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Revista de Saúde Pública

Print version ISSN 0034-8910

Rev. Saúde Pública vol.48 no.1 São Paulo Feb. 2014 

Artigos Originais

Common mental disorders and intimate partner violence in pregnancy

Transtornos mentais comuns e violência por parceiro íntimo durante a gravidez

Trastornos mentales comunes y violencia por pareja íntima durante el embarazos

Ana Bernarda Ludermir I   II  

Sandra Valongueiro II  

Thália Velho Barreto de Araújo I   II  

IDepartamento de Medicina Social. Centro de Ciências da Saúde. Universidade Federal de Pernambuco. Recife, PE, Brasil

IIPrograma de Pós-Graduação Integrado em Saúde Coletiva. Centro de Ciências da Saúde. Universidade Federal de Pernambuco. Recife, PE, Brasil



: To investigate the association between common mental disorders and intimate partner violence during pregnancy.


: A cross sectional study was carried out with 1,120 pregnant women aged 18-49 years old, who were registered in the Family Health Program in the city of Recife, Northeastern Brazil, between 2005 and 2006. Common mental disorders were assessed using the Self-Reporting Questionnaire (SRQ-20). Intimate partner violence was defined as psychologically, physically and sexually abusive acts committed against women by their partners. Crude and adjusted odds ratios were estimated for the association studied utilizing logistic regression analysis.


: The most common form of partner violence was psychological. The prevalence of common mental disorders was 71.0% among women who reported all form of violence in pregnancy and 33.8% among those who did not report intimate partner violence. Common mental disorders were associated with psychological violence (OR 2.49, 95%CI 1.8;3.5), even without physical or sexual violence. When psychological violence was combined with physical or sexual violence, the risk of common mental disorders was even higher (OR 3.45; 95%CI 2.3;5.2).


: Being assaulted by someone with whom you are emotionally involved can trigger feelings of helplessness, low self-esteem and depression. The pregnancy probably increased women`s vulnerability to common mental disorders

Key words: Pregnant Women; Mental Disorders; Violence Against Women; Spouse Abuse; Cross-Sectional Studies



: Investigar associação entre transtornos mentais comuns e violência por parceiro íntimo durante a gravidez.


: Estudo transversal realizado com 1.120 mulheres grávidas com idade entre 18 e 49 anos, cadastradas no Programa Saúde da Família da cidade do Recife, PE, entre 2005 e 2006. Os transtornos mentais comuns foram avaliados pelo Self-Reporting Questionnaire (SRQ-20). A violência por parceiro íntimo foi definida por atos concretos de violência psicológica, física e sexual infligidos à mulher pelo parceiro. Foram estimadas odds ratios simples e ajustadas para a associação estudada, utilizando-se análise de regressão logística.


: A violência psicológica foi a forma mais frequente de violência por parceiro íntimo. A prevalência de transtornos mentais comuns foi 71,0% entre as mulheres que relataram todas as formas de violência e 33,8% entre as que não relataram violência por parceiro íntimo. Os transtornos mentais mantiveram-se associados à violência psicológica (OR = 2,49, IC95% 1,8;3,5), mesmo na ausência de violência física ou sexual. Quando a violência psicológica esteve combinada com violência física ou sexual, o risco dos transtornos mentais comuns foi ainda mais elevado (3,45; IC95% 2,3;5,2).


: Ser agredido por alguém com quem você está emocionalmente envolvido pode desencadear sentimentos de impotência, baixa autoestima e depressão. A gravidez provavelmente aumenta a vulnerabilidade das mulheres aos transtornos mentais comuns.

Palavras-Chave: Gestantes; Transtornos Mentais; Violência contra a Mulher; Maus-Tratos Conjugais; Estudos Transversais



: Investigar asociación entre trastornos mentales comunes y violencia por pareja íntima durante el embarazo.


: EEstudio transversal realizado con 1.120 mujeres embarazadas con edad entre 18 y 49 años, catastradas en el Programa Salud de la Familia de la ciudad de Recife, Pernambuco-Brasil, entre 2005 y 2006. Lo trastornos mentales comunes fueron evaluados por el Self-Reporting Questionnaire (SRQ-20). La violencia por pareja íntima fue definida por actos concretos de violencia psicológica, física y sexual infligidos a la mujer por la pareja. Se estimaron odds ratios simples y ajustados para la asociación estudiada, utilizándose análisis de regresión logística.


: La violencia psicológica fue la forma más frecuente de violencia por pareja íntima. La prevalencia de trastornos mentales comunes fue de 71,0% entre las mujeres que relataron todas las formas de violencia y 33,8% entre las que no relataron violencia por pareja íntima. Los trastornos mentales se mantuvieron asociados a violencia psicológica (OR= 2,49, IC95% 1,8;3,5), inclusive en ausencia de violencia física o sexual. Cuando la violencia psicológica estuvo combinada con la violencia sexual o física, el riesgo de los trastornos mentales comunes fue aún más elevado (3,45; IC95% 2,3;5,2).


: Ser agredido por alguien con quien se está emocionalmente involucrado puede desencadenar sentimientos de impotencia, baja autoestima y depresión. El embarazo probablemente aumenta la vulnerabilidad de las mujeres a los trastornos mentales comunes.

Palabras-clave: Mujeres Embarazadas; Trastornos Mentales; Violencia contra la Mujer; Maltrato Conyugal; Estudios Transversales


Common mental disorders (CMD) during pregnancy, like depression and anxiety, constitute a public health problem due to their high prevalence, 6 , 12 , 13 the suffering caused to women and its potential impact on infant outcomes. 11 , 19 , 27

There are few studies 11 on the occurrence of depression during pregnancy. Rates of depressive symptoms during pregnancy vary across the world from 6.0% 11 to 35.0%. 27 This variation depends upon the methods of assessment, study design and social, demographic and economic characteristics of the women studied. A few studies have analyzed mental disorders during pregnancy in Brazil 6 , 8 , 12 and found a prevalence of depression around 20.0%. They have been performed with women and adolescents 8 who attending hospital 12 or private health services. 6

Intimate partner violence (IPV) against women is common during pregnancy and may have adverse effects on women’s mental health during pregnancy and after delivery. 1 , 4 , 23 Rates of violence perpetrated by intimate male partners during pregnancy vary worldwide from 3.0% in London 1 to 31.0% in Mexico City 4 though this variation also depends on the methods of assessment. In the United States, IPV affects between 4.0% and 8.0% of pregnant women. 23

The objective of this article is to investigate the association between common mental disorders and psychological, physical and sexual violence against women by their intimate partners during pregnancy.


The study was conducted in Health District II of the city of Recife, the capital of the state of Pernambuco in Northeastern Brazil. The health district’s population was 217,293 inhabitants, a which represented almost 15.0% of Recife’s population and has a high proportion of low-income families.

The coverage of the Family Health Program (FHP) was about 78.0% of the population. It was estimated that only 10.0% of the population in this area were not in need of the public primary health care services provided by the government as they had private insurance. a

Pregnant women were identified from antenatal care records from 42 primary care teams as well as from the records of community health workers in order to include those not receiving antenatal care at Health Family Program units. Confidentiality and privacy of the interviewees were guaranteed. 14

A cross-sectional study was carried out with the baseline data of a cohort study designed to investigate intimate partner violence and adverse maternal and perinatal outcomes. 14 The study population consisted of all (1,133) pregnant women aged 18-49 years in the third trimester of pregnancy registered in the Family Health Strategy (Health Family Program – HFP and Community Health Workers Program). After informed consent was obtained, data were collected by trained female interviewers between July 2005 and March 2006. The interview was most often performed at a healthcare unit, but some interviews were conducted in the interviewee’s home at the woman’s request.

Common mental disorders (CMD) include depression and anxiety and were evaluated by using the 20-item Self-Reporting Questionnaire (SRQ-20). The SRQ-20 was developed in 1980 by Harding et al to screen for CMD in primary health care settings. 10 It is composed of 20 “yes” or “no” questions – four on physical symptoms and 16 on psycho-emotional disturbances. The psychometric qualities of the SRQ-20 have been assessed in Brazil. 16 In the analysis of the data, one point was awarded for each positive answer and zero for each negative answer. The cut-off point in the SRQ-20 for this study was set at 7/8 16 and the women were divided into two groups: non-cases of mental disorders (a score less than or equal to seven) and cases of mental disorders (a score equal to or greater than eight).

The questions relating to partner violence were developed by the international team of the WHO multi-country study on women’s health and domestic violence. 9 As in all other countries, the Brazilian/Portuguese questionnaire was independently back-translated and discussed during interviewer training and piloting. Intimate partners were defined as being the partner or ex-partner with whom the woman lived or used to live, regardless of a formal union, including current partners with whom they maintain sexual relations. Therefore women could report partner violence even if they were not with a partner at the time of the antenatal interview. To identify IPV, the questions characterized physical violence as physical aggression or use of objects or weapons to produce injuries; psychological violence as threatening behavior, humiliation and insults; and sexual violence as sexual intercourse imposed using physical force or threats and imposition of acts that were considered humiliating. IPV was considered positive, if the woman answered “yes” to at least one of the questions that comprise each type of violence. A three level variable was used to describe the exposure to violence in pregnancy: none; psychological violence alone; physical or sexual with or without psychological violence.

Other variables described in the literature as being associated with CMD and IPV were investigated: age (18-24; ≥ 25), living with a partner at present (yes; no), years of schooling (0-4; ≥ 5), race/skin color (white and non-white) and employment status (unemployed versus others). The quality of the relationship with the current or most recent partner 15 was measured using two variables: communication with the current or most recent partner and the controlling behavior of the current or most recent partner. The ‘‘communication with the current or most recent partner’’ variable comprised four questions to evaluate how they talk about what has happened to them during the day: things that have happened to him in his day; things that have happened to her in her day; her worries or feelings and his worries or feelings. It was considered good when they talk about what has happened to them during the day and about worries or feelings (yes for all questions), and poor when conversation does not occur (no to one or more of the questions). For controlling behavior, a point was assigned to each of the following items: husband tries to keep her from seeing friends, tries to restrict contact with her family of birth, insists on knowing where she is at all times, ignores her and treats her indifferently, gets angry if she speaks to another man, is often suspicious that she is unfaithful, and expects her to ask permission before seeking health care for herself. The partners were considered to be not controlling (0), moderately controlling (one to three points) and very controlling (four to seven points). Self-reported personal history of common mental disorders was assessed (yes, no).

Analysis was performed with Stata for Windows (version 10.1). Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals of the association between CMD, forms of IPV during pregnancy, and with sociodemographic and other characteristics of participants. This analysis was carried out with 1,120 women. Potential confounding factors were chosen on the basis of published reports and the results of analysis of sociodemographic and other characteristics of the sample.

The research was approved by the Ethics Committee of the Universidade Federal de Pernambuco (Protocol 303/2004).


The study achieved a high response rate (98.8%) and 1,120 of the 1,133 eligible pregnant women completed the interview. A total of 347 (31.0%; 95%CI 28.3;33.8) reported some type of IPV during pregnancy. The most frequent form of partner violence was psychological (16.5%; 95%CI 14.4;18.8).

Sociodemographic variables were strongly associated with CMD, with the exception of age and race/skin color ( Table 1 ). CMD were more likely in women not living with a partner at the interview, with lower education and who were unemployed. Poor communication with the current or most recent partner, very controlling behavior by the partner and history of mental illness before pregnancy showed statistically significant associations with CMD.

Table 1 Sociodemographic and other characteristics of the sample and their association with common mental disorders, odds ratio (OR) and confidence intervals (95%CI). Municipality of Recife, Northeastern Brazil, 2005-2006. 

Variable Women with common mental disorders
n % n % OR 95%CI p
Age (years)             0.085
  18-24 227 20.3 110 48.5 1    
  ≥ 25 893 79.7 376 42.1 0.77 0.6;1.0  
Race/skin color             0.124
  White 224 20,0 87 38.8 1    
  Non-white 896 80.0 399 44.5 1.26 0.9;1.7  
Living with partner             0.022
  Yes 968 86.4 407 42.0 1    
  No 152 13.6 79 52.0 1.49 1.0;2.1  
Years of schooling             0.001
  0-4 268 23.9 140 52.2 1    
  ≥ 5 852 76.1 346 40.6 1.60 1.2;2.1 0.014
Employment status              
  Unemployed 195 17.4 100 51.3 1.47 1.1;2.0  
  Others 925 85.6 386 41.7 1    
Communication with partner             0.002
  Good 786 7.20 318 40.5 1    
  Poor 334 29.8 168 50.3 1.49 1.1;1.9  
Controlling behavior of the partner              
  None 329 29.4 91 27.7 1   < 0.0001
  Moderate 575 51.3 262 45.6 2.19 1.6;2.9  
  Very 216 19.3 133 61.6 4.19 2.9;6.0  
History of mental illness             < 0.0001
  No 985 87.9 393 39.9 1    
  Yes 1,351 12.1 93 68.9 3.33 2.3;4.9  

All forms of violence were more frequent in unemployed women, who were not living with a partner, had four or fewer years of schooling, had a very controlling partner, had poor communication with a partner, and history of mental illness before pregnancy (data not shown).

The prevalence of CMD for the sample was 43.1% (95%CI 40.2;46.1) and 71.0% of women who reported physical or sexual with or without psychological violence in pregnancy had CMD ( Table 2 ).

Table 2 Association of common mental disorders with controlling behavior of the partner, forms of partner violence during pregnancy and history of mental health. Municipality of Recife, Northeastern Brazil, 2005-2006. 

Variable Women with common mental disorders
n % n % Unadjusted OR 95%CI Adjusted OR 95%CIa
Controlling behavior of the partner                
  None 329 29.4 91 27.7 1   1  
  Moderate 575 51.3 262 45.6 2.19 1.6;2.9 1.73 1.3;2.3
  Very 216 19.3 133 61.6 4.19 2.9;6.0 2.29 1.5;3.5
  p         < 0.0001 0.0001
Forms of violence                
  None 773 69.0 261 33.8 1   1  
  Psychological alone 185 16.5 110 59.5 2.88 2.1;4.0 2.49 1.8;3.5
  Physical or sexual with and without psychological 162 14.5 115 71.0 4.80 3.3;6.9 3.45 2.3;5.2
  p         < 0.0001 < 0.0001
History of mental illness                
  No 985 87.9 393 39.9 1   1  
  Yes 135 12.1 93 68.9 3.33 2.3;4.9 3.04 2.0;4.6
  p         < 0.0001 < 0.0001

Odds ratio were first adjusted for marital status, years of schooling, employment status, communication with current or most recent partner, controlling behavior of current or most recent partner and for history of mental illness. The association of marital status, years of schooling, employment status, communication with current or most recent partner showed in the univariate analysis ceased to be statistically significant in the multivariate analysis. The final model (controlling behavior of current or most recent partner, IPV and for history of mental illness) was highly statistically significant (LRSc 2 = 151.75; p < 0.0001) and the association between CMD and IPV during pregnancy remained after adjustment for controlling behavior of current or most recent partner. Women who reported physical or sexual, with or without psychological, violence showed the highest association (OR = 3.45, 95%CI 2.3;5; LRSc 2 = 53.21) with CMD ( Table 2 ).


We found that CMD were associated with psychological violence during pregnancy (OR = 2.49, 95%CI 1.8;3.5), even when it occurred without physical or sexual violence. Women who reported all forms of IPV showed the highest association (OR = 3.45; 95%CI 2.3;5.2) with CMD.

As far as we are aware this is the first population-based study designed specifically to investigate the association between CMD and psychological, physical or sexual violence against women by their intimate partners during pregnancy. As in previous studies, 18 psychological IPV was much more common than physical or sexual violence. IPV is commoner in women with limited schooling and living in poverty 18 so the high frequency of partner violence found could reflect the characteristics of the community we studied.

Several strengths of this study need to be highlighted. Our large sample was recruited from Health Family and Community Health Workers’ Programs with an excellent response rate. It provided a representative community sample of poor people in this setting. We used an internationally recognized questionnaire that takes a non-judgmental and more acceptable approach to this sensitive subject. 9 , 15 Also, we were able to adjust for a large number of possible confounding factors, including the woman’s report of pre-pregnancy mental illness.

Some limitations are also important to consider. The prevalence of CMD might seem high but it is similar to previous studies in lower-middle-income countries, 7 and in Brazil. 21 The threshold we used was established in previous validation studies. 16

The cross-sectional design limits the establishment of a possible causal relationship between IPV and CMD. It is possible that women with CMD at pregnancy had exaggerated the level of violence as a result of their mental status, and this could have led to an overestimate of the observed association. On the other hand, it is possible that violence was under-reported because of the associated stigma and shame. 5 Furthermore, mental illness before pregnancy could have been a result of earlier partner violence, so our adjustment could have led to an underestimate of the strength of association. Episodes of IPV tend to be severe and repeated, with a pattern of continuity. 3 , 24 , 26

Lastly, the interpretation that controlling behavior by the partner is a violent act is controversial. 22 We have made a theoretical distinction between violence and unequal gender power relations, and so we have adjusted for controlling behavior by the partner. Focus groups in Brazil have suggested that Brazilian women with low or high educational levels welcome some controlling behavior as a form of attention or even affection by the partner. 22 However, we recognize the potential for overlap between some aspects of psychological violence and this measure of relationship quality. If so, our adjustment would have led to an underestimate in our reported association between experience of psychological violence in pregnancy and common mental disorders in pregnancy, so we believe that this finding is robust. 14

The mental suffering of women in the antenatal period is important in its own right. During pregnancy women experience physical and emotional changes and the effect of psychological violence could be exacerbated. Castro et al 3 (2003), in México, and Silva et al 24 (2011), in Brazil, showed a decrease in physical violence followed by an increase in psychological violence during pregnancy. Even though psychological violence does not leave visible marks, it can interfere with the woman’s relationship with motherhood and may lead to poor mental health for the child. 19

Violence during pregnancy is found to be strongly associated with stress. 2 A study in North Carolina, United States, found that women who were victims of sexual or physical violence before or during pregnancy had higher levels of depression than those who were not. 17

In our study, most cases of IPV were inflicted by the fathers of their offspring. This probably increased women’s vulnerability since many of them were economically dependent of their partners. Negative feelings are very common among aggressed women, such as fear that a physical aggression reaches the belly and also of early losses consequent to the aggression and premature labor. Moreover, to be assaulted by someone with whom you are emotionally involved can trigger feelings of helplessness, low self-esteem and depression. 14

Our results have both clinical and public health implications. Antenatal care could provide an opportunity to detect CMD and IPV. 3 , 4 Beside the identification of abused women, it is necessary that a social network such as referral to shelters, transitional housing, legal advice, psychological support 25 and women’s empowerment protocols be available. 20 , 25 Also, health care services should have closer relationships with governmental and non-governmental women’s organizations working on violence. 20 , 25

Interventions that might prevent maternal mental health problems or help to treat its consequences should reduce the considerable burden of CMD experienced by the woman and the health services.


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aPrefeitura da Cidade do Recife. Plano Municipal de Saúde 2006-2009. Recife saudável: inclusão social e qualidade no SUS. Recife; 2006.

Received: May 9, 2012; Accepted: October 10, 2013

Correspondence : Ana Bernarda Ludermir. Hospital das Clínicas. Av. Prof. Moraes Rêgo, s/n Bloco E 4º andar Cidade Universitária. 50670-901 Recife, PE, Brasil. E-mail:

This study was supported by the Departamento de Ciência e Tecnologia da Secretaria de Ciência, Tecnologia e Insumos Estratégicos , and the Conselho Nacional de Desenvolvimento Científico e Tecnológico (Process 403060/2004-4 and 473545/2004-7).

The authors declare that there are no conflicts of interest.

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