613346

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JIVXXX10.1177/0886260515613346Journal of Interpersonal ViolenceBarcelona de Mendoza et al.

Article
Journal of Interpersonal Violence
2018, Vol. 33(6) 938­–959
Experiences of © The Author(s) 2015
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DOI: 10.1177/0886260515613346
https://doi.org/10.1177/0886260515613346
Neighborhood Violence journals.sagepub.com/home/jiv

and Their Association

With Mental Health in
Pregnant Women

Veronica Barcelona de Mendoza,1

Emily W. Harville,1 Jane Savage,2
and Gloria Giarratano3

Abstract
Both intimate partner violence and neighborhood crime have been
associated with worse mental health outcomes, but less is known about
cumulative effects. This association was studied in a sample of pregnant
women who were enrolled in a study of disaster exposure, prenatal care,
and mental and physical health outcomes between 2010 and 2012. Women
were interviewed about their exposure to intimate partner violence and
perceptions of neighborhood safety, crime, and disorder. Main study
outcomes included symptoms of poor mental health; including depression,
pregnancy-specific anxiety (PA), and posttraumatic stress disorder (PTSD).
Logistic regression was used to examine predictors of mental health with
adjustment for confounders. Women who experienced high levels of intimate
partner violence and perceived neighborhood violence had increased odds
of probable depression in individual models. Weighted high cumulative
(intimate partner and neighborhood) experiences of violence were also

1Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
2Loyola University, New Orleans, LA, USA
3Louisiana State University Health Sciences Center, New Orleans, LA, USA

Corresponding Author:
Veronica Barcelona de Mendoza, Department of Epidemiology, Tulane University School of Public
Health and Tropical Medicine, 1440 Canal Street, Suite 2000, New Orleans, LA 70112, USA.
Email: barcelonaveronica@yahoo.com
Barcelona de Mendoza et al. 939

associated with increased odds of having probable depression when

compared with those with low violence. Weighed high cumulative violence
was also associated with increased odds of PTSD. This study provides
additional evidence that cumulative exposure to violence is associated with
poorer mental health in pregnant women.

Keywords
violence, neighborhood, intimate partner violence, mental health, pregnancy

Introduction
Women of childbearing age are at increased risk for intimate partner violence
(IPV; El Kady, Gilbert, Xing, & Smith, 2005; Silverman, Decker, Reed, &
Raj, 2006), which commonly occurs in pregnancy (James, Brody, & Hamilton,
2013), and often results in adverse mental health outcomes and serious physi-
cal injury (McFarlane, Campbell, Sharps, & Watson, 2002). IPV may include
emotional, physical, or sexual violence, and mental health outcomes become
more severe with more than one type of IPV (Lagdon, Armour, & Stringer,
2014). IPV is consistently linked to depression and other mental health issues
in pregnancy (Urquia, O’Campo, Heaman, Janssen, & Thiessen, 2011), and
increased risk for adverse birth outcomes (Shah, Shah, & Knowledge
Synthesis Group on Determinants of Preterm/LBW Births, 2010). Women
exposed to violence in pregnancy are also at increased risk of serious injury
or homicide (McFarlane et al., 2002). This risk is even higher for African
American women compared with White women (Chang, Berg, Saltzman, &
Herndon, 2005).
Neighborhood violence is an additional risk factor for poor mental health
(Aisenberg & Herrenkohl, 2008; Egan, Tannahill, Petticrew, & Thomas,
2008; Kelly & Hall, 2010; Wilson-Genderson & Pruchno, 2013). Witnessing
or experiencing neighborhood violence has been associated with depres-
sion (Clark et al., 2008; Gillespie et al., 2009; Tracy, Morgenstern, Zivin,
Aiello, & Galea, 2014), posttraumatic stress disorder (PTSD; Goldmann
et al., 2011), and anxiety (Casciano & Massey, 2012) in studies of urban
nonpregnant adults. Neighborhood violence can also be a cause of increased
stress and fraying of social ties. High levels of perceived crime have been
associated with more psychological distress (Giurgescu et al., 2015), lack
of social support, racism, and depression (Messer, Maxson, & Miranda,
2013). Low-income women are disproportionately exposed to neighbor-
hood crime and violence (Pinchevsky & Wright, 2012), and pregnancy is an
especially vulnerable time in a woman’s life. Few studies on neighborhood
940 Journal of Interpersonal Violence 33(6)

violence, however, have focused on women (Aisenberg & Herrenkohl,

2008), and none were found that included pregnant women.
There is also a paucity of published research on the cumulative effects of
violence on pregnant women at both the individual and neighborhood levels.
Exposure to multiple kinds of violence is not uncommon, and minority
women disproportionately reside in communities where stress, racism, and
violence are daily struggles (Amaro, Vega, & Valencia, 2001; Taylor &
Holden, 2009). Only three studies were identified that investigated cumula-
tive effects of violence at both the individual and neighborhood levels, results
were inconsistent, and none of these included pregnant women in their study
populations (Bogat et al., 2005; Brown, Hill, & Lambert, 2005; Clark et al.,
2008). In one study, after adjustment for IPV, witnessing neighborhood vio-
lence was associated with increased odds of high depressive symptoms com-
pared with those who never witnessed crime in their communities (odds ratio
[OR] = 2.6, 95% confidence interval [CI] = [1.4, 4.9]; Clark et al., 2008).
Others reported increased exposure to either IPV or neighborhood violence
was associated with increased PTSD symptoms, and that additive interaction
was present (as violence increased, so did trauma symptoms; Brown et al.,
2005). Finally, Bogat et al. (2005) examined the association of cumulative
violence, anxiety, depression, and PTSD using objective measures of geo-
graphic information systems (GIS) neighborhood crime data. They reported
that when community violence was present without IPV, there were no
adverse mental health outcomes; however, IPV alone was related to mental
health, regardless of objective measures of neighborhood violence (Bogat
et al., 2005).
The community context of violence and the long-term effects of natural
disasters that contribute to violence must also be considered. Poor, urban
communities are disproportionately affected by disasters and among the
slowest to recover (Davidson, Price, McCauley, & Ruggiero, 2013;
Fothergill, Maestas, & Darlington, 1999; Phillips, Thomas, Fothergill, &
Blinn-Pike, 2010). New Orleans is one example of a city that has been
plagued with violence as well as disaster, as Hurricane Katrina hit in 2005.
There is some evidence that intimate partner violence rises after disaster
(Harville, Taylor, Tesfai, Xu, & Buekens, 2011), though IPV levels were
comparable to national levels (James et al., 2013). Overall crime statistics
indicate a dip in crime in that city immediately following the disaster, then
an increase afterwards, with a leveling-off in the last few years (Federal
Bureau of Investigation, 2012). Nonetheless, New Orleans remains a city
with a high violent crime rate, and crime is a constant concern for residents
(CommonHealth ACTION, 2009). Therefore, social disempowerment, pov-
erty, unemployment, and other factors related to IPV and neighborhood
Barcelona de Mendoza et al. 941

violence may be more important considerations for maternal and child health
than simply living in a postdisaster recovery area.
Therefore, the cumulative effect of lack of safety within and outside the
home for pregnant women has not been studied extensively. The purpose of
this analysis was to examine how perceptions of crime and violence, both
intimate partner and neighborhood-wide, as well as cumulative effects of
both types of violence predicted adverse mental health outcomes in a cohort
of New Orleans pregnant women.

Method
Women (N = 398) from the metropolitan New Orleans area were recruited for
the GUMBO (Growing up Moms and Babies in new Orleans) study from
2010 to 2012. The objective of this cross-sectional study was to investigate
how models of prenatal care, self-care strategies, and stress and hurricane
recovery influence mental and physical health during pregnancy. Data were
collected between 5 and 7 years after Hurricane Katrina. Participants were
recruited from seven sites, including private prenatal clinics, University hos-
pital-affiliated clinics, and prenatal and childbirth classes. Women were
approached in clinic waiting rooms and from prenatal classes by trained data
collectors at patients’ scheduled appointments. Eligible women spoke either
English or Spanish, were between 18 and 45 years of age, had an established
prenatal care provider (at least three visits), and were currently living in the
Greater New Orleans area. Women were asked about exposure to Hurricane
Katrina, which occurred in 2005, but moving to New Orleans after the storm
did not exclude them from study participation, as the main exposure of inter-
est in the original study was the effects of living in the postdisaster recovery
environment. Informed consent was obtained in the preferred language of the
client, and Spanish interviews were conducted by fully bilingual and bicul-
tural data collectors. Participants’ responses to survey questions were
recorded on paper questionnaires. The study was carried out according to
protocol and institutional review board (IRB) approval was obtained from
affiliated Universities and hospitals. Three women were missing data on
crime or race, leaving 398 for analysis.

Exposure Assessment
The main exposures of interest were intimate partner violence and neighbor-
hood violence. Intimate partner violence was assessed using items from the
Centers for Disease Control and Prevention’s Pregnancy Risk Assessment
Monitoring System (PRAMS) questionnaire (2009). Physical and emotional
942 Journal of Interpersonal Violence 33(6)

Question Response options

CS1. How Very Somewhat Somewhat Very
satisfied are dissatisfied dissatisfied satisfied satisfied
you with police
protection
in your
neighborhood?
CS2. How Very often Fairly Not too Hardly ever Never
often are there often often
problems with
muggings,
burglaries,
assaults, or
anything
else like
that in your
neighborhood?
CS3. How Not a Not too A fairly A very
much of a serious serious a serious serious
problem is problem problem problem problem
the selling
and using of
drugs in your
neighborhood?
CS4. If you Yes No Not sure
witnessed a
serious crime,
would you
report it to the
police?
CS5. In the Safer Less safe About the
past year, same
do you feel
that your
neighborhood
has become:
CS6. Do you Yes No
have a weapon
for your own
or your family’s
safety?

Figure 1.  Crime and safety questionnaire items.

Barcelona de Mendoza et al. 943

abuse during pregnancy was assessed using six “yes/no” questions. Three
questions addressed physical abuse (whether their partner hit, hurt her, or
forced sexual activity), and three questions addressed emotional abuse and
issues of control (whether their partner threatened, frightened, or tried to con-
trol her). Positive responses of abuse were summed for each domain (physi-
cal and emotional abuse), and ranged from zero to three, with 0 = none, 1
indicator = some, 2 or more yes responses = high.
Perception of neighborhood violence, crime, and safety were also assessed.
Women were asked to rate their perceptions of life in the city and expecta-
tions for the city’s future. The majority of the questions were taken from the
Kaiser Family Foundation (2007) survey “Giving Voice to the People of New
Orleans.” Questions on crime were taken from both general community sur-
veys (e.g., How satisfied are you with police services? SOSNA/NAC/CDC
Public Safety Committee, n.d.) and previous studies of neighborhood influ-
ences on well-being (Ajrouch, Reisine, Lim, Sohn, & Ismail, 2010; Earls,
Brooks-Gunn, Raudenbush, & Sampson, 1994). Additional questions asked,
“If you witnessed a serious crime, would you report it to the police?” and
“Have you bought a weapon for your own or your family’s protection?”
(Questions and response options are provided in Figure 1).
A cumulative violence exposure index was then created to measure overall
lack of safety. To achieve this, we first performed factor analysis on the six
questions for intimate partner violence and the six questions for neighborhood
violence. Intimate partner violence indicated two factors, consistent with the
scale construction: emotional and physical violence. Overall intimate partner
violence was summed across all six questions and reported on the same scale
as the individual violence measures (0 = none, 1 indicator = some, 2 or more
yes responses = high). Three factors were indicated for neighborhood vio-
lence: “Perceived neighborhood safety” (Figure 1: CS1-3 and 5), “Reporting”
(CS4), and “Weapon ownership” (CS6). Weapon possession was unrelated to
any of the outcomes studied as well as minimally related to other indicators of
violence exposure, and was excluded from further analysis. “Perceived neigh-
borhood safety” was created by dichotomizing each of the contributing vari-
ables to high/low, then summing the four questions to develop a total scale.
Total neighborhood violence was created by weighting the “Perceived neigh-
borhood safety” and “Reporting” factors equally, then summing and creating
tertiles (equal weighting). The cumulative violence indicator was then calcu-
lated by summing the average score on the neighborhood and the intimate
partner violence scales. A weighted cumulative violence indicator was also
created by weighting the beta coefficient associated with the total neighbor-
hood and total intimate partner violence scales. Finally, scores for each scale
were converted to tertiles (low, medium, high).
944 Journal of Interpersonal Violence 33(6)

Outcome Assessment
The primary study outcomes were depression, PA, and PTSD. The Edinburgh
Postnatal Depression Scale (EDS) was used to assess symptoms of depres-
sion and has been validated for use in pregnancy in English and Spanish
(Alvarado-Esquivel, Sifuentes-Alvarez, Salas-Martinez, & Martinez-Garcia,
2006), with a Cronbach’s alpha of .76 (Adouard, Glangeaud-Freudenthal, &
Golse, 2005) and .85 (Adewuya, Ola, Dada, & Fasoto, 2006) in two diverse
populations. The EDS is not a diagnostic measure but instead a screening tool
that indicates “probable” or “likely” depression. Probable depression was
defined as EDS score greater than 12 (Matthey, Henshaw, Elliott, & Barnett,
2006). PA was assessed using the Revised Prenatal Distress Questionnaire
(Yali & Lobel, 1999) and was dichotomized (high score >17; top quintile) as
others have done (Clements & Bailey, 2010) to identify the women with the
highest prenatal anxiety. Cronbach’s alphas were reported between .80 and
.81 among diverse groups internationally (Alderdice, Lynn, & Lobel, 2012).
The PTSD checklist (PCL-S) is the posttraumatic checklist, which asks about
symptoms related to a stressful experience. Ventureyra, Yao, Cottraux, Note,
and De Mey-Guillard (2002) reported a Cronbach’s alpha of .86 for the
PCL-S (Ventureyra et al., 2002). PTSD symptoms were dichotomized at 50
(Andrykowski, Cordova, Studts, & Miller, 1998).
We utilized the validated Spanish language versions of the EDS and PCL-
S; the PCL-S in Spanish was found to be functionally equivalent to the
English (Miles, Marshall, & Schell, 2008). The Revised Prenatal Distress
Questionnaire was translated into Spanish, as no validated instrument was
available. All instruments in Spanish were then examined for discrepancies
with the original English versions by two independent, fully bilingual review-
ers. We also calculated the reliability for the EDS, PA, and PCL-S instru-
ments in our sample, and alpha ranged from .86 to .92. Among participants
who only spoke Spanish, the alpha coefficient was .83, .71, and .92, respec-
tively (n = 57).

Statistical Analysis
The relationship between intimate partner violence and neighborhood vio-
lence with mental health outcomes was assessed as follows. First, descriptive
data and frequencies were computed, and then bivariate associations were
tested using chi-square and Fisher’s exact tests. Second, unadjusted and
adjusted multivariable logistic regression was employed to examine relation-
ships between each aspect of intimate partner violence and neighborhood
violence as well as the overall lack of safety variable was examined as a
Barcelona de Mendoza et al. 945

predictor of mental health outcomes. Third, both intimate partner violence

and neighborhood violence were included in the same models. Finally, we
calculated a cumulative measure of total violence, which incorporated both
intimate partner and neighborhood violence to examine effects on mental
health. Potential confounders (age, race, education, marital status, and smok-
ing) were identified by a priori knowledge of the literature and included in
multivariable models. Smoking during pregnancy was assessed via one ques-
tion, “What is the average number of cigarettes that you smoke each day?”
Responses were then categorized into yes/no groups for smoking during
pregnancy. Missing data for covariates was dealt with using multiple imputa-
tion; most commonly missing was income for 6% (18) of participants. Due to
a questionnaire error, for some participants, one question on the EDS was
omitted and another was repeated. The mean was imputed based on the other
EDS questions for these participants (n = 89). All analyses were conducted
using SAS 9.3 (Cary, NC).

Results
The study population was largely in their 20s, majority African American,
unmarried, and low-income (Table 1). The median and mean gestational
age at interview was 31 weeks. Twelve percent of women interviewed
reported intimate partner violence. The majority of respondents said that
their neighborhoods were about the same or safer than last year. Nearly
one third of participants stated that they were somewhat or very dissatis-
fied with police protection in their neighborhoods and that muggings
occurred fairly or very often. Almost a third of the women in this sample
had probable depression (EDS > 12), while fewer had high PA (> 17 and
less commonly, symptoms of PTSD (PCL .50). All study participants
lived in the metropolitan area within 5 years of the Hurricane Katrina’s
landfall. Approximately 10% of the women who did not report living in
New Orleans before Hurricane Katrina reported some degree of exposure
to the storm, most likely due to living in other affected areas, or because
friends or relatives were affected. In addition, there was no interaction
found for main outcomes of interest by hurricane-survival status (data not
shown).
Unadjusted and multivariable (adjusted) logistic regression was conducted
next to investigate the associations between intimate partner violence and
mental health outcomes (Table 2). Women who experienced some and high
physical violence had higher odds of probable depression compared with
women who reported no physical violence in both unadjusted and adjusted
models. Similarly, women who reported some or high emotional intimate
partner violence were more likely to have probable depression than women
946 Journal of Interpersonal Violence 33(6)

Table 1.  Study Population.

N %
Age category
  1 = <20 62 15.6
  2 = >20-25 119 29.9
  3 = >25-30 116 29.2
  4 = >30 101 25.4
Race/ethnicity
  White non-Hispanic 105 26.4
  Black non-Hispanic 227 57.0
 Hispanic 66 16.6
Education
  Less than high school 89 22.5
  High school 111 28.0
  Greater than high school 196 49.5
Relationship status
 Married 111 28.2
  Living with partner 115 29.2
  Single, divorced, or 168 42.6
widowed
Annual income
 <US$15,000 193 51.7
 US$15,000-US$30,000 76 20.4
 >US$30,000 104 27.9
Parity
 Primipara 236 60.2
 Multipara 156 39.8
Smoke
 Yes 37 9.3
 No 360 90.7
How quickly returned to New Orleans
  <1 year 162 40.7
  1-2 years 120 30.2
  3-4 years 68 17.1
  5+ years 48 12.1
Lived in New Orleans prior to Katrina
 Yes 277 69.6
 No 121 30.4
Serious experiences of the hurricane
  Three or more 72 18.1
  Less than three 326 81.9

Note. Percentages may not sum to 100 due to missing data.

 Table 2.  Unadjusted and Adjusteda Multivariable Logistic Regression of Intimate Partner Violence and Mental Health Outcomes
(N = 398).
Probable Depression PTSD Pregnancy-Specific Anxiety

Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted

N % OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Overall intimate partner violenceb

  None (0) 344 86.7 Reference Reference Reference Reference Reference Reference
  Some (1) 32 8.1 4.45 [2.11, 9.40] 3.92 [1.71, 9.02] 2.57 [0.90, 7.30] 1.75 [0.56, 5.46] 2.39 [1.07, 5.32] 2.15 [0.89, 5.20]
  High (≥2) 21 5.3 9.75 [3.47, 27.41] 13.97 [4.43, 44.07] 5.55 [1.97, 15.65] 6.61 [1.90, 22.95] 1.64 [0.58, 4.67] 1.69 [0.54, 5.29]
Physical intimate partner violencec
  None (0) 365 91.9 Reference Reference Reference Reference Reference Reference
  Some (1) 21 5.3 4.49 [1.81, 11.16] 4.78 [1.76, 13.00] 5.41 [1.93, 15.15] 4.83 [1.48, 15.76] 3.19 [1.27, 8.04] 3.06 [1.13, 8.27]
  High (≥2) 11 2.8 27.62 [3.49, 218.57] 27.54 [3.17, 239.45] 5.07 [1.27, 20.31] 5.43 [1.14, 26.01] 1.95 [0.5, 7.55] 1.85 [0.41, 8.25]
Emotional intimate partner violencec
  None (0) 360 90.7 Reference Reference Reference Reference Reference Reference
  Some (1) 21 5.3 4.53 [1.82, 11.28] 4.41 [1.62, 11.97] 1.24 [0.28, 5.60] 1.15 [0.24, 5.53] 1.13 [0.37, 3.48] 1.07 [0.32, 3.58]
  High (≥2) 16 4.0 8.37 [2.64, 26.58] 14.20 [3.91, 51.49] 3.93 [1.19, 12.99] 4.83 [1.12, 20.76] 1.60 [0.5, 5.13] 2.01 [0.54, 7.50]

Note. PTSD = posttraumatic stress disorder; OR = odds ratio; CI = confidence interval.

aAdjusted for age, race, education, marital status, and smoking.
bSum of “yes” responses for physical and emotional intimate partner violence.
cSum of three questions, range 0-3.

947
948 Journal of Interpersonal Violence 33(6)

who did not report emotional violence. Women who had high levels of total
intimate partner violence were more likely to have probable depression, in
both unadjusted and adjusted models. Those who experienced some or high
levels of physical intimate partner violence had significantly higher odds of
PTSD compared with those with none. Women who reported high levels
of emotional intimate partner violence also had significantly higher odds of
PTSD. Total intimate partner violence was significantly associated with
PTSD for women experiencing high violence compared with none. Total inti-
mate partner violence was not significantly associated with PA; however,
women who reported some physical intimate partner violence were more
likely to have PA than those with none.
Next, unadjusted and multivariable (adjusted) logistic regression was uti-
lized to investigate the association between indicators of neighborhood crime
and safety and mental health outcomes (Table 3). Women who reported
medium and high neighborhood safety had significantly higher odds of prob-
able depression after adjustment for important confounders than those who
had perceived low levels of neighborhood safety. Women who were not sure
if they would or would not report a crime if they witnessed it were more
likely to have depression than those who would report a crime to police.
Similarly, medium and high total neighborhood violence were significantly
associated with increased odds of probable depression, when compared with
low neighborhood violence. Perceived neighborhood safety was not signifi-
cantly associated with PTSD although women who were not sure if they
would report a crime if witnessed or would not report a crime were more
likely to have PTSD than those who would report. High total neighborhood
violence was also significantly associated with increased odds of PTSD.
After adjustment, none of the neighborhood crime indicators were associated
with PA.
Finally, unadjusted and multivariable (adjusted) logistic regression was
used to investigate whether cumulative (intimate partner and neighborhood)
violence was associated with mental health outcomes (Table 4). Findings are
reported for both equal weighting (both types of violence weighted equally),
and for weighted cumulative violence indicators (types of violence weighted
by association with outcome). After adjustment, women with medium (mid-
dle tertile) total violence and those with high total violence (top tertile) had
increased odds of having probable depression when compared with those
with low violence (in the lowest tertile; equal weighting). Women with
medium and high total violence (weighted) had higher odds of probable
depression than those with low total violence. Findings for PTSD demon-
strated that both high total violence (equal weighting) and high total violence
(weighted) were associated with increased odds of the disorder, while there
 Table 3.  Unadjusted and Adjusteda Multivariable Logistic Regression of Neighborhood Violence Indicators and Mental Health
Outcomes (N = 398).
Probable Depression PTSD Pregnancy-Specific Anxiety

Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted

N % OR [95% CI] OR [95% CI] OR [95% CI] OR [95% CI] OR [95% CI] OR ]95% CI]

Perceived neighborhood safety

 Low 179 45.0 Reference Reference Reference Reference Reference Reference
 Medium 23 23.4 2.24 [1.27, 3.95] 1.88 [1.02, 3.48] 1.49 [0.50, 4.43] 1.10 [0.36, 3.40] 1.30 [0.65, 2.64] 1.05 [0.50, 2.19]]
 High 126 31.7 3.30 [1.98, 5.52] 2.11 [1.19, 3.72] 4.07 [1.73, 9.58] 2.32 [0.92, 5.85] 2.31 [1.28, 4.18] 1.61 [0.84, 3.08]
Would report a crime if witnessed
 Yes 265 66.9 Reference Reference Reference Reference Reference Reference
  Not sure 104 26.3 2.46 [1.51, 4.00] 1.80 [1.05, 3.07] 4.17 [1.86, 9.32] 3.47 [1.48, 8.13] 1.39 [0.78, 2.46] 1.12 [0.60, 2.09]
 No 27 6.8 6.98 [2.98, 16.35] 3.53 [1.4, 8.89] 8.02 [2.8, 22.94] 4.82 [1.53, 15.15] 1.17 [0.42, 3.27] 0.64 [0.21, 1.92]
Total neighborhood violence
 Low 130 32.7 Reference Reference Reference Reference Reference Reference
 Medium 177 44.5 4.25 [2.25, 8.03] 2.13 [1.20, 3.77] 3.12 [0.86, 11.28] 2.98 [0.96, 9.23] 1.63 [0.86, 3.11] 1.35 [0.71, 2.60]
 High 91 22.9 8.85 [4.44, 17.65] 2.70 [1.45, 5.04] 11.17 [3.20, 39.05] 6.54 [2.18, 19.57] 2.14 [1.05, 4.37] 1.12 [0.54, 2.32]

Note. PTSD = posttraumatic stress disorder; OR = odds ratio; CI = confidence interval.

aAdjusted for age, race, education, marital status and smoking.

949
950
Table 4.  Unadjusted and Adjusteda Multivariable Regression of Cumulative Violence Indicator (Total Violence) and Mental Health
Outcomes (N = 398).
Probable Depression PTSD Pregnancy-Specific Anxiety

  Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted

  OR [95% CI] OR [95% CI] OR [95% CI)] OR [95% CI] OR [95% CI] OR [95% CI]

Total violence, equal weighting

 Low Reference Reference Reference Reference Reference
 Medium 3.39 [1.88, 6.13] 2.45 [1.29, 4.65] 2.17 [0.67, 7.08] 1.45 [0.42, 5.04] 1.60 [0.80, 3.17] 1.21 [0.58, 2.53]
 High 5.53 [3.29, 9.31] 3.73 [2.13, 6.55] 7.48 [3.08, 18.15] 5.45 [2.12, 14.02] 1.81 [1.01, 3.27] 1.28 [0.67, 2.44]
Total violence, weighted
 Low Reference Reference Reference Reference Reference Reference
 Medium 2.78 [1.49, 5.20] 1.88 [0.94, 3.73] 2.08 [0.64, 6.77] 1.44 [0.42, 4.99] 1.60 [0.8, 3.17] 1.21 [0.58, 2.53]
 High 5.85 [3.5, 9.75] 4.14 [2.39, 7.19] 7.75 [3.19, 18.81] 5.54 [2.15, 14.29] 1.81 [1.01, 3.27] 1.28 [0.67, 2.44]

Note. PTSD = posttraumatic stress disorder; OR = odds ratio; CI = confidence interval.

aAdjusted for age, race, education, marital status, and smoking.
Barcelona de Mendoza et al. 951

was not a significant increased odds in medium total violence (equal weight-
ing or weighted) compared with low groups. Adjusted models did not reveal
a statistically significant association between total violence measures and PA.
As IPV and neighborhood violence are predictive of the outcomes sepa-
rately, the question arises whether a combined measure is a better predictor
than the individual measures. One possibility is that different types of vio-
lence are correlated with each other, so that the relationship observed both
represent the effect of one confounded by the other. We did not find this to be
likely, as both kinds of violence were significant when included in a single
model. Next, we examined whether a cumulative measure was more predic-
tive of the outcome than individual measures using logistic regression to
examine the area under the receiver operating curve (aROC). The predictive
power of the total violence measure was significantly better than the neigh-
borhood violence measure, and was higher but not statistically stronger than
the predictive power of the IPV model. IPV was strongly associated with
poorer mental health, but the CI was very wide due to the small number of
exposed. Therefore, the cumulative measure had better precision, but the pre-
dictive power of the model was not statistically stronger.

Discussion
In this cross-sectional study of women living in metropolitan New Orleans
between 5 and 7 years after Hurricane Katrina, we found, after adjustment for
important risk factors, that intimate partner (physical, emotional, and overall)
violence was associated with higher odds of probable depression and PTSD
and that physical domestic violence alone was associated with high odds of
PA. Indicators of neighborhood crime and safety were also significantly asso-
ciated with probable depression and PTSD. When both intimate partner vio-
lence and neighborhood crime were combined, cumulative violence (equal
weighting and weighted) was associated with increased odds of probable
depression and PTSD, but not PA.
The observed prevalence of probable depression was 30.4% in our study,
which is slightly higher than the observed EDS in two cohort studies of pri-
miparas in the Northeast. In both of those studies, women were interviewed
earlier in pregnancy (before 22 weeks gestation), compared with our study
(mean gestational age at interview = 31 weeks). Among African American
pregnant women enrolled in Project Viva (N = 113), 14.2% had EDS scores
>12 (Ertel et al., 2012). Depression was also measured in a prospective cohort
study (conducted in 2006-2007) of demographically similar New Orleans
women who were pregnant during Hurricane Katrina or soon afterwards (N =
199). In that sample, 11.6% of women had probable depression (EDS > 12;
952 Journal of Interpersonal Violence 33(6)

Xiong et al., 2008). We observed that 17.6% of participants had PA, while
others have reported that 21% to 24% of women have anxiety disorders in
pregnancy (Grant, McMahon, & Austin, 2008; Sutter-Dallay, Giaconne-
Marcesche, Glatigny-Dallay, & Verdoux, 2004). The prevalence of PTSD in
the current study was 9.2% (mean = 29.6). A study of New Orleans women
post-Katrina reported 23.1% had a PCL >50 (Xiong et al., 2008). A longitu-
dinal study (N = 119) in Hawaii assessed PTSD four times during pregnancy
and reported a mean PCL of 27.4 between 28.0 and 32.9 weeks gestation
(Onoye et al., 2013).
Our findings were consistent with previous studies (Dutton, Kaltman,
Goodman, Weinfurt, & Vankos, 2005; Hathaway et al., 2000; Pico-Alfonso
et al., 2006; Seng, Low, Sperlich, Ronis, & Liberzon, 2009) linking intimate
partner violence with adverse mental health outcomes. A secondary analysis
(N = 182) found that exposure to a combination of physical and psychologi-
cal IPV had higher rates of depression, anxiety, and PTSD symptoms (Pico-
Alfonso et al., 2006). A population-based study (N = 2,043) reported that
women who disclosed IPV had significantly increased risk of anxiety
(Relative Risk [RR] = 2.2, 95% CI = [1.1, 4.4) than those not reporting abuse
(Hathaway et al., 2000). Another sample of 1,581 nulliparous women (<28
weeks gestation) reported that women who experienced IPV had significantly
higher odds of PTSD (OR 11.9, 95% CI = [3.6, 39.9]; Seng et al., 2009).
Finally, another study (N = 406) reported that women who experienced phys-
ical and psychological abuse but little sexual violence were more likely to
have major depressive disorders (OR 2.50, 95% CI = [1.22, 5.12]; Dutton
et al., 2005) and those who also reported sexual violence were more likely to
have symptoms of PTSD than those with physical, psychological abuse but
little sexual violence (OR 2.51, 95% CI = [1.43, 4.41]).
Similarly, our finding that exposure to neighborhood violence is associ-
ated with poorer mental health in pregnancy reinforces some previous work
(Casciano & Massey, 2012; Giurgescu et al., 2015), but not all (Yang,
Kestens, Dahhou, Daniel, & Kramer, 2015). A prospective study of 95 preg-
nant African American women and found that depressive symptoms were
associated with perceived measures of neighborhood violence, including
physical disorder (r = .380, p < .01), social disorder (r = .324, p < .01), and
crime (r = .280, p < .01; Giurgescu et al., 2015). A cross-sectional study
examined the association between a neighborhood disorder scale and anxiety
symptoms among African Americans (N = 116) and reported that residents
living in projects were exposed to less neighborhood violence than nonresi-
dents and experienced fewer anxiety symptoms than nonresidents (1.76 vs.
2.06 [on a scale of 1-5], p = .01; Casciano & Massey, 2012). In contrast, Yang
et al. (2015) studied 5,337 pregnant women (24-26 weeks) and reported a
Barcelona de Mendoza et al. 953

null association between high neighborhood material (β = .65, 95% CI =

[–0.01, 1.32]) and social deprivation and psychological distress (β = .07, 95%
CI = [–0.56, 0.72]) after adjustment (Yang et al., 2015). The differences in
reported effect sizes and findings may be explained by inconsistent defini-
tions and measurement of neighborhood itself, as well as disorder and crime.
Finally, the few studies that investigated cumulative effects of IPV and
neighborhood violence on mental health have demonstrated mixed results;
two reported similar positive findings (Brown et al., 2005; Clark et al., 2008)
and one did not (Bogat et al., 2005). We found that cumulative violence was
associated with 7 to 14 times increased odds of PTSD and probable depres-
sion. Differences in findings here were likely due to variation in measure-
ment of neighborhood violence, as perception of community crime and
violence is more likely to be associated with women’s mental health than
objective measures (Giurgescu et al., 2015).
This study offers additional insight on how violence at multiple levels and
neighborhood disorder contribute to individual health and illness, and has
both strengths and limitations. Strengths include combined focus on indi-
vidual experiences of violence as well as perception of neighborhood factors.
One limitation of the study is the relatively small sample size. This was par-
ticularly the case in the highly exposed IPV group and for PTSD, and led to
unstable estimates for some ORs. In addition, social desirability bias may be
present, as women were interviewed by apparent strangers regarding crime
and safety in their neighborhoods, and may have felt pressure to respond to
questions in a socially acceptable way. We found that women who would not
report a crime if they witnessed it were more likely to have symptoms of
mental illness, which may indicate feelings of stress related to these crimes
and could have led to underreporting and possible residual confounding.
Another limitation is that we did not collect information on eligible women
who declined to participate in the study. Although we studied a convenience
sample of pregnant women, it may be that women with worse mental health
declined to participate, which would have biased our results toward the null.
Future research should include a broader description and understanding of
exposure to multiple types of violence over the life course, including cumula-
tive effects on women, and how diversity of socioeconomic status and ethnic/
racial backgrounds affect disaster recovery. Consideration of larger social
issues, such as political and social disempowerment, may improve our under-
standing of the mechanisms at play. Women who mistrust the criminal justice
system or fear for their own personal safety are not likely to report crimes,
and improved political empowerment of African Americans may be part of
the answer to improve perinatal health in disadvantaged communities (Bell,
Zimmerman, Almgren, Mayer, & Huebner, 2006).
954 Journal of Interpersonal Violence 33(6)

This research adds to the limited body of knowledge around cumulative

effects of violence on pregnant women, and has implications for improved
clinical practice. Violence occurs commonly in pregnancy, and all women
should be screened for IPV during prenatal care. We would like to propose
further recommendations that prenatal care providers in communities
affected by violence (which are also often affected by disaster) devote
increased attention to IPV screening. Providers can ascertain during prenatal
visits if there is a gun in the home as part of prenatal care and health promo-
tion for homes with young children. Further assessment of women who
screen positive for IPV should then include a lethality assessment, safety
planning, and referral to counseling services. Community-based interven-
tions are also necessary, and could include collaboration with law enforce-
ment to strengthen policies for removal of guns from homes where there is a
known history of IPV. Finally, high-quality programs for perpetrators of
abuse (Campbell, Glass, Sharps, Laughon, & Bloom, 2007) must not be
forgotten as an important intervention to support the health expectant moth-
ers and families.
Data from this study are available upon written request to the authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This article was supported by
National Institutes of Health (NIH), National Institute of Nursing Research
(NINR), 5R03NR012052-02, and National Institute of Child Health and Human
Development (NICHD) T32HD057780.

References
Adewuya, A. O., Ola, B. A., Dada, A. O., & Fasoto, O. O. (2006). Validation of
the Edinburgh Postnatal Depression Scale as a screening tool for depression in
late pregnancy among Nigerian women. Journal of Psychosomatic Obstetrics &
Gynecology, 27, 267-272.
Adouard, F., Glangeaud-Freudenthal, N. M. C., & Golse, B. (2005). Validation of
the Edinburgh Postnatal Depression Scale (EPDS) in a sample of women with
high-risk pregnancies in France. Archives of Women’s Mental Health, 8, 89-95.
Aisenberg, E., & Herrenkohl, T. (2008). Community violence in context: Risk and
resilience in children and families. Journal of Interpersonal Violence, 23, 296-315.
doi:10.1177/0886260507312287
Barcelona de Mendoza et al. 955

Ajrouch, K. J., Reisine, S., Lim, S., Sohn, W., & Ismail, A. (2010). Situational stressors
among African American women living in low-income urban areas: The role of
social support. Women & Health, 50, 159-175. doi:10.1080/03630241003705045
Alderdice, F., Lynn, F., & Lobel, M. (2012). A review and psychometric evaluation
of pregnancy-specific stress measures. Journal of Psychosomatic Obstetrics and
Gynecology, 33, 62-77.
Alvarado-Esquivel, C., Sifuentes-Alvarez, A., Salas-Martinez, C., & Martinez-
Garcia, S. (2006). Validation of the Edinburgh postpartum depression scale in a
population of puerperal women in Mexico. Clinical Practice in Epidemiological
Mental Health, 29, 2-33.
Amaro, H., Vega, R. R., & Valencia, D. (2001). Gender, context and HIV prevention
among Latinos. In M. Aguirre-Molina, C. Molina, & R. E. Zambrana (Eds.),
Health issues in the Latino community (1st ed., pp. 301-326). San Francisco, CA:
Jossey-Bass.
Andrykowski, M. A., Cordova, M. J., Studts, J. L., & Miller, T. W. (1998).
Posttraumatic stress disorder after treatment for breast cancer: Prevalence of
diagnosis and use of the PTSD checklist-civilian version (PCL-C) as a screening
instrument. Journal of Consulting and Clinical Psychology, 66, 586-590.
Bell, J. F., Zimmerman, F. J., Almgren, G. R., Mayer, J. D., & Huebner, C. E. (2006).
Birth outcomes among urban African American women: A multilevel analy-
sis of the role of racial residential segregation. Social Science & Medicine, 63,
3030-3045.
Bogat, G. A., Leahy, K., von Eye, A., Maxwell, C., Levendosky, A. A., & Davidson,
W. S. (2005). The influence of community violence on the functioning of women
experiencing domestic violence. American Journal of Community Psychology,
36, 123-132. doi:10.1007/s10464-005-6237-2
Brown, J. R., Hill, H. M., & Lambert, S. F. (2005). Traumatic stress symptoms in
women exposed to community and partner violence. Journal of Interpersonal
Violence, 20, 1478-1494.
Campbell, J. C., Glass, N., Sharps, P. W., Laughon, K., & Bloom, T. (2007). Intimate
partner homicide: Review and implications of research and policy. Trauma,
Violence, & Abuse, 8, 246-269.
Casciano, R., & Massey, D. S. (2012). Neighborhood disorder and anxiety symptoms:
New evidence from a quasi-experimental study. Health & Place, 18, 180-190.
doi:10.1016/j.healthplace.2011.09.002
Centers for Disease Control and Prevention, Division of Reproductive Health at
National Center for Chronic Disease Prevention and Health Promotion. (2009).
Pregnancy Risk Assessment Monitoring System (PRAMS). Retrieved from
http://www.cdc.gov/prams/questionnaire.htm
Chang, J., Berg, C. J., Saltzman, L. E., & Herndon, J. (2005). Homicide: A leading
cause of injury deaths among pregnant and postpartum women in the United
States, 1991-1999. American Journal of Public Health, 95, 471-477.
Clark, C., Ryan, L., Kawachi, I., Canner, M. J., Berkman, L., & Wright, R. J. (2008).
Witnessing community violence in residential neighborhoods: A mental health
956 Journal of Interpersonal Violence 33(6)

hazard for urban women. Journal of Urban Health: Bulletin of the New York
Academy of Medicine, 85, 22-38. doi:10.1007/s11524-007-9229-8
Clements, A. D., & Bailey, B. A. (2010). The relationship between temperament and
anxiety: Phase I in the development of a risk screening model to predict stress-
related health problems. Maternal Child Health Journal, 17, 1151-1157.
CommonHealth ACTION. (2009). New Orleans: Community perspectives on the root
causes of violence. Washington, DC: CommonHealth ACTION National Office.
Davidson, T. M., Price, M., McCauley, J. L., & Ruggiero, K. J. (2013). Disaster
impact across cultural groups: Comparison of Whites, African Americans, and
Latinos. American Journal of Community Psychology, 52, 97-105. doi:10.1007/
s10464-013-9579-1
Dutton, M. A., Kaltman, S., Goodman, L. A., Weinfurt, K., & Vankos, N. (2005).
Patterns of intimate partner violence: Correlates and outcomes. Violence and
Victims, 20, 483-497.
Earls, F. J., Brooks-Gunn, J., Raudenbush, S., & Sampson, R. (1994). The project
on human development in Chicago neighborhoods, community survey. U.S.
Department of Justice. Retrieved from http://www.icpsr.umich.edu/icpsrweb/
PHDCN/studies/02766
Egan, M., Tannahill, C., Petticrew, M., & Thomas, S. (2008). Psychosocial risk fac-
tors in home and community settings and their associations with population
health and health inequalities: A systematic meta-review. BMC Public Health, 8,
239. doi:10.1186/1471-2458-8-239
El Kady, D., Gilbert, W. M., Xing, G., & Smith, L. H. (2005). Maternal and neonatal
outcomes of assaults during pregnancy. Obstetrics & Gynecology, 105, 357-363.
Ertel, K. A., James-Todd, T., Kleinman, K., Krieger, N., Gillman, M., Wright,
R., & Rich-Edwards, J. (2012). Racial discrimination, response to unfair
treatment, and depressive symptoms among pregnant Black and African
American women in the United States. Annals of Epidemiology, 22, 840-846.
doi:10.1016/j.annepidem.2012.10.001
Federal Bureau of Investigation. (2012). Crime in the United States, 2012: Uniform
crime reports. Washington, DC: U.S. Department of Justice.
Fothergill, A., Maestas, E. G., & Darlington, J. D. (1999). Race, ethnicity and disas-
ters in the United States: A review of the literature. Disasters, 23, 156-173.
Gillespie, C. F., Bradley, B., Mercer, K., Smith, A. K., Conneely, K., Gapen, M.,
. . .Ressler, K. J. (2009). Trauma exposure and stress-related disorders in
inner city primary care patients. General Hospital Psychiatry, 31, 505-514.
doi:10.1016/j.genhosppsych.2009.05.003
Giurgescu, C., Zenk, S. N., Templin, T. N., Engeland, C. G., Dancy, B. L., Park, C. G.,
. . .Misra, D. P. (2015). The impact of neighborhood environment, social support,
and avoidance coping on depressive symptoms of pregnant African American
women. Women’s Health Issues: Official Publication of the Jacobs Institute of
Women’s Health, 25, 294-302. doi: 10.1016/j.whi.2015.02.001
Goldmann, E., Aiello, A., Uddin, M., Delva, J., Koenen, K., Gant, L. M., & Galea,
S. (2011). Pervasive exposure to violence and posttraumatic stress disorder in a
Barcelona de Mendoza et al. 957

predominantly African American urban community: The Detroit neighborhood

health study. Journal of Traumatic Stress, 24, 747-751. doi:10.1002/jts.20705
Grant, K. A., McMahon, C., & Austin, M. P. (2008). Maternal anxiety during the
transition to parenthood: A prospective study. Journal of Affective Disorders,
108, 101-111.
Harville, E. W., Taylor, C. A., Tesfai, H., Xu, X., & Buekens, P. (2011). Experience of
hurricane Katrina and reported intimate partner violence. Journal of Interpersonal
Violence, 26, 833-845. doi:10.1177/0886260510365861
Hathaway, J. E., Mucci, L. A., Silverman, J. G., Brooks, D. R., Mathews, R., &
Pavlos, C. A. (2000). Health status and health care use of Massachusetts women
reporting partner abuse. American Journal of Preventive Medicine, 19, 302-307.
doi:S0749-3797(00)00236-1
James, L., Brody, D., & Hamilton, Z. (2013). Risk factors for domestic violence dur-
ing pregnancy: A meta-analytic review. Violence and Victims, 28, 359-380.
Kaiser Family Foundation. (2007). Giving voice to the people of New Orleans: The
Kaiser post-Katrina baseline survey. Menlo Park, CA: Author.
Kelly, S., & Hall, L. (2010). Measuring anxiety in adolescents exposed to community
violence: A review, comparison, and analysis of three measures. Issues in Mental
Health Nursing, 31, 28-38. doi:10.3109/01612840903200027
Lagdon, S., Armour, C., & Stringer, M. (2014). Adult experience of mental health
outcomes as a result of intimate partner violence victimisation: A systematic
review. European Journal of Psychotraumatology, 5. doi:10.3402/ejpt.v5.24794
Miles, J. N. V., Marshall, G. N., & Schell, T. L. (2008). Spanish and english versions
of the PTSD checklist – civilian version (PCL-C): Testing for differential item
functioning. Journal of Traumatic Stress, 21(4), 369-376. doi:10.1002/jts.20349
Matthey, S., Henshaw, C., Elliott, S., & Barnett, B. (2006). Variability in use of cut-off
scores and formats on the Edinburgh postnatal depression scale: Implications for
clinical and research practice. Archives of Women’s Mental Health, 9, 309-315.
doi:10.1007/s00737-006-0152-x
McFarlane, J., Campbell, J. C., Sharps, P., & Watson, K. (2002). Abuse during
pregnancy and femicide: Urgent implications for women’s health. Obstetrics &
Gynecology, 100, 27-36.
Messer, L. C., Maxson, P., & Miranda, M. L. (2013). The urban built environment and
associations with women’s psychosocial health. Journal of Urban Health: Bulletin of
the New York Academy of Medicine, 90, 857-871. doi:10.1007/s11524-012-9743-1
Onoye, J. M., Shafer, L. A., Goebert, D. A., Morland, L. A., Matsu, C. R., & Hamagami,
F. (2013). Changes in PTSD symptomatology and mental health during pregnancy
and postpartum. Archives of Women’s Mental Health, 16, 453-463. doi:10.1007/
s00737-013-0365-8
Phillips, B. D., Thomas, D. S. K., Fothergill, A., & Blinn-Pike, L. (Eds.). (2010).
Social vulnerability in disasters (1st ed.). Boca Raton, FL: CRC Press.
Pico-Alfonso, M. A., Garcia-Linares, M. I., Celda-Navarro, N., Blasco-Ros, C.,
Echeburua, E., & Martinez, M. (2006). The impact of physical, psychological,
and sexual intimate male partner violence on women’s mental health: Depressive
958 Journal of Interpersonal Violence 33(6)

symptoms, posttraumatic stress disorder, state anxiety, and suicide. Journal of

Women’s Health, 15, 599-611. doi:10.1089/jwh.2006.15.599
Pinchevsky, G. M., & Wright, E. M. (2012). The impact of neighborhoods on intimate
partner violence and victimization. Trauma, Violence, & Abuse, 13, 112-132.
doi:10.1177/1524838012445641
Seng, J. S., Low, L. K., Sperlich, M., Ronis, D. L., & Liberzon, I. (2009). Prevalence,
trauma history, and risk for posttraumatic stress disorder among nulliparous
women in maternity care. Obstetrics & Gynecology, 114, 839-847. doi:10.1097/
AOG.0b013e3181b8f8a2
Shah, P. S., & Shah, J., & Knowledge Synthesis Group on Determinants of Preterm/
LBW Births. (2010). Maternal exposure to domestic violence and pregnancy and
birth outcomes: A systematic review and meta-analyses. Journal of Women’s
Health, 19, 2017-2031. doi:10.1089/jwh.2010.2051
Silverman, J. G., Decker, M. R., Reed, E., & Raj, A. (2006). Intimate partner violence
around the time of pregnancy: Association with breastfeeding behavior. Journal
of Women’s Health, 15, 934-940. doi:10.1089/jwh.2006.15.934
SOSNA/NAC/CDC Public Safety Committee. (n.d.). Resident survey on police ser-
vices. Retrieved from http://www.southphillyblocks.org/sosna/site_archive/about/
police.html
Sutter-Dallay, A. L., Giaconne-Marcesche, V., Glatigny-Dallay, E., & Verdoux, H.
(2004). Women with anxiety disorders during pregnancy are at increased risk of
intense postnatal depressive symptoms: A prospective survey of the MATQUID
cohort. European Psychiatry: The Journal of the Association of European
Psychiatrists, 19, 459-463.
Taylor, S. E., & Holden, K. B. (2009). The health status of Black women. In R. L.
Braithwaite, S. E. Taylor, & H. M. Treadwell (Eds.), Health issues in the Black
community (3rd ed., pp. 53-72). San Francisco, CA: Jossey-Bass.
Tracy, M., Morgenstern, H., Zivin, K., Aiello, A. E., & Galea, S. (2014). Traumatic
event exposure and depression severity over time: Results from a prospective
cohort study in an urban area. Social Psychiatry and Psychiatric Epidemiology,
49, 1769-1782. doi:10.1007/s00127-014-0884-2
Urquia, M. L., O’Campo, P. J., Heaman, M. I., Janssen, P. A., & Thiessen, K. R.
(2011). Experiences of violence before and during pregnancy and adverse preg-
nancy outcomes: An analysis of the Canadian maternity experiences survey.
BMC Pregnancy & Childbirth, 11, 42. doi:10.1186/1471-2393-11-42
Ventureyra, V. A., Yao, S. N., Cottraux, J., Note, I., & De Mey-Guillard, C. (2002).
The validation of the posttraumatic stress disorder checklist scale in posttraumatic
stress disorder and nonclinical subjects. Psychotherapy and Psychosomatics, 71,
47-53.
Wilson-Genderson, M., & Pruchno, R. (2013). Effects of neighborhood violence and
perceptions of neighborhood safety on depressive symptoms of older adults.
Social Science & Medicine, 85, 43-49. doi:10.1016/j.socscimed.2013.02.028
Xiong, X., Harville, E. W., Mattison, D. R., Elkind-Hirsch, K., Pridjian, G., &
Buekens, P. (2008). Exposure to hurricane Katrina, post-traumatic stress disorder
Barcelona de Mendoza et al. 959

and birth outcomes. The American Journal of the Medical Sciences, 336, 111-115.
doi:10.1097/MAJ.0b013e318180f21c
Yali, A. M., & Lobel, M. (1999). Coping and distress in pregnancy: An investi-
gation of medically high risk women. Journal Psychosomatic Obstetrics &
Gynaecology, 20, 39-52.
Yang, S., Kestens, Y., Dahhou, M., Daniel, M., & Kramer, M. S. (2015). Neighborhood
deprivation and maternal psychological distress during pregnancy: A multilevel
analysis. Maternal and Child Health Journal, 19, 1142-1151. doi:10.1007/
s10995-014-1623-8

Author Biographies
Veronica Barcelona de Mendoza, PhD, MSN, RN, APHN-BC, is an advanced prac-
tice public health nurse with a doctorate in epidemiology. She has worked in local and
international maternal and child health for several years and is currently a postdoc-
toral associate at Yale School of Nursing.
Emily W. Harville, PhD, has a doctorate in epidemiology and has worked for several
years in the area of perinatal and reproductive health. She is an expert on perinatal
health and disasters, having conducted several studies and published extensively on
the health of women and children post-Hurricane Katrina.
Jane Savage, PhD, MS, RN, CNE, LCCE, FACCE, is a seasoned nurse and educator
who has taught mental health nursing and maternal and child health nursing for more
than 30 years. She is has been involved in disaster research since 2005.
Gloria Giarratano, PhD, APRN, CNS, is an advanced practice nurse who has taught
maternal/child nursing for many years and has been involved in disaster research and
preparedness in her local community.