Violence and depression among pregnant women in Egypt.

BACKGROUND: Depression is a serious mental health disorder that might affect women in the childbearing period. Incidences increase during pregnancy as well as after delivery. Its association with intimate partner violence (defined as physical, sexual, or psychological harm by a current or former partner) has been reported in many countries. Data about this sensitive issue are lacking in Egypt. The aim of the study was to determine the relation between intimate partner violence and depression during pregnancy.
METHODS: This was a case control study conducted at the outpatient clinics in Suez Canal University hospital, from January 2019 to March 2020. The study included two groups, the study group included women exposed to violence during the current pregnancy and a control one included women with no history of violence. Both groups were recruited according to the predetermined inclusion criteria (women aged 18-45 years, continuous marital relationship, no history of depression in current or previous pregnancies, and singleton pregnancy). Women were asked to complete the Arabic validated NorVold Domestic Abuse Questionnaire (measuring four types of abuse: emotional, physical, sexual, and violence in the health care system, the last one being excluded). Depression was evaluated using the Arabic validated form of the Edinburgh Postnatal Depression Scale (comprises 10 questions that represent patients' feelings in the last 7 days). The main outcome measure was to assess the association between intimate partner violence and depression.
RESULTS: We recruited 158 women in each group. Both groups were matched in their demographic characters. Although emotional violence was reported prominently among women exposed to IPV 87.9% (139/158), it was not significantly reported in depressed women (P value 0.084). Physical and sexual violence were significantly reported among depressed women (P value 0.022 and 0.001, respectively). There was a significant difference between women exposed to violence and those who were not exposed to violence in the total depression scores (13.63 ± 5.47 and 10.65 ± 5.44, respectively with a p value < 0.001). Emotional (p value < 0.001) and sexual violence (mild and severe with p value of 0.026 and 0.002 respectively) had significant roles as risk factors for depression during pregnancy in single regression and after control of other confounders.
CONCLUSION: There was a strong association between intimate partner violence and depression during pregnancy.

Background

Depression, anxiety, and somatoform disorders affect women during pregnancy [1] with depression the most serious one [2]. It has a wide range of risk factors including poverty, illiteracy, unemployment, social deprivation, and intimate partner violence (IPV) [3, 4]. IPV has numerous unwanted effects on physical and mental health [5]. According to WHO estimates, about one- third of women are exposed to one form of violence (physical or sexual) during their lifetime, while emotional violence predominated significantly [5]. IPV is the most common type of violence practiced against women worldwide [6]. For example; 46% of Ugandan women, 60% of Tanzanian women, 42% of Kenyan women, and 40% of Zambian women reported physical abuse [7]. However; its global estimates are not accurate because of the stigma and shame associated with IPV. Also, disclosure is low and taboos about revealing such family problems exist among certain cultural groups [8].

Recent studies demonstrated the relation between IPV and postpartum depression (PPD) [9], while depression is the most common psychiatric disorder during pregnancy [10]. It has a significant cargo during pregnancy, with higher prevalence than PPD [11]. Besides, it is considered a major risk factor for PPD, with about 41.5% of PPD being developed during pregnancy [12].

Accordingly, there is an urgent need to gather evidence-based information to solve the problem appropriately. Although many studies exist, the impact of violence on women’s health during pregnancy remains an area where robust evidence is lacking. So, there is a need to disclose the association between IPV and women’s health with special attention to mental health [7]. There are no studies evaluating the relation between IPV and depression during pregnancy, especially in Egypt. Early detection of depression, would lead to early intervention and the avoidance of disease progression [13]. The aim of this study was to determine the relationship between different forms of violence and depression during pregnancy among Egyptian women.

Methods

This was a case control study conducted in the outpatient clinics in Suez Canal University hospital, after approval of our research ethics committee. The study started from January 2019 to March 2020. We recruited women from the same general population attending for routine antenatal care. Women were invited consecutively every day. The aim of the study was explained for eligible participants. Women accepting to participate in the study were interviewed after they had received their care. At the end of the consultation, the participant was transferred to a private room to fill in the questionnaires.

Three hundred- fifty one women were eligible for the study. Twenty three women and twelve women refused to participate in the study and control groups respectively. This resulted in a total of 158 women in each group. We allocated women into two groups. The study group included women exposed to IPV during the current pregnancy and a control one included women with no history of IPV. Women were recruited according to the following inclusion criteria: a) women aged [18-]45 years, b) continuous marital relationship, c) no history of depression in previous or current pregnancy, d) singleton pregnancy, and e) gestational age in the second and third trimesters. Women who refused to participate in our research were excluded.

Patients were evaluated regarding their demographic parameters. These data were selected after literature review to determine possible factors contributing to maternal exposure to IPV [14, 15]. These included age, level of education (illiterate, middle, and high), occupation (housewife, worker, and employee), parity, residency (urban or rural areas), and duration of marriage. Partners’ data included age, level of education, and occupation. The socioeconomic level was determined according to the scale developed by El- Gilany et al. the scale included 7 domains with a total score of 84. The socioeconomic level was classified as very low, low, middle, and high levels depending on the quartiles of the score calculated [16]. Women were asked to complete the Arabic validated NorVold Domestic Abuse Questionnaire (NORAQ). The NORAQ measures four types of abuse: emotional, physical, sexual, and violence in the health care system, the last one being excluded. The NORAQ-Arabic version evaluated measurements of the three kinds of lifetime abuse – emotional (12 items), physical (11 items), and sexual abuse (12 items). The content of the questions ranged from mild to severe lifetime abuse. Women who reported more than one degree of a specific kind of abuse were categorized according to the most severe abusive act. Emotional, physical, and sexual abuses were defined by an affirmative answer to one or several of the three or four questions about each kind of violence in NORAQ [17].

Depression was evaluated using the Arabic validated form of the Edinburgh Postnatal Depression Scale (EPDS). The scale comprises 10 questions that represent patients’ feelings in the last 7 days. Each question has multiple choices for answering it. Questions 1, 2, and 4 are scored 0, 1, 2, or 3 with the top choice scored as 0 while the last one as 3. Questions 3, 5–10 are reverse scored with the top choice scored as 3 while the last one as 0. The maximum score is 30. Scores were interpreted as follows: a score less than 8 as depression was not likely, a score of 9–11 as depression was possible, a score of 12–13 as fairly high possibility of depression, and a score ≥ 14 as possible depression (positive screen). A positive score for question 10 meant suicidality risk. Each situation was dealt with according to the recommendations of the reproductive health program [18, 19].

Data collection was done by one of the study researchers, who had the interviews with each patient. An informed written consent was obtained from each participant before completing the questionnaire. The questionnaires were self- administered, anonymous, and without address, to ensure confidentiality. The available researcher provided help and clarification for patients when needed (also for illiterate patients). The average time for filling the questionnaire was 20–25 min.

Statistical analysis

Data were statistically described in terms of mean and standard deviation, frequencies (number of cases) and percentages when appropriate. P values less than 0.05 were considered statistically significant. All statistical calculations were done using computer program SPSS (Statistical Package for the Social Science; SPSS Inc. 2013, Chicago, IL, USA) release 22 for Microsoft Windows. For comparing proportions between groups, Chi squared or Fisher’s Exact tests were used. Mann- Whitney U test was used for comparison of quantitative continuous non- parametric variables. For the construction of logistic regression models for the prediction of antenatal depression the dependent variable was the presence or absence of depression. This was put against all of the variables that it depended upon; hence, there were multiple simple logistic models each with a significant factor. These significant factors were put in a model and factors were removed one by one to produce a best-fit multiple logistic model. A p-value ≤0.05 was considered statistically significant.

Results

Three hundred- fifty one women were eligible for the study. Twenty three women and twelve women refused to participate in the study and control groups respectively. This resulted in a total of 158 women in each group. Both groups were matched in their demographic characters (Table 1).

Table 1

Descriptive statistics of the sociodemographic variables of the study groups

Group		No IPV (158)	IPV (158)	p-value
Wife’s age (years) (mean ± sd)		28.58 ± 5.61	28.34 ± 5.17	0.799
Wife’s education N (%)	Illiterate	42 (26.58%)	47 (29.75%)	0.822
	Middle	75 (47.47%)	72 (45.57%)
	High	41 (25.95%)	39 (24.68%)
Wife’s occupation N (%)	Housewife	113 (71.52%)	103 (65.19%)	0.407
	Worker	10 (6.33%)	15 (9.49%)
	Employee	35 (22.15%)	40 (25.32%)
Husband’s age (years) (mean ± sd)		32.54 ± 5.81	32.82 ± 5.28	0.705
Husband’s education N (%)	Illiterate	48 (30.38%)	51 (32.28%)	0.347
	Middle	66 (41.77%)	74 (46.84%)
	High	44 (27.85%)	33 (20.89%)
Husband’s occupation N (%)	Unemployed	33 (20.89%)	26 (16.46%)	0.417
	Worker	50 (31.65%)	46 (29.11%)
	Employee	75 (47.47%)	86 (54.43%)
Total duration of marriage (years) (mean ± sd)		6.0 ± 3.78	6.1 ± 4.76	0.686
Socioeconomic status N (%)	Low	64 (40.51%)	59 (37.34%)	0.726
	Moderate	55 (34.81%)	54 (34.18%)
	High	39 (24.68%)	45 (28.48%)
Residence N (%)	Rural	60 (37.97%)	54 (34.18%)	0.482
	Urban	98 (62.03%)	104 (65.82%)
Age difference (mean ± sd)		4.18 ± 3.65	4.58 ± 3.65	0.582
Body mass index (kg/m^2) (mean ± sd)		27.47 ± 4.06	27.94 ± 4.63	0.193
Parity	Nullipara	36 (22.78%)	33 (20.89%)	0.006
	Multipara	122 (77.22%)	125 (79.11%)
Gestational age (weeks) (mean ± sd)		30.03 ± 8.02	29.1 ± 9.2	0.06

Emotional violence was the most common reported pattern among women exposed to IPV 87.9% (139/158). However, it was not significantly prominent in depressed women (P value 0.084). Physical and sexual violence were significantly reported among depressed women (P value 0.022 and 0.001, respectively) (Table 2).

Table 2

Distribution of different types of violence (emotional, physical, sexual) among study groups

		Not Depressed (156)	Depressed (160)	P value
Emotional N (%)	No	95 (60.9%)	82 (51.25%)	0.084a
	Yes	61 (39.1%)	78 (48.75%)
Physical N (%)	No	129 (82.69%)	115 (71.88%)	0.022a
	Yes	27 (17.31%)	45 (28.13%)
Sexual N (%)	No	154 (98.72%)	145 (90.63%)	< 0.001a
	Yes	2 (1.28%)	15 (9.38%)

Depression was considered in women with a score ≥ 14. Emotional, physical, and sexual abuses were defined by an affirmative answer to one or several of the three or four questions about each kind of violence in NORAQ

a Chi- square test

There was a significant difference between women exposed to violence and those who were not exposed to violence in the total depression scores (13.63 ± 5.47 and 10.65 ± 5.44, respectively with a p value < 0.001). Two out of 158 women exposed to violence committed suicide actually (Table 3).

Table 3

Associations between violence and different variables regarding depression among both study groups

	No IPV (158)	IPV (158)	P value
Depression score (mean ± sd)	10.65 ± 5.44	13.63 ± 5.47	< 0.001a
Trial of suicide N (%)	0 (0%)	2 (1.27%)	0.156b
Depression not likely Score < 8*	61 (38.6%)	25 (15.8%)	< 0.0001c	< 0.0001
Depression possible Score 9–11*	22 (13.9%)	32 (20.3%)	0.174c
Fairly high possibility of depression Score 12–13*	26 (16.5%)	19 (12%)	0.297c
Probable depression Score ≥ 14*	49 (31%)	82 (51.9%)	0.004c
Positive score on question 10 (suicidal risk)	49 (31%)	53 (33.5%)	0.629c

* EPDS parameters were used to characterize depression

a Mann- Whitney U test

b Fisher’s- Exact test

c chi- square test

Multiple factors had a significant role in the prediction of IPV individually as age, parity, education, and husbands’ age (p value 0.003, 0.021, 0.032, and < 0.001 respectively). Emotional (p value < 0.001) and sexual violence (mild and severe with p value of 0.026 and 0.002 respectively) had significant roles as risk factors for depression during pregnancy either individually or when combined with other factors (Table 4).

Table 4

Single and multiple linear regressions for significant factors related to depression

Variables	Single linear	Multiple linear
	P value	P value	β (95% CI)
Age (years)	0.003	< 0.001	0.210 (0.101–0.32)
Husband’s age (years)	< 0.001	–	–
Husband’s Education	0.032	0.005	1.072 (0.318–1.825)
Psychological violence- mild	0.001	–	–
Psychological violence- moderate	< 0.001	–	–
Psychological violence- severe	< 0.001	< 0.001	4.799 (2.347–7.251)
Physical violence- mild	< 0.001	–	–
Physical violence- moderate	< 0.001	–	–
Physical violence- severe	0.014	–	–
Sexual violence- mild, no genital contact	< 0.001	0.026	31.246 (3.721–58.772)
Sexual violence- moderate	< 0.001	–	–
Sexual violence- severe	< 0.001	0.002	5.999 (2.168–9.829)
Parity	0.021	–	–
Gestational age (weeks)	< 0.001	< 0.001	−0.018 (−0.027 - -0.008)
Duration of marriage (years)	0.006	–	–

For the construction of logistic regression models for the prediction of antenatal depression the dependent variable was the presence or absence of depression. This was put against all of the variables that it depended upon; hence, there were multiple simple logistic models each with a significant factor. These significant factors were put in a model and factors were removed one by one to produce a best-fit multiple logistic model

Discussion

This was the first study conducted in Egypt to evaluate the association between IPV and depression during pregnancy. A previous study evaluated the effect of enabling resources and childhood adverse events on anxiety associated with IPV among Egyptian women [20]. In addition, a recent one was conducted to evaluate the association between mental disorders (anxiety and/or depression) with domestic violence [21]. Other studies were conducted among non-pregnant women [22, 23].

Both groups were matched in their demographic characters. Close results were reported by previous studies [24-26]. Emotional violence was the most common reported pattern among women exposed to IPV, followed by physical and sexual violence. These results are higher than a previous research in Vietnam [24]. This would be rendered to the larger sample recruited by them. Also, emotional violence was reported as the most common pattern of violence experienced by women in different countries [25, 26]. Similar results were reported by a systematic review that included studies conducted from 72 countries about IPV during pregnancy [27].

There was a significant difference between women exposed to violence and those who were not exposed to violence in the total depression scores. Two women exposed to violence committed suicide actually, while suicide ideation was present in about one third of women. Only two studies from Zimbabwe and Pakistan reported on the association between IPV and suicidal ideations or attempts. They concluded that women exposed to violence were at risk of suicidal ideation 5 times than those not exposed to violence [28, 29], while the current study revealed no significant difference in suicide ideation among both groups.

Emotional and sexual violence had significant roles as risk factors for depression during pregnancy. In a study performed among Brazilian women, emotional or physical abuse increased the odds ratio of current major depressive disorder significantly [11]. This agreed with the current study. Recent studies reported that psychological abuse was significantly associated with antenatal depression [30, 31], however; one study reported violence among low income women which limits the validity of their results [31].

Another study reported that physical violence was a powerful determinant for postpartum depression, followed by sexual and emotional violence with no data available about depression during pregnancy [24]. Multiple studies confirmed the association between IPV and postpartum depression [32-34]. This was explained by the relationship between violent behavior and poor mental health [35, 36]. Another study demonstrated that emotional abuse has a damaging effect as physical abuse [37]. This would be explained by the presence of common features between violence and depression such as humiliation and entrapment. Also, depression in women develops as a result of sense of loss which may be provoked by violence [21].

Strength and limitations of the study

We addressed a very sensitive issue that could be underestimated as women might be ashamed to disclose their actual experiences. We recruited a control group who were not exposed to violence. The study was conducted as a cross sectional study, which cannot determine a causal relationship. This was a hospital based study which limits the generalizability of the results. We did not evaluate the recruited women for evidence of postpartum depression.

Research implications

Conducting community based studies would be recommended. Evaluating the effect of IPV on depression during pregnancy with continuing follow up after delivery would be more informative. Also, its impact on perinatal outcome would be evaluated.

Conclusions

There was a strong association between IPV and depression during pregnancy. Other factors contributed significantly to antepartum depression as husbands’ age and education.