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 (18). In addition, a recent one was conducted to evaluate the association between mental disorders (anxiety and/or depression) with domestic violence (19). Other studies were conducted among non-pregnant women (20, 21).
The main age for the studied population was 28.58 ± 5.61 and 28.34 ± 5.17 for those not exposed or exposed to IPV, respectively. Both groups were matched in their demographic characters. Close results were reported by previous studies (22, 23, and 24).
About one third of Egyptian women experienced some form of IPV (25), while another study reported that about 44.1% of Egyptian pregnant women were exposed to IPV (12). Emotional violence was the most common reported pattern among women exposed to IPV 87.9% (139/158). This was followed by physical violence (46.2%) and sexual violence (18.9%). These results are higher than a previous research in Vietnam in which emotional violence was reported by 32.3% of the participants (22). 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 (23, 24). Similar results were reported by a systematic review that included studies conducted from 72 countries about IPV during pregnancy (26). The incidence of IPV differ according to the economic state of the countries with lower incidences were reported in high income countries, however; emotional violence remained the most common pattern of violence experienced by women (64.38%) (27).
The overall incidence of depression with variable severity during pregnancy was 72.8% (230/316), with 84.2% (133/158) were reported among women exposed to IPV. Probable and high possibilities of depression were reported in 47.5% of the studied population. A meta- analysis reported that rates of antepartum depression ranged from 15- 65% (28), with the current study reporting average results. This was higher than reported results in Egypt where they documented that depression affected 10.4% of participants only while both depression and anxiety were documented in up to 60% of patients (19). This would be rendered to the different tools used for screening for mental disorders and IPV during pregnancy. Besides, they recruited women with criteria suggestive of social disadvantages which might be a source of bias. Also, they used the Hospital Anxiety and Depression Scale (HADS) questionnaire which lacked validity testing in Egypt.
Lower results were reported in a Brazilian and Vietnamese populations (14.2% and 5%, respectively) (9, 22). This would be rendered to the use of diagnostic criteria for depression in the former study while we depended on a screening tool that needs further confirmation as the latter one. Also, different samples recruited would explain the difference. Besides, both studies reported on postpartum depression rates. Higher rates were reported by a previous study that used the same screening tool used in the current study (37.8%) (29). Another study conducted in Japan, reported that 9.5% of recruited women had scores ≥ 9 using EPDS when screened for PPD (30).
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, while suicide ideation was present in 33.5% 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 (31, 32), while the current study revealed no significant difference in suicide ideation among both groups. A systematic review reported rates of suicidal ideation of 5- 11% during pregnancy (28).
Emotional and sexual violence had significant roles as risk factors for depression during pregnancy in single regression or after control of other confounders. In a study performed among Brazilian women, emotional or physical abuse increased the odds ratio of current major depressive disorder significantly (p value < 0.001). Also, casual employment was significantly associated with depression during pregnancy (9). This was evident in the current study but for employment. We reported that husbands' age and education influenced the development of depression significantly. Recent studies reported that psychological abuse was significantly associated with antenatal depression (27, 28), however; one study reported violence among low income women which limits the validity of their results (28).
Another study reported that physical violence was a powerful determinant for postpartum depression (OR=5.08; 95%CI: 2.58-10.02), followed by sexual and emotional violence (OR=1.92; 95%CI: 1.10-3.35 and OR=1.60; 95%CI: 1.07-2.41, respectively). Also, after control of confounders, they reported that physical and sexual violence remained significantly associated with postpartum depression (22) with no data available about depression during pregnancy. Multiple studies confirmed the association between IPV and postpartum depression (33, 34, and 35). This was explained by the relationship between violent behavior and poor mental health (36, 37). Another study demonstrated that emotional abuse has a damaging effect as physical abuse (38). 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 (19).
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.