Continued Intimate Partner Violence During Pregnancy and After Birth and Its Effect on Child Functioning

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Continued Intimate Partner Violence During Pregnancy and After Birth and Its Effect on Child Functioning Ann L. Bianchi, Judith McFarlane, Sandra Cesario, Lene Symes, and John Maddoux

Correspondence Ann L. Bianchi, PhD, RN, Nursing Building, Room 208C, College of Nursing, The University of Alabama in Huntsville, 301 Sparkman Dr., Huntsville, AL 35899. [email protected]

ABSTRACT

Keywords abuse during pregnancy abused women child behavioral functioning conception rape intimate partner violence (IPV)

Methods: Abused women who reported IPV answered a questionnaire on the effects of abuse during pregnancy and continued abuse after birth and child behaviors. Women who continued to experience abuse during pregnancy were compared with women who did not report abuse during pregnancy and after birth. The Achenback Child Behavior Checklist was used to evaluate child behavior. Research questions were analyzed through the use of nonparametric analyses.

Objective: To investigate the effect of intimate partner violence (IPV) during pregnancy with continued IPV up to 6 months after birth and its effect on child functioning. Design: Nonexperimental descriptive design. Setting: Safe shelters and the District Attorney’s office in a large urban community in the United States. Participants: Abused women (N ¼ 284) who reported IPV and reached out for services.

Results: Between the two groups, the relationship between IPV during pregnancy and IPV during the first 6 months after birth was significant (p < .001). The relation between women who reported abuse during pregnancy and conception rape was significant (p < .001). Most abused women (76%) were not screened for IPV during pregnancy (p ¼ .025). Significant findings related to child behaviors and IPV during pregnancy were found for internalizing behaviors (p < .009), externalizing behaviors (p < .001), and total behavioral problems (p < .001). Conclusion: Intimate partner violence during pregnancy increases the risk of IPV 6 months after birth. These findings also indicated a negative intergenerational effect of IPV during pregnancy on child behavior. Screening for IPV during pregnancy is vital to interrupt ongoing IPV and possible negative outcomes for mother and child.

JOGNN, 45, 601–609; 2016. http://dx.doi.org/10.1016/j.jogn.2016.02.013 Accepted February 2016

Ann L. Bianchi, PhD, RN, is an associate professor in the College of Nursing, The University of Alabama in Huntsville, Huntsville, AL.

(Continued)

The authors report no conflict of interest or relevant financial relationships.

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T

he childbirth experience has the potential to instill strength in women, and many women go to great lengths to prepare for childbirth and motherhood. Unfortunately, intimate partner violence (IPV) can occur during pregnancy. Intimate partner violence adversely affects the health and safety of women, and the effects of IPV may extend for the woman and her child long after the pregnancy has ended. Acts of violence such as IPV during pregnancy are targeted toward women and affect women of all ages, races, ethnic backgrounds, religions, educational levels, and economic levels (World Health Organization [WHO], 2013). The WHO reported that IPV is a global public health problem and documented that 35% of women worldwide have experienced physical or sexual violence from an intimate partner at least once (WHO, 2013).

Approximately 324,000 pregnant women in the United States experience IPV each year (Tjaden & Thoennes, 2006), and during pregnancy, the abuse may escalate (Martin, Harris-Britt, Moracco, Kupper, & Campbell, 2004), may be more severe (Brownridge, Tailieu, Tyler, Tiwari, & Ling, 2011), and may be more frequent (Martin et al., 2004); it therefore poses a health risk to the mother and the fetus. Abused pregnant women are more likely than nonabused pregnant women to experience all forms of violence, including physical assault (Catalano, 2013), sexual assault (WHO, 2011), and psychological aggression (Martin et al., 2004). Physical violence during pregnancy has been associated with an increased risk of antepartum hemorrhage (Watson & Taft, 2013), intrauterine

ª 2016 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

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growth restriction (Janssen et al., 2003), increased risk of operative birth (Boy & Salihu, 2004), and perinatal death (El Kady, Gilbert, Xing, & Smith, 2005). Intimate partner violence during pregnancy can also be a strong predictor of physical abuse that extends up to 1 year after birth (Charles & Perreira, 2007). Daoud et al. (2012) found that women who were abused before and during pregnancy were also abused after the pregnancy.

Judith McFarlane, DrPH, RN, is a professor and the Parry Chair for the Health Promotion & Disease Prevention and PI 7-Year Mother Child Study to Determine Long Term Impact of Intimate Partner Violence on Health and Functioning, College of Nursing, Texas Woman’s University, Houston, TX.

One type of IPV is conception rape, which is defined as a rape-related pregnancy that may lead to an increased risk for negative physical and psychological health outcomes (Holmes, Resnick, Kilpatrick, & Best, 1996). In 2010, the National Intimate Partner and Sexual Violence Survey of 9,080 women indicated that approximately 50% of female rapes were by intimate partners and that as many as 227 (5%) pregnancies resulted from conception rape (Black et al., 2011). Stewart, Gagnon, Merry, and Dennis (2012) investigated 774 pregnant migrant workers in Canada; 59 reported violence during pregnancy. Of these, 16 (27.1%) became pregnant as a result of forced sex. de Haas, Berlo, and Vanwesenbeeck (2012) investigated the prevalence of rape leading to pregnancy in The Netherlands and found a prevalence rate of 7%. Sexual assault that results in a pregnancy produces physical and mental burdens on the woman, and her sexual and reproductive selfdetermination is violated. Such violence is a global issue that warrants more attention.

experienced more problems with depression and anxiety for 24 months after birth. To potentially interrupt the negative effect of IPV on mothers and child behavioral functioning, identification of IPV during pregnancy is essential. Inquiring about IPV during the prenatal period on a routine basis has been shown to increase disclosure rates of women who experience IPV during pregnancy (Bacchus, Mezey, & Bewley, & Haworth, 2004; O’Reilly, Beale, & Gilles, 2012; Ramsden, & Bonner, 2002). In 2015, the Association of Women’s Health, Obstetric and Neonatal Nurses released a position statement on IPV and recommended that women be universally screened in safe and private settings where health care is offered (Association of Women’s Health, Obstetric and Neonatal Nurses, 2015). In 2012, the American College of Obstetricians and Gynecologists recommended that IPV screening during obstetric care should occur at the initial visit and at least once per trimester to increase the opportunity for disclosure (American College of Obstetricians and Gynecologists, 2012). The U.S. Preventive Services Task Force (2013) listed IPV screening as a B-grade recommendation (high certainty that the net benefit is moderate) and stated that all health care providers should screen women between the ages of 14 and 46 years for IPV and provide referrals to services that offer support to abused women. Collaboration between health care professionals and policy makers is needed to develop evidencebased models of care that improve the health and safety of abused women.

John Maddoux, MA, is a statistical analyst in the Office of Research, Texas Woman’s University, Denton, TX.

Intimate partner violence during pregnancy may also affect the mother–child relationship and make it more difficult to establish and strengthen this bond (Zeitlin, Dhanjal, & Colmsee, 1999). Burke, Lee, and O’Campo (2008) found that a compromised mother–child relationship may affect child functioning and explored the relationship between IPV and infant general health and temperament at 1 year of age. Their findings indicated that infant temperament was significantly associated with any abuse of the mother at baseline and follow-up, and the mother’s experiences of physical abuse were significantly associated with the infant’s general health. Flach et al. (2011) investigated whether antenatal domestic violence was associated with adverse child development and found that antenatal and postnatal domestic violence were associated with behavioral problems of the child at 42 months of age. In 2014, McFarlane et al. found that children who lived with mothers abused during pregnancy

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Sandra Cesario, PhD, RNC, FAAN, is a professor and a PhD/DNP program coordinator in the College of Nursing, Texas Woman’s University, Houston, TX. Lene Symes, PhD, RN, is an associate professor in the College of Nursing, Texas Woman’s University, Houston, TX.

The purpose of this study was to extend current knowledge and to better promote the health, safety, and well-being of pregnant women who report IPV or no IPV during pregnancy. We investigated abused women who reached out for services and compared past pregnancy history and child functioning outcomes for 284 mothers within two groups: abused mothers who reported continued IPV during a past pregnancy (Group A) and abused women who reported no IPV during a past pregnancy (Group B). The research questions included the following:  What percentage of women reported conception rape in each group?  What was the prevalence of IPV during the first 6 months after birth in each group?  What percentage of women in each group reported that they were screened for IPV

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during antenatal care and in the hospital after birth?  What percentage of women in each group reported exposure of child to IPV at younger than 2 years of age or older than 2 years of age in each group?  What percentage of women in each group reported normative, borderline, or clinical levels with regard to their children’s behavioral functioning on the Child Behavior Checklist?

Table 1: Frequencies and Percentages of Categorical Demographic Variables (N [ 284) Variable

n

%

White

31

10.9

Black

72

25.2

Asian

4

1.4

American Indian/Native Alaskan

1

0.3

162

57.7

13

4.5

142

50.3

140

49.7

Less than high school

93

33.0

High school/high school equivalency

54

19.1

119

42.2

16

5.7

Born in United States

182

64.1

Immigrant

102

35.9

Ethnicity

a

Spanish or Hispanic Biracial/multiracial

Methods

Child’s sex

Study Design We used a nonexperimental descriptive design to compare two groups of abused women who reached out for services: those who experienced IPV during pregnancy and those who did not experience IPV during pregnancy. Approval was received from an institutional review board.

a

Male Female Level of education

a

Some college

Setting This study took place in a large urban community in the United States. Recruitment took place at each of the five shelters that offered safe refuge in the community. Recruitment also took place in the District Attorney’s Office for processing protection orders in this large urban community.

College degree or higher Immigration status

Birth data

a

Birth method

Participants

Vaginal

178

62.9

The population for this study included abused mothers who were first-time users of safe shelters who had not applied for protective orders or who were first-time applicants for protective orders who had not used safe shelters. All of the women had at least one child between the ages of 18 months and 18 years. The mother and the child were included in the study, and if the mother had more than one child, one of her children was randomly selected to be in the study. We wanted to ask mothers who reached out for the first time for services about their past pregnancies and if they had experienced conception rape and IPV during pregnancy and how the IPV may have affected the child’s behavior. Sample size was determined with G*Power (version 3.0; HeinrichHeine-Universita¨t Du¨sseldorf, 2016). For two independent samples (use of safe shelter and protective order applicant) with a conservative effect size of .40, power of .90, and alpha of .05, 135 women were needed in each of these groups. To allow for attrition, we set the sample at 150 women and 150 children in each group, for a total of 300 women and 300 children. In total, 284

Cesarean

105

37.1

$2,500 g

247

87.1

<2,500 g

37

12.9

No

87

30.6

Yes

197

69.4

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Birth weight

Breastfeeding during hospitalization

a

Missing demographic data on some participants.

abused mothers responded to the questions about IPV during pregnancy, conception rape, IPV during the first 6 months after birth, screening offered during the antenatal period or before hospital discharge, and age child was exposed to abuse in the home. Each participant completed a Child Behavior Checklist.

Measures Demographic data included ethnicity, child’s sex, mother’s level of education, child’s age, and

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Abuse during pregnancy places women at risk for continued abuse well beyond the pregnancy and may compromise their safety and well-being.

immigration status. Demographics were also collected related to the abused woman’s birth experience, including birth method, newborn birth weight, and initiation of breastfeeding during hospitalization (see Table 1). Each participant responded to the following questions: Thinking about your pregnancy with (name of child in the study), did the pregnancy result from forced sex? Were you physically or sexually abused during your pregnancy with (name of child in the study)? Were you physically or sexually abused during the first 6 months of (name of the child in the study)’s life? Did anyone ask you about IPV during the pregnancy of (name of child in the study) or before you left the hospital? Thinking about (name of child in the study), what age was she/he first exposed to IPV in the home? We used the Achenback Child Behavior Checklist (CBCL; Achenback & Rescorla, 2000, 2001) to evaluate child behaviors. The CBCL provides a standardized parental report of child behavioral problems, with a form for children ages 18 months to 5 years and a form for youth ages 6 to 18 years (Achenback & Rescorla, 2000, 2001). The parent is asked the CBCL orally and rates the presence and frequency of certain behaviors on a 3-point scale (0 ¼ not true, 1 ¼ somewhat or sometimes true, and 2 ¼ very true or often true). Examples of behaviors for younger children include physically attacks people and doesn’t want to sleep alone. Examples of behaviors for older children include bully behavior, vandalism, and prefers being with older children. The CBCL consists of two broadband factors of behavioral problems: internalizing (e.g., depression, withdrawal) and externalizing (e.g., anger, hostility) and includes mean scale scores for national normative samples and clinically referred, borderline-clinical, and nonreferred samples of children. For this study the coefficient alphas for youth ages 18 months to 5 years were 0.81, 0.92, and 0.84 for internalizing, externalizing, and total behavior problems, respectively. The coefficient alphas for children ages 6 years to 18 years were 0.77, 0.77, and 0.88 for internalizing, externalizing, and total behavior problems, respectively.

604

Data Analysis Data were confidentially encoded and entered into a secure database through the use of SPSS version 19. Exploratory analyses were conducted to obtain the frequencies of demographics of abused women who reported IPV during pregnancy or reported no IPV during pregnancy. These preliminary analyses showed low observations across groups and violations of normality, and, as such, the primary research questions were analyzed through the use of nonparametric analyses, including cross-tabulations with Pearson’s chi-square with Cramer’s V. In instances in which observed sample size across cells was insufficient for the parameters, nonparametric of Pearson’s chi-square, exact tests were used to test for significant differences in proportions. Cross-tabulation with Fisher’s exact test was conducted to test for differences in number of rapes with IPV during pregnancy and the number of rapes with no IPV during pregnancy. Fisher’s exact test examines statistically significant differences in observed proportions across two categoric variables. We used Fisher’s exact test because it can handle low numbers of observations, including no observations across particular combinations of categoric variables, which is likely to occur with the current data set. Additional cross-tabulations using Fisher’s exact test were conducted to test for differences between IPV during pregnancy and no IPV during pregnancy, IPV during the first 6 months after birth, whether women were screened for IPV during pregnancy, child’s age exposed to IPV in the home, and child behavior functioning. To test for differences between Group A and Group B regarding internalizing and externalizing problems of child functioning based on mean scale scores for normative and borderline/clinical levels by the Child Behavior Checklist, a series of cross-tabulations with Pearson’s chi-square test were conducted.

Results Sample Characteristics The final sample consisted of 284 mother–child pairs. Mothers’ ages ranged from 18 years to 52 years with a mean age of 30.76 years. The mean age of the children in this study was 6.9 years. The frequencies and percentages of the demographic data are shown in Table 1. The frequencies and percentages of abuse by group of abused mothers are reported in Table 2.

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Table 2: Frequencies and Percentages of Abuse Groups (N [ 284) Abuse Group

n

%

IPV during pregnancy (Group A)

77

27.1

No IPV during pregnancy (Group B)

207

72.9

Note. IPV ¼ intimate partner violence.

Table 3: Frequencies and Percentages of Pregnancy Abuse Questions and Child Functioning (N [ 284) Question

n

%

No

271

95.4

Yes

13

4.6

No

186

65.5

Yes

98

34.5

No

218

76.8

Yes

66

23.2

<2 years

138

48.6

$2 years

146

51.4

215

75.7

69

24.3

201

70.8

83

29.2

201

70.8

83

29.2

Conception rape

IPV during first 6 months after birth

Specially, 77 mothers (27.1%) reported IPV during pregnancy.

Findings The frequencies and percentages of pregnancy abuse questions and child behavioral functioning questions are reported in Table 3. Most participants (95.4%) in this study did not report conception rape (n ¼ 271). Most participants (65.5%) reported no IPV during the first 6 months after birth (n ¼ 186). Seventy-six percent of participants (n ¼ 218) reported that they were not asked about IPV during the pregnancy or before they left the hospital. The age at which the child was first exposed to IPV was somewhat evenly split between younger than 2 years old (n ¼ 138, 48.6%), and 2 years or older (n ¼ 146, 51.4%). Most participants (n ¼ 215, 75.7%) reported that their children had internalizing problems; 201 participants (70.8%) reported externalizing problems; and 201 participants (70.8%) reported a combination of internal and external behavioral problems. A series of cross-tabulations with Pearson’s chi-square was conducted to test for significant differences in observed proportions across key outcomes by whether or not a participant reported IPV during pregnancy. The measure of effect size associated with this test is Cramer’s V, which can be interpreted as follows: 0 to .1 ¼ no association, .1 to .3 ¼ low association, .3 to .5 ¼ moderate association, and greater than .5 ¼ strong association. A summary of outcomes by whether or not a participant reported IPV during pregnancy is outlined in Table 4. As shown, a greater proportion of participants who reported a conception rape reported IPV during pregnancy (c2 (2) ¼ 17.10, p ¼ <.001, Cramer’s V ¼ .25). The relationship between the abuse groups (Groups A and B) and abused 6 months after birth was significant (c2 (2) ¼ 128.87, p < .001, with a strong association of Cramer’s V ¼ .67). For the participants in Group A who reported IPV during pregnancy, more of these participants (n ¼ 67;

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Asked about IPV

Age child exposed to IPV

Internalizing problems Normative Borderline/clinical Externalizing problems Normative Borderline/clinical Total problems Normative Borderline/clinical Note. IPV ¼ intimate partner violence.

87.0%) reported continued abuse 6 months after birth compared with only 10 participants (13%) who reported no IPV 6 months after birth. For those participants in Group B, only 31 participants (15%) reported being abused 6 months after birth compared with 176 participants (85%) who reported no IPV 6 months after birth. The relationship between abuse groups (Groups A and B) and asked about IPV during pregnancy was significant (c2 (2) ¼ 5.04, p ¼ .025, Cramer’s V ¼ .13). In Group A there were more participants who were not asked about IPV during pregnancy (n ¼ 52, 67.5%) than of those who were asked about IPV during pregnancy (n ¼ 25, 32.5%). In Group B there were also more participants who were not asked about IPV during pregnancy (n ¼ 166, 80.2%) compared with participants who were asked about IPV during pregnancy (n ¼ 41, 9.8%). Additionally, the number of participants (n ¼ 73; 94.8%) in Group A compared with

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Table 4: Frequencies and Percentages of Outcomes by Group (N [ 284)

Outcome

No IPV During

IPV During

Pregnancy

Pregnancy

(Group A)

(Group B)

n

%

n

%

204

98.6

67

87.0

3

1.4

10

13.0

No

176

85.0

10

13.0

Yes

31

15.0

67

87.0

Conception rape? No Yes IPV 6 month after birth?

Asked about IPV No

166

80.2

52

67.5

Yes

41

19.8

25

32.5

Age exposed to IPV? <2 years

65

31.4

73

94.8

$2 years

142

68.6

4

5.2

c2

p

Cramer’s V

17.10

<.001

.25

128.87

<.001

.67

5.04

.025

.13

90.32

<.001

.56

6.88

.009

.16

13.84

<.001

.22

16.11

<.001

.24

Child outcomes Internalizinga Normative Borderline/clinical

164

79.6

49

64.5

42

20.4

27

35.5

Externalizinga Normative Borderline/clinical

158

76.7

41

53.9

48

23.3

35

46.1

159

77.2

40

52.6

47

22.8

36

47.4

a

Total problems Normative

Borderline/clinical

Note. IPV ¼ intimate partner violence. a Missing data on two participants.

Group B who indicated that their children were exposed to IPV before the age of 2 years was significant (c2 (2) ¼ 90.32, p ¼ < .001, with a strong association of Cramer’s V ¼ .56). Cross-tabulation analyses using Pearson’s chisquare and Cramer’s V tests were conducted to examine the relationships among abuse groups and the child functioning variables (see Table 4). The relationship between Groups A and B and internalizing problems was significant (c2 (2) ¼ 6.88, p ¼ .009, Cramer’s V ¼ .16.) A much greater proportion of children whose mothers reported no abuse during pregnancy (Group B) were in the borderline/clinical range of

606

functioning (n ¼ 42, 20.4%) compared with children whose mothers reported abuse during pregnancy (Group A; n ¼ 27, 35.5%). The relationship between Groups A and B and externalizing problems was also significant (c2 (2) ¼ 13.84, p < .001, Cramer’s V ¼ .22). More participants in Group B reported normative functioning in their children (n ¼ 158; 76.7%) compared with Group A (n ¼ 41, 53.9%). Finally, the relationship between Groups A and B and total problems was significant (c2 (2) ¼ 16.11, p < .001, Cramer’s V ¼ .24). More participants in Group B reported normative functioning in their children (n ¼ 159; 77.2%) compared with Group A (n ¼ 40, 52.6%).

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Discussion To our knowledge, our study is unique because the sample represents all abused mothers who were first-time users of safe shelters who had not applied for protective orders or who were firsttime applicants for protective orders who had not used safe shelters for IPV for the first time. From this sample, we were able to compare the effects of abuse during pregnancy between two groups of women, that is, those who experienced abuse during their pregnancy and those who did not experience abuse. Abuse during pregnancy places mothers at risk for continued abuse beyond the pregnancy and affects child behavioral functioning. We found a strong association between mothers who reported IPV during pregnancy and conception rape. We identified a 4.6% conception rape compared with the 5% conception rape reported by the National Intimate Partner and Sexual Violence Study in 2010 (Black, et al., 2011). A strong association was also found between mothers who reported IPV during pregnancy and continued IPV 6 months after birth. This finding is consistent with those in other published studies. Charles and Perreira (2007) suggested that IPV during pregnancy can be a strong predictor of IPV up to 1 year after the pregnancy. Daoud et al. (2012) found that women who were abused before pregnancy and during pregnancy were also abused after pregnancy. Our sample in this study included all abused women, with approximately 27% who reported IPV during pregnancy; within this group of women abused during pregnancy, 34.5% reported being abused during the first 6 months after birth. Our findings indicate an intergenerational effect related to mothers who are abused during pregnancy. We found significant findings in total behavioral problems on the Child Behavior Checklist for children whose mothers reported IPV during pregnancy. Similar findings were identified by other researchers. McFarlane et al. (2014) reported that children of mothers who were abused during pregnancy had greater internalizing problems at 24 months of age within the borderline and clinical ranges. These researchers also found it significant that more mothers abused during pregnancy reported that their children were exposed to IPV at younger than 2 years of age than mothers not abused during pregnancy. Flach et al. (2011) found that children at 42 months of age exhibited behavioral problems (i.e., conduct problems) when the mother was exposed to abuse during the

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antenatal period. Durand, Schrailber, FrancaJunior, and Barros (2011) found that children between the ages of 5 and 12 years whose mothers were exposed to IPV exhibited symptoms of aggressive behaviors, school problems, and behavioral dysfunction, which supports our findings in this study related to negative externalizing behaviors of children whose mothers were abused. We found that women who reported abuse but did not report abuse during their pregnancy had better IPV outcomes, that is, less conception rape and less abuse 6 months after birth. Fewer children were exposed to IPV before the age of 2 years, and the children had fewer functioning problems such as externalizing problems and issues with normative functioning. Identification of IPV during pregnancy is paramount. Routine inquiry for IPV during pregnancy can increase the rate of detection (Bacchus et al., 2004; O’Reilly et al., 2012; Ramsden, & Bonner, 2002) in clinical settings. Evidence from the literature supports the potential for improved maternal and infant outcomes when screening for partner abuse is conducted. Most abused mothers in this study (>75%) reported that they were not screened for IPV. This lack of screening may not be uncommon, because many barriers to routine screening exist among health care professionals. Abused mothers who are not screened for IPV during pregnancy or screened for IPV during the first 6 months after birth may not be afforded the use of the referral services offered to women whose IPV is identified. Women abused 1 year before pregnancy are more likely to disclose abuse early in pregnancy when screened (Keeling & Mason, 2010).

Limitations Sample selection is a limitation of the study. Participants were recruited only from safe shelters that offered safe refuge and the District Attorney’s Office in only one large urban community. The sample was limited to first-time users of these agencies. Abused mothers who accessed other community services such as counseling services, faith-based services, or homeless shelters would have been missed, as

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To improve outcomes for abused women and prevent continued intimate partner violence during pregnancy and beyond, effective screening and community agency referrals are required.

would abused women who may have requested protective orders with private lawyers. Participants were limited to English and Spanish speakers. Recall bias for reporting IPV 6 months after birth and being asked about IPV during pregnancy can be seen as a limitation of the study. The mother’s self-report of her child’s behavior was also a limitation of the study, because no outside observation of the child’s behavior occurred before the mother reported it on the Child Behavior Checklist, although the Child Behavior Checklist is well established and has excellent reliability and validity.

Recommendations for Future Research Further study that investigates the effect of IPV during pregnancy and prevention of continued IPV beyond pregnancy is needed. More attention is also needed to prevent the intergenerational transmission of violence. To improve outcomes in abused mothers and prevent continued IPV into pregnancy and beyond, an urgent need exists to develop effective screening programs so that effective interventions can be implemented. Nurses are in the ideal position to advocate for abused mothers and their children, and researchers must provide evidence through rigorous research studies that will support future funding for interventions and programs that serve to improve the health and well-being of abused mothers and their children. Our recommendations for further study include the following:  Investigation of effective home visit interventions conducted by nurses for mothers abused during pregnancy, with continued home visits on a regular schedule during the first year after birth is needed. Identification of the best methods to conduct home visits may serve to support the new mother, assist with her safety needs, and promote a positive mother–child relationship.  Investigation of the intersection of IPV during pregnancy, the mother–child relationship, and child behavioral functioning is warranted. This investigation would offer increased understanding of IPV during pregnancy and how it mediates the

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mother–child relationship and child behavioral functioning.  Investigation of best methods that offer support to children of mothers abused during pregnancy that will promote normal child functioning behavior is needed. When IPV continues beyond pregnancy, the child is exposed to a violent environment that may affect child behaviors.  Inquiry into effective training programs for health care providers that offers essential tools to conduct screenings and guided referrals for women is vital. These recommended studies are intended to better equip nurses with the best evidence to formulate effective interventions and develop policies and guidelines in all clinics and hospital settings that will better serve the health and safety needs of mothers who experience IPV during pregnancy and their children. These recommendations will also provide evidence to encourage policy makers to seek increased funding for programs on a state or national level.

Conclusion Clearly, women are abused during pregnancy. Our findings were similar to national prevalence rates. Unfortunately, mothers who experience IPV during pregnancy may also experience continued IPV up to 6 months after birth, which was evident in this study. This scenario may lead to child behavior problems that extend beyond early childhood. In our study, child behavior functioning and IPV during pregnancy were found to be significantly related. It must remain clear that all mothers in this study experienced abuse. Therefore, all mothers should be afforded the opportunity to participate in effective screening programs. Identification of IPV during pregnancy is vital; therefore, efforts must be directed to thwart continued IPV beyond pregnancy. These efforts may reduce the intergenerational effects of IPV on children so they can grow and develop to their full potential in an environment that is free of IPV.

Acknowledgment Funded by The Houston Endowment. The authors thank the administrators and staff of the five shelters in Harris County and the Chief and staff of The Harris County District Attorney’s Office, Family Criminal Law Division.

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