9 for which legal definitions across most cultures are similar. Subjects who reported any type of physical assault or incident of unwanted sexual approach, with associated physical injuries or fear of death or injury, were coded as positive for a history of assault victimization. Physical assault was defined as attack with a weapon, attacks without a weapon when the perpetrator was perceived as intending to injure, or attacks that resulted in physical injuries to the victim.
To our knowledge this was the first study on violence against women in Kuwait (MEDLINE and Psychinfo searches from 1966 to December 1998 using the terms "Middle East," "gulf," "Arab," "depression," "depressive," "pregnancy," "violence," "assault," and "wife beating"), and because violence is perceived as a forbidden topic in Arab culture, our research committee placed several restrictions on our assessment of violent events. We were not permitted to ask questions about important details of interpersonal violence events, such as age at the time of event, recurrence of events, and relationship to the perpetrator of the violence. We were also not allowed to ask about sexual assault that involved sexual penetration. Instead, respondents were asked if they had ever been approached sexually against their will.
To assess for chronic stressors, a checklist of items adapted from a section of the Stress Audit10 was used to measure family-related stress in the past 6 months. Subjects rated their degrees of distress caused by relationships with immediate and extended family members (relatives, parents, and in-laws), child care demands, special child needs, fertility and childbirth difficulties, and marital relationships. Validity of the checklist was established by review by five physicians and five psychiatrists, and administration to 15 women. Examination of responses of 467 obstetric-gynecology outpatients for internal consistency also suggested that the measure was reliable (
= .8614). Subjects who reported moderate to extreme distress related to marital difficulties or arguments with their spouses, or marital separation or divorce in the past 6 months on the family stress measure, were coded as positive for marital conflict. The remaining items on the family stress checklist were added to create a family stress score.
An Arabic translation of the Hopkins Symptom Checklist11 was used to assess severity of depression symptoms. This 25-item self-report measure of emotional distress has been used in several countries including Kuwait. Scores for depression are computed by averaging the degree of distress reported for 15 pertinent symptoms and can range from 0 to 3, with increasing scores for greater severity of symptoms. A score of 1.5 might be considered moderate severity of symptoms; scores above 1.75 indicate psychiatrically significant levels of symptoms. We chose to use depression scores over classifying subjects as clinically depressed versus not depressed for two reasons: Clinical cutoffs for scores have yet to be validated in Kuwait and recent research suggests limited utility of diagnostic cutoffs for depression.12
Sociodemographic and medical information (number of pregnancies, abortions, miscarriages, preterm deliveries, and presenting problems) for each subject were obtained from the subject records and corroborated by self-report.
|
Results |
|---|
|
Top
AbstractMaterials and MethodsResultsDiscussionReferences |
|---|
Table 2 presents data on self-reported histories of assault victimization and stressful events other than assault. When recent assault was included, 42 women (16.9%) had histories of assault victimization. Marital conflict was frequently reported, with 46.4% (n = 115) subjects coded positive for marital conflict. Depression scores ranged from 0 to 2.5; 13% of all subjects reported overall moderate severity of symptoms (score of 1.5 or higher) and 6.5% reported high to extreme severity of symptoms (score of 1.75 or higher).
|
). An initial analysis of variance found significant differences in depression scores for assault victim history and marital conflict, with no significant assault victim history and marital conflict interactions. Correlation analyses were used to examine associations between depression scores, family stress scores, and other lifetime stressful events scores. Both scores were positively associated with depression (r = .39, P < .01; r = .34, P < .01, respectively). The mean family stress and mean (± standard deviation) lifetime stressful events scores were also significantly higher for the group with assault victimization histories (5.21 ± 3.10 and 1.53 ± 3.10; P < .01, respectively) than for the group with no histories (2.00 ± 2.20 and 0.92 ± .66; P < .01, respectively).
|
|
Discussion |
|---|
|
Top
AbstractMaterials and MethodsResultsDiscussionReferences |
|---|
Webster et al7 reported that 29.7% of women who presented to an antenatal clinic reported a history of being abused, 5.8% during the pregnancy. Despite a more restrictive definition of assault, involving physical injury, a significant proportion of women (one in six) reported lifetime histories of criminal assault victimization, and 8% reported a recent criminal assault. Together, those findings suggest that assault victimization is a noteworthy issue for women presenting for obstetric care. Our findings also suggest that assault victimization history might effect depression during pregnancy more strongly than marital conflict per se. Effects of marital conflict on depression might be mediated by family stress and perhaps marital violence.
To the best of our knowledge, according to our search, there is only one other published report in the Middle East on postpartum depression and marital stress,13 which examined marital conflict including possible assault defined as self-reported "clashes" and "beatings." An additional strength of the present study is its examination of marital conflict that occurs with physical assault versus that which does not. We were not able to ask about relationships of perpetrators in our sample owing to restrictions imposed by our research committee, but it is likely that women were assaulted by someone they knew. Research in other countries has established that violence against women is most often perpetrated by family members and spouses. In contrast, assaults experienced by men typically involve people outside the family, or strangers.14 Several women who reported assault victimization in our study also spontaneously described violence against them by their husbands. It is important to specifically ask women about possible spousal assaults, particularly when marital conflict is reported. This study reinforces the need to assess assault victimization history in detail and shows the feasibility of assessing violence, even though perceived as a forbidden subject in a non-Western culture, with structured behaviorally defined assessment.
A recent review article suggested that prenatal abuse of the mother is associated with adverse postpartum family outcomes, particularly postpartum depression.8 The association of prenatal depression with postpartum depression1,3 suggests that assessing for abuse history and depressive symptoms is essential for early intervention and prevention of depression in expectant mothers. Psychiatric literature indicates that depressive symptoms, even when below clinical cutoffs, predict future psychiatric disorders, largely because they represent chronic vulnerability.15 Assault victimization history might increase that vulnerability.
Depression and history of assault victimization in women who present to obstetric-gynecology clinics is often missed. With 13% and 6.5% of women reporting moderate and high-to-extreme severity of depressive symptoms, respectively, routine assessment of depressive symptoms and factors affecting depression is crucial. Despite evidence that women want their doctors to ask routinely direct questions about violence,16 physicians’ attention to violence against women remains inadequate.17 We found that assault is commonly experienced by women in Kuwait and recommend that physicians conduct routine assessments of history of assault victimization with measures such as those in our study.
The present study is not without limitations. The small number of women with histories of assault victimization who reported no marital conflict might have limited our ability to detect interactions between assault victimization history and marital conflict. Our ability to detect effects of marital conflict after controlling for family stress and other lifetime stressful events also might have been limited. Lack of assessment of less severe forms of violence that might be common in women’s lives may have limited the ability to demonstrate the effect of other lifetime stressful events. It is also possible that women underreported physical assaults that occurred in the context of their marriages, reporting their experience as marital conflict instead. Asking for details, such as about perpetrators of physical assault and specifically asking about conflict resolution behaviors within the marriage, can be helpful in separating marital conflict that does not involve assault from that which does. However, we could not adequately assess for spousal violence or sexual assault owing to restrictions imposed by our research committee. Further research needs to assess different types of interpersonal violence in the study of chronic and discrete stressors associated with depression in obstetric practice.
|
Footnotes |
|---|
Received October 16, 1998. Received in revised form January 4, 1999. Accepted January 28, 1999.
|
References |
|---|
|
Top
AbstractMaterials and MethodsResultsDiscussionReferences |
|---|
2. Llewellyn AM, Stowe ZN, Nemeroff CB. Depression during pregnancy and the puerperium. J Clin Psychiatry 1997;58:26–32.
3. Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI. Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. J Consult Clin Psychol 1989;57: 269–74.[Medline]
4. Steer RA, Scholl TO, Hediger ML, Fischer RL. Self-reported depression and negative pregnancy outcomes. J Clin Epidemiol 1992;45:1093–9.[Medline]
5. Seguin L, Potvin L, St-Denis M, Loiselle J. Chronic stressors, social support, and depression during pregnancy. Obstet Gynecol 1995; 85:583–9.[Abstract]
6. Koss MP, Heise L, Russo NF. The global health burden of rape. Psychol Women Q 1994;18:509–37.
7. Webster J, Sweett S, Stolz TA. Domestic violence in pregnancy: A prevalence study. Med J Aust 1994;161:466–7.[Medline]
8. Wilson LM, Reid AJ, Midmer DK, Biringer A, Carroll JC, Stewart DE. Antenatal psychosocial risk factors associated with adverse postpartum family outcomes. Can Med Assoc J 1996;154:785–99.[Abstract]
9. Resnick HS, Falsetti SA, Kilpatrick DG, Freedy JR. Assessment of rape and other civilian trauma-related PTSD: Emphasis on assessment of potentially traumatic events. In: Miller TW, ed. Theory and assessment of stressful life events. 2nd ed. Madison, Connecticut: International Universities Press, 1996:235–71.
10. Miller LH, Smith AD. Stress audit, version 4.2. Brookline, Massachusetts: Biobehavioral Associates Ltd, 1987.
11. Derogatis LR, Cole JO, Park LC. The Hopkins Symptom Checklist (HSCL): A measure of primary symptom dimensions. Mod Probl Pharmacopsychiatry 1974;7:79–110.[Medline]
12. Kendler KS, Gardner CO Jr. Boundaries of major depression: An evaluation of DSM-IV criteria. Am J Psychiatry 1998;155:172–7.
13. Abou-Saleh MT, Ghubash R. The prevalence of early post-partum psychiatric morbidity in Dubai: A transcultural perspective. Acta Psychiatr Scand 1997;95:428–32.[Medline]
14. Stewart DE, Robinson GE. Violence against women. In: Oldham JM, Riba ME, eds. Review of psychiatry. Washington, DC: American Psychiatric Press, Inc., 1995:261–82.
15. Zonderman AB, Herbst JH, Schmidt C Jr, Costa PT Jr, McCrae RR. Depressive symptoms as a nonspecific, graded risk for psychiatric diagnoses. J Abnorm Psychol 1993;102:544–52.[Medline]
16. Richardson J, Feder G. Domestic violence: A hidden problem for general practice. Br J Gen Pract 1996;46:623–4.[Medline]
17. Parsons LH, Zaccaro D, Wells B, Stovall TG. Methods of and attitudes towards screening obstetrics and gynecology patients for domestic violence. Am J Obstet Gynecol 1995;173:381–7.[Medline]
This article has been cited by other articles:
|
|
 |
|
  K. A. Kendall-Tackett Violence Against Women and the Perinatal Period: The Impact of Lifetime Violence and Abuse on Pregnancy, Postpartum, and Breastfeeding Trauma Violence Abuse, July 1, 2007; 8(3): 344 - 353. [Abstract] [PDF]
|
|
|
|
 |
|
 S. L. Martin, Y. Li, C. Casanueva, A. Harris-Britt, L. L. Kupper, and S. Cloutier Intimate Partner Violence and Women's Depression Before and During Pregnancy Violence Against Women, March 1, 2006; 12(3): 221 - 239. [Abstract] [PDF]
|
|
|
|
 |
|
 M. B. NAYAK Factors Influencing Hesitancy in Medical Students to Assess History of Victimization in Patients J Interpers Violence, February 1, 2000; 15(2): 123 - 133. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
