Maltreatment in childhood and intimate partner violence: A latent class growth analysis in a South African pregnancy cohort

Intimate partner violence (IPV) is a significant global problem, prevalent in low and middle-income countries (LMICs). IPV is particularly problematic during the perinatal and early postnatal period, where it is linked with negative maternal and child health outcomes. There has been little examination of profiles of IPV and early life adversity in LMIC contexts. We aimed to characterize longitudinal IPV and to investigate maternal maltreatment in childhood as a predictor of IPV exposure during pregnancy and postnatally in a low resource setting. This study was nested in the Drakenstein Child Health Study, a longitudinal birth cohort. Maternal IPV (emotional, physical and sexual) was measured at six timepoints from pregnancy to two years postpartum (n = 832); sociodemographic variables and maternal maltreatment in childhood were measured antenatally at 28–32 weeks’ gestation. Associations between maternal maltreatment in childhood and IPV latent class membership (to identify patterns of maternal IPV exposure) were estimated using multinomial and logistic regression. We observed high levels of maternal maltreatment during childhood (34%) and IPV during pregnancy (33%). In latent class analysis separating by IPV sub-type, two latent classes of no/low and moderate sexual IPV and three classes of low, moderate, and high emotional and physical IPV (separately) were detected. In combined latent class analysis, including all IPV sub-types together, a low, moderate and high exposure class emerged as well as a high antenatal/decreasing postnatal class. Moderate and high classes for all IPV sub-types and combined analysis showed stable intensity profiles. Maternal childhood sexual abuse, physical abuse and neglect, and emotional abuse predicted membership in high IPV classes, across all domains of IPV (aORs between 1.99 and 5.86). Maternal maltreatment in childhood was associated with increased probability of experiencing high or moderate intensity IPV during and around pregnancy; emotional neglect was associated with decreasing IPV class for combined model. Intervening early to disrupt this cycle of abuse is critical to two generations.

This study is nested in the Drakenstein Child Health Study (DCHS), a multidisciplinary birth cohort investigating the determinants of child health in a peri-urban area in South Africa (Stein et al., 2015; Zar, Barnett, Myer, Stein, & Nicol, 2015). Data used in the current study were collected from pregnant women enrolled into the DCHS from March 2012 to March 2015. The DCHS is located in the Drakenstein area in the town of Paarl, a peri-urban area, 60 km outside Cape Town, South Africa with a population of approximately 200,000. More than 90% of the population access health care in the public sector including antenatal and child health services. This area has a well-established, free primary health care system. An area of focus in the DCHS is investigating maternal psychosocial risk factors of child health (Stein et al., 2015). Pregnant women were recruited from two primary health care clinics, Mbekweni (serving a predominantly black African community) and TC Newman (serving a mixed ancestry community). Mothers were enrolled in the DCHS at 20 to 28 weeks’ gestation while attending routine antenatal care and are prospectively followed through their pregnancy until 5 years postnatally. Women were eligible for the study if they were 18 years or older, between 20–28 weeks gestation, planned attendance at one of the two recruitment clinics and intended to remain in the area. Data included in the current study were collected antenatally at 28–32 weeks’ gestation and postnatally at 10 weeks, 6, 12, 18 and 24 months. Between March 2012 and March 2015, 1225 pregnant women were enrolled into the DCHS antenatally; 88 (7.2%) mothers were lost to follow up antenatally, had a miscarriage or a stillbirth. Of the 1137 women who had live births, 100 mothers did not attend the second antenatal visit, where sociodemographic variables and childhood maltreatment data were collected. Of the 1037 mothers who did attend this visit, 832 (80%) were included in this analysis, restricted to those who contributed data for at least 3 of the 6 time points. A sensitivity analysis was done to compare all included variables between mothers included and excluded in the current analysis (Supplemental Table 1, further detail in Statistical Analysis section). IPV exposure: The Intimate Partner Violence Questionnaire (IPVQ) is a 12-item inventory adapted from the WHO multicountry study (Jewkes, 2002) and the Women’s Health Study in Zimbabwe (Shamu et al., 2011) and assessed recent (past-year) exposure to emotional (4 of 12 questionnaire items), physical (5 of 12 items), and sexual abuse (3 of 12 items). Mothers were asked about exposure to partner behavior and frequency of occurrence (“never”, “once”, “a few times” or “many times”). Mothers completed the IPVQ at the 28–32 week antenatal visit and at 10 weeks, 6, 12, 18 and 24 months postpartum. Partner behavior indicating emotional IPV included having been insulted or made to feel bad, having been humiliated in front of others, intentionally scared or intimidated or threatened with physical harm. Physical IPV included being slapped, pushed, shoved, hit with an object, beaten or choked. Sexual IPV exposure was classified based on having been forced to have sex, afraid not to have sex or forced to do something sexual which was degrading or humiliating. Using questionnaire responses mothers were grouped into four categories of exposure: no IPV where all past year behaviours were “never” experienced; isolated or low IPV was designated where any past year behaviours were experienced as “once” and none more frequently than once; moderate where past year behavior was experienced “a few times”; and high where “many times” was indicated. This was done at each of the six time points to investigate changing exposure patterns during the 2 year period of follow up. Scoring guidelines were devised for the purposes of this study, and were based on prior work in South Africa (Dunkle, Jewkes, Brown, Gray et al., 2004; Dunkle, Jewkes, Brown, Yoshihama et al., 2004). Maternal Maltreatment in Childhood: The Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 1994) is a 28- item inventory assessing three domains of childhood abuse (sexual, physical, and emotional), and two domains of childhood neglect (physical and emotional), occurring at or before the age of 12 years. Each item is scored on a frequency scale from 1 (“never true”) to 5 (“very often true”), such that each subscale (domain of abuse or neglect) is scored on a spectrum from 5 (no history of abuse or neglect) to 25 (very extreme history of abuse or neglect). Dichotomous variables were included in the present analysis, as previously described, such that above threshold for each domain was defined as: physical neglect (score of ≥8); physical abuse (score of ≥8); emotional neglect (score of ≥10); emotional abuse (score of ≥9); and sexual abuse (score of ≥6) (Bernstein et al., 1994). Mothers completed the CTQ antenatally at 28–32 weeks’ gestation. Sociodemographic variables were collected from an adapted questionnaire used in the South African Stress and Health (SASH) study (Myer, Stein, Grimsrud, Seedat, & Williams, 2008). Maternal age, income [ R1,000/month], education (any secondary versus completed secondary), employment and partnership status (single or married/marriage-like relationship) were self-reported antenatally at 28–32 weeks’ gestation. The DCHS was approved by the Faculty of Health Sciences, Human Research Ethics Committee, University of Cape Town (401/2009) and by the Western Cape Provincial Health Research committee. Mothers provided informed consent in their preferred language: English, Afrikaans or isiXhosa and were given R100 (approximately 8USD) for travel reimbursement to reach study sites. Study staff were trained on the content of questionnaires and ethical conduct of violence research, including confidentiality and safety issues. Interviews were conducted privately, data were de-identified and only accessible by study staff to ensure confidentiality. Staff were trained to recognise signs of mental health issues (depression, PTSD symptoms and suicide risk) as well as circumstances endangering mothers or children, including Department of Health mandatory reporting requirements for endangerment. Where identified, staff were trained to refer participants to appropriate care or social services in the Paarl area specialising in the issue identified (including support services for IPV, substance abuse and mental health issues). Further, all women involved in the study, independent of identified mental or physical health issues, receive information regarding social and support service providers in the area.

• barnett, whitney
• halligan, sarah l.
• heron, jon
• fraser, abigail
• koen, nastassja
• zar, heather j.
• donald, kirsten a.
• stein, dan j.