Children and Youth Services Review 33 (2011) 2103–2111

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Children and Youth Services Review

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c h i l d yo u t h

The impact of emotional and physical violence during pregnancy on maternal and
child health at one year post-partum
Sarah McMahon a,⁎, Chien-Chung Huang a, Paul Boxer b, Judy L. Postmus a
a
School of Social Work, Rutgers University, 536 George Street, New Brunswick, NJ, United States
b
Department of Psychology, Rutgers University, 101 Warren Street, Newark, NJ, United States

a r t i c l e i n f o a b s t r a c t

Article history: Intimate partner violence (IPV) during pregnancy is increasingly recognized as having a negative impact on
Received 10 March 2011 both the mother and her unborn child. The current study extends previous work to examine the impact of
Received in revised form 6 June 2011 both physical and emotional IPV separately and cumulatively on the mother and her child. Specifically, we
Accepted 7 June 2011
used the Fragile Families dataset (N = 3961) to determine the effect of emotional and physical IPV on women
Available online 13 June 2011
and children at one year postpartum. Analyses revealed that both physical and emotional victimization have
Keywords:
independent and negative impacts on mothers and their children. Emotional victimization was associated
Intimate partner violence (IPV) with poorer overall health for the mother, elevated maternal depression, poorer overall health for the child,
Pregnancy and difficult child temperament. Experiencing a combination of physical and emotional victimization resulted
Maternal and child health in more problematic outcomes. Implications for practice and research are discussed.
© 2011 Elsevier Ltd. All rights reserved.

1. Introduction
Researchers are increasingly turning their attention to intimate
partner violence (IPV) that occurs during pregnancy due to its potential
for particularly devastating consequences for both the woman and her
unborn baby (Taylor & Nabors, 2009). In a meta-analytic review,
Gazmararian et al. (1996) found that between one and 20% of pregnant
women experience some form(s) of IPV (including physical, psycho-
logical and sexual abuse), with an average finding of between four and
eight percent. Obtaining accurate information on the prevalence of IPV
during pregnancy is challenging due to a number of factors including
different or narrow definitions of IPV, lack of screening by healthcare
providers, inconsistent use and type of screening tools, and under-
reporting by survivors. Even national data systems such as the Center for
Disease Control's (CDC) Pregnancy Risk Assessment Monitoring System
(PRAMS) are viewed as providing inconclusive information about the
prevalence of IPV during pregnancy for women in the U.S. due to these
methodological challenges (GAO, 2002; Silverman, Decker, Reed, & Raj,
2006).
The extant research literature is unclear in specifying the nature of the
relationship between pregnancy and IPV, with some studies reporting
that women are at an increased risk for abuse to begin or escalate during
pregnancy, and other studies suggesting that the level of abuse might
actually decrease (see Jasinski, 2004, and Taylor & Nabors, 2009, for
reviews). Regardless of the direction of the relationship between IPV and
⁎ Corresponding author. Tel.: + 1 732 932 7520x164; fax: + 1 732 932 8181.
E-mail addresses: smcmahon@ssw.rutgers.edu (S. McMahon),
chuang@ssw.rutgers.edu (C.-C. Huang), pboxer@rutgers.edu (P. Boxer),
postmus@ssw.rutgers.edu (J.L. Postmus).
pregnancy, there is growing consensus that when abuse occurs, there are
serious consequences for the health of mothers and their unborn children
(see Sharps, Laughon, & Giangrande, 2007, for a systematic review). Such
consequences include injuries sustained from the abuse, (Rachana,
Suraiya, Hisham, Abdulaziz, & Hai, 2002), premature labor (Huth-Bocks,
Levendosky, & Bogat, 2002; Reichman, Teitler, Garfinkel, & McLanahan,
2001), and miscarriage (Fanslow, Silva, Whitehead, & Robinson, 2008).
Additionally, IPV may also result in the death of the mother or the fetus
(Campbell et al., 2003; Chambliss, 2008).
Although the literature addressing the problem of IPV during
pregnancy is growing, there remain several important areas needing
further research. One key issue is that many studies focus solely on
physical abuse during pregnancy without assessing the impact of other
forms of IPV such as psychological abuse. In fact, non-physical abuse
during pregnancy has thus far been regarded as a largely ignored area of
research (Bell, Busch-Armendariz, Sanchez, & Tekippe, 2008). This occurs
despite the recognition in the larger IPV literature that psychological
abuse is a widespread and devastating form of victimization with
detrimental consequences for women's long term health and mental
health (Coker et al., 2002). Measuring psychological abuse is admittedly
challenging, however, as it is a personal and subjective experience that
may be defined differently by individuals. Hence, researchers struggle
with how to address this issue empirically (Kelly, 2004). Additionally,
those studies that include measures of both physical and psychological
abuse during pregnancy often report the results collectively, without
distinguishing the significance of each form of violence, or their
interaction (Bailey & Daugherty, 2007; Jasinski, 2004). Those studies
that do look separately at psychological abuse often focus on prevalence
or socio-demographic correlates among pregnant women, without
assessing the impact on mothers and children. Increasingly, research on

0190-7409/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.childyouth.2011.06.001
2104 S. McMahon et al. / Children and Youth Services Review 33 (2011) 2103–2111
children's exposure to violence has taken up the issue of whether and
how multiple forms of violence and victimization produce independent
or additive effects on children's psychological and social adjustment (e.g.,
Boxer & Terranova, 2008; Mrug, Loosier, & Windle, 2008). Extending this
line of inquiry to mothers' experiences during pregnancy will provide a
fuller picture of how different sorts of violence in the home impact child
development.
A second gap is that the research investigating the impact of IPV
during pregnancy typically focuses on health outcomes for the mother
and fetus during or immediately after pregnancy; however, there is a
lack of information as to the longer term impact, especially on children.
Given research illuminating the intergenerational transmission of
aggressive, antisocial, and to some extent violent behavior (Huesmann,
Dubow, & Boxer, 2010), as well as studies highlighting the long-term
impact of aversive familial and related social experiences during early
and middle childhood (Huston & Ripke, 2006), it will be useful to slide
the window of inquiry to an earlier period of development in order to
examine the potential enduring effects of violence during pregnancy. As
such, the purpose of this study is to assess the impact of both physical
and psychological abuse during pregnancy on maternal and child health
and mental health outcomes at one year post-birth.
2. Literature review
2.1. Definitions, prevalence, and correlates of IPV during pregnancy
The definition of IPV varies widely, but is commonly conceptualized
as a pattern of coercive behaviors in a relationship whereby one person
uses tactics of power and control over the other person over a period of
time (Danis & Bhandari, 2010). The Centers for Disease Control defines
IPV as public health problem, including physical, sexual, emotional or
psychological abuse as well as threats of harm (CDC, 2009). Others have
emphasized the need to include financial abuse, controlling behaviors
and coercion as forms of IPV (Stark, 2007).
Perinatal IPV is defined as abuse that occurs before, during, or after
pregnancy up to one year postpartum (Sharps et al., 2007). Research
consistently indicates that pregnant women experience multiple forms
of abuse during pregnancy, with psychological abuse most frequently
reported (Macy, Martin, Kupper, Casanueva, & Guo, 2007). Some studies
indicate that women are three times as likely to experience psycholog-
ical abuse during pregnancy as they are to experience physical abuse
(Bailey & Daugherty, 2007), while other studies indicate psychological
abuse occurring more or less frequently. For example, Charles and
Perreira's (2007) analysis of data from a selected sample of the larger
Fragile Families sample found that 1.7% of women experienced physical
abuse compared to 7.5% who reported psychological abuse.
IPV may best be understood using an ecological framework in which
risk factors for IPV can be organized at the individual (self-system),
micro-, exo-, and macrosystem levels (Bronfenbrenner, 1979; Heise,
1998). For example, exposure to violence as a child or other individual
factors (e.g., impulsivity, emotional lability) might place adults at risk of
becoming victims or perpetrators of IPV. At the microsystem level, men
may perpetrate violence against their pregnant partners due to
increased stress over having to support a baby, anger over an unplanned
pregnancy, and jealousy that their partner's attention might have
shifted to the baby (Brewer & Paulsen, 1999; CDC, 2007). Exosystem
factors such as poverty, communitywide norms supporting the use of
violence, or lack of resources for pregnant women and/or struggling
families are also risk factors for IPV. Finally, at the macrosystem level, IPV
may result in part because of the patriarchal context of our society,
whereby men utilize various tactics to control and dominate women
and families (Bell & Naugle, 2008; Dobash & Dobash, 1979).
A number of studies have investigated correlates of IPV during
pregnancy, often with a focus on the socio-demographic characteristics
of the mother. Consistently, researchers have found that women of a
younger age, lower education, and lower income levels are at greater
risk for IPV both generally and during pregnancy (see review by Taylor &
Nabors, 2009). The role of race and ethnicity is less well understood,
with some studies finding that African-American women are more
at risk (Chu, Goodwin, & D'Angelo, 2010; Silverman et al., 2006), while
others have found Hispanic women more likely to experience IPV
during pregnancy (Charles & Perreira, 2007). There is a call to further
investigate the role of race and ethnicity in the occurring of IPV both
generally, and specific to pregnancy (Taylor & Nabors, 2009). Other
studies have documented the role of family dynamics as playing a
significant role in the risk of IPV during pregnancy, with women more at
risk when they are not married or co-habitating (see Taylor & Nabors,
2009), are separated or divorced (Chu et al., 2010), report negative
interactions with the baby's father, and receive less support from the
father (Sagrestano, Carroll, Rodriguez, & Nuwayhid, 2004).
2.2. Impact of IPV during pregnancy on mother
There is a substantial body of literature demonstrating negative
health outcomes for women experiencing IPV during pregnancy. These
outcomes not only impact the mother, but may impact her unborn child.
In addition to the negative impact of IPV on women's health generally,
specific physical health outcomes for mothers who experience IPV
during pregnancy include complications from physical assaults on the
pregnant abdomen (Rachana et al., 2002), infectious complications
(Chambliss, 2008), increased likelihood of premature labor due to
placenta abruptions (Huth-Bocks et al., 2002; Rachana et al., 2002), and
miscarriage (Fanslow et al., 2008). Mothers experiencing IPV have been
found to have later entrance into prenatal care (Huth-Bocks et al., 2002)
and insufficient weight gain during pregnancy (Shadiagan & Bauer,
2004). Women who are abused during pregnancy are also at increased
risk for homicide (Campbell et al., 2003) which has been identified as
the leading cause of pregnancy related death (Shadiagan & Bauer, 2005).
Additionally, mothers who experience IPV during pregnancy are
shown to be at increased risk for mental health problems, including PTSD
(Stampfel, Chapman, & Alvarez, 2010) and depression (Lipsky, Holt,
Easterling, & Critchlow, 2004; Manzolli et al., 2010; Martin et al., 2006).
Pregnant women are already at increased risk for depression, but the
experience of violence is shown to significantly increase this risk
(Manzolli et al., 2010). This is of particular concern because depression
during pregnancy can impair the attachment between a mother and her
fetus and/or infant, which may then lead to problems in the child's
cognitive, social, psychological and behavioral development (Martin et al.,
2006; Misri & Kendrick, 2008).
Those researchers who have studied both physical and psychological
abuse separately to determine their independent impact on women's
health during pregnancy have found that both are detrimental. For
example, in their study of 104 pregnant Appalachian women, Bailey and
Daugherty (2007) found that both physical and psychological abuse
separately increased the risk of mothers engaging in damaging health
behaviors during pregnancy including tobacco and alcohol use. Similarly,
Morland, Leskin, Block, Campbell, and Friedman (2008) found that both
physical and psychological abuse during pregnancy each separately
increased the risk of miscarriage within a sample of 118 women in a
clinic/hospital sample. In particular, they found that violence severity was
a strong predictor of miscarriage, especially for those women with a PTSD
diagnosis. The authors point out the challenge of sorting out physical and
psychological abuse, especially when occurring with other risk factors.
Therefore, they call for future research to include comparison groups
without histories of mental health issues such as PTSD. In another study
with 95 pregnant women, Martin et al. (2006) found that psychological
aggression occurring during pregnancy, even low-level, was associated
with maternal depression during pregnancy, measured by the CES-D, a
validated scale assessing clinical levels of depression. Those women
experiencing multiple forms of abuse (physical, psychological and sexual)
had higher levels of depression. However, the authors note that recall
and response bias may have occurred, and therefore call on researchers to
 S. McMahon et al. / Children and Youth Services Review 33 (2011) 2103–2111
engage in longitudinal studies to follow women during pregnancy to
better understand the relationship between IPV, pregnancy and
depression.
2.3. Impact of IPV during pregnancy on fetal/child health
Most studies of the impact of IPV during pregnancy on the child
focus on fetal health. Although there have been conflicting findings,
the research generally indicates negative outcomes. A recent meta-
analysis by Shah and Shah (2010) concluded that premature birth of
the fetus and low birth weight were significantly associated with IPV
during pregnancy. Additionally, IPV during pregnancy has been
associated with fetal injury and even death (Chambliss, 2008).
Other studies have emphasized the role of IPV in combination with
other risk factors such as depression or PTSD as having the most
significant relationship with poor birth outcomes for the child (Rosen,
Seng, Tolman, & Mallinger, 2007), while other researchers have
identified possible mediating variables to explain the relationship,
such as a mother's level of stress, smoking, and substance abuse (see
Campbell, Garcia-Moreno, & Sharps, 2004).
There are few studies examining the impact of pregnancy related IPV
on the health of the child past birth. These studies address the issue
indirectly by documenting problematic relationships between mothers
who were abused during pregnancy and their infants during the first
year postpartum, which in turn may lead to challenges for the child's
wellbeing. In particular, there are a number of studies asserting that IPV
leads to poor mother-infant attachment, which can lead to problems in
child development. For example, Zeitlin, Dhanjal, and Colmsee's (1999)
study with 38 women found that those experiencing abuse during
pregnancy had weaker mother-fetal and mother-infant attachment
than their non-abused counterparts. Through interviews with 206
women, Huth-Bocks, Levendosky, Theran, and Bogat (2004) found that
women who experienced IPV during pregnancy, compared to those who
did not, reported less secure attachments to their infants, perceived
their infants in more negative ways, and viewed themselves as less
competent caregivers. Similarly, in their study with adolescent mothers,
Quinlavin and Evans (2005) found an independent, negative effect of
IPV during pregnancy on maternal attachment with their infants, as well
as an increased likelihood for mothers to rate their infant's tempera-
ment as difficult.
In addition to poor attachment, other negative effects have been
documented on new mothers' abilities to care for their infants after
experiencing IPV during pregnancy. For example, women experiencing
IPV are more likely than are other mothers to ask their doctors about
problems their infants are having during the first six weeks after delivery
(Ellis et al., 2008). The authors explain that it is unclear from this study
whether the newborns are actually experiencing a greater number of
problems or whether the mothers are more concerned about their child
due to safety concerns. Hence, more research is needed to better
understand this phenomenon. In another study, Casanueva and Martin
(2007) found that among 88 low-income women, mothers who
experienced physical or sexual violence during pregnancy had higher
child abuse potential scores on the Child Abuse Potential Inventory (CAPI)
than did a non-abused comparison group at one month post-delivery. The
authors note that the study does not indicate a causal relationship
between IPV and child abuse, however, so further work is needed in this
area.
Together, these studies suggest that IPV during pregnancy affects not
only the health of the mother and child during pregnancy, but also post-
partum. Many of the consequences of IPV for women and their children
during and after pregnancy can be devastating and life-threatening.
Given the seriousness of this issue, there is clearly a need for further
investigation to better understand the relationship between IPV during
pregnancy, health and mental health of the mother, and health and
temperament of the child. Additionally, more information is needed to
determine the role of psychological and physical abuse independently as
2105
well as additively. Many studies on IPV during pregnancy have been
conducted on small, community-based samples, so further research
with a larger representative sample is warranted.
3. Current study
The purpose of the current study is to explore the relationship
between IPV during pregnancy and health outcomes for the mother
and child post partum. Specifically, we focus on examining the role of
both physical and psychological IPV, and build upon the work of
others such as Charles and Perreira (2007) to look at each of these
forms of abuse separately and cumulatively. We extend their work by
looking not only at the outcomes on the mother at one year post
partum, but also at the health and well being of the child at one year.
Similarly, we use the Fragile Families dataset but rely on a broader
sample. We also include a number of key covariates, including
education level, relationship history with the father, fertility history,
family structure, and gender and age of the child.
4. Methodology
4.1. Data
The data for this paper come from the first and second waves of the
Fragile Families and Child Wellbeing Study, a longitudinal study
designed to provide comprehensive information on characteristics of
unmarried parents and outcomes for child well-being. The data were
collected in 20 U.S. cities with populations over 200,000 via stratified
random sampling (see Reichman et al., 2001, for detailed research
design). The initial interviews with the mother were conducted at the
time of the baby's birth between 1998 and 2000. The baseline data
contained 4898 mothers (3712 unmarried and 1186 married). The
second wave data were collected when the child was, on average, 15-
months old. Out of the 4898 eligible mothers at baseline, 4364 were
interviewed at year 1; of those mothers, 403 were dropped from the
analysis due to incomplete data. The final sample of this paper included
3961 mothers with complete information on all variables at both waves.
4.2. Measures
4.2.1. Dependent variables
Mother's health and mental health are measured by two dimensions:
overall health and depression. The overall health of mothers was assessed
by the question of “In general, how is your health?” The possible
responses were “excellent,” “very good,” “good,” “fair,” and “poor,” coded
as “5,” “4,” “3,” “2,” and “1,” respectively. Depression within the year after
the child was born was measured by the Composite International
Diagnostic Interview Short Form (CIDI-SF; Walters, Kessler, Nelson, &
Mroczek, 2002). The study identified mothers who admitted feeling sad,
blue, or depressed, or who reported losing interest in most things, for at
least a 2-week period. These mothers were subsequently asked seven
questions related to those feelings, indicating whether they lost interest in
most things, felt tired or lower on energy than usual, gained or lost 10 lb
without trying, had trouble falling asleep, had trouble concentrating, felt
down, and had thoughts about death. Consistent with the CIDI-SF scoring
method, mothers who reported experiencing three or more items were
counted as having a major depressive episode.
Child's outcomes were measured by the child's overall health and
temperament, both reported by the mother. The overall health of
children was assessed by the question “In general, would you say your
child's health is?” The possible responses and coding were the same as
the ones used in the mother's overall health, meaning the possible
responses were “excellent,” “very good,” “good,” “fair,” and “poor,”
coded as “5,” “4,” “3,” “2,” and “1,” respectively. Maternal perception of
child temperament was assessed using a 6-item scale at year 1: child
tends to be shy, often fusses and cries, is very sociable (reverse coded),
2106 S. McMahon et al. / Children and Youth Services Review 33 (2011) 2103–2111

is easily upset, reacts strongly when upset, and is very friendly with and age. For mother's depression, logit regression was used because
strangers (reverse coded). The scores ranged from 1 (not at all like my the outcome of the variable was categorical variable with two values:
child) to 5 (very much like my child); higher scores indicate a more yes (1) or no (0). For the three dependent variables (mother's overall
difficult temperament. health, child's overall health and temperament), separate ordinary least
square (OLS) regressions were used to examine the effects of indepen-
4.2.2. Independent variables dent variables on the outcomes.
Independent variables included maternal and child's characteristics
from baseline survey data. Maternal characteristics include physical
and emotional victimization experienced during pregnancy, race and 5. Results
ethnicity, age, education, relationship with the father, fertility history,
and family background. 5.1. Descriptive statistics
Intimate partner violence was measured in two dimensions:
physical and emotional victimization. A total of three items were used The descriptive statistics for the explanatory variables are presented
to assess victimization; two from the baseline survey and one from in Table 1. A total of 5.6% of mothers experienced physical victimization
the Year 1 data. From the baseline survey, physical victimization was and 29.4% reported emotional victimization during pregnancy. The
indicated by the item “He hit or slapped you when he was angry” percentage of mothers who experienced both physical and emotional
and emotional victimization was indicated by the item “He insulted or victimization was 3.6%. With respect to other socioeconomic charac-
criticized you or your ideas”. There were three possible responses for teristics, nearly half of the sample was African American (48.7%),
each item: “never” “sometimes,” and “often.”, that we coded as “0”, “1”, followed by Hispanic (26%) and Non-Hispanic White (22%). The
and “2”, respectively. Mothers were asked to report the frequency with majority of the mothers were between the ages of 20 and 29 at time
which the child's father committed these types of behavior during the of the birth, while 19% and 22% of mothers were 19 years or younger or
last month prior to the interview, which occurred in the hospital after 30 years or older, respectively. Approximately two-thirds of the sample
delivery. For mothers who were not romantically involved with the had at least a high school diploma. A total of 38.8% of the sample
child's father, the timeframe for the items was the last month of their reported that the birth was the mother's first child, and 42.3% of mothers
relationship. An additional item from the Year 1 survey asked mothers had lived with both of their biological parents when they were 15.
whether they were ever cut, bruised, or seriously hurt in a fight with the Regarding child characteristics, close to half were boys (53.1%), and the
father during pregnancy. This item was used along with the baseline mean age of child at Year 1 interview was 15-months.
item to measure physical victimization. Because all types of violence are A total of 22.4% of mothers were married to the child's biological
important and the fact that only small portion of mothers reported often father and 37.6% of them were cohabiting with the father when the child
physical or emotional victimization (about 1% and 4%, respectively), was born. Another 27.2% of mothers were romantically involved with
we combined “sometimes” and “often” into a “yes” category. Hence, if the father. A total of 12.8% of the sample were not in a relationship with
participants indicated that they experienced physical aggression either the father at the time of the interview, so for this group we were unable
sometimes or often from either the baseline survey or the Year 1 survey, to determine if the victimization occurred immediately prior to or
they were coded as “yes” for physical IPV; if they indicated sometimes or during pregnancy. We removed this group from the analysis and found
often experiencing emotional aggression from the baseline survey they that there were no significant changes in the results. Given that perinatal
were coded as “yes” for emotional IPV. IPV is often defined as including the year prior to and year after birth, we
Four dummy-coded variables represented race and ethnicity: non- decided to include this group as well.
Hispanic white, non-Hispanic black, Hispanic, and other race. Age was
measured in 3 groups: 16–19, 20–29, and 30 and above. The level of Table 1
education was specified in 3 categories: less than a high school degree, Characteristics of explanatory variables.
high school degree, and some college and above. Relationship status
Percent or mean (S.D.)
with the child's father at baseline was classified into four mutually
Mother's characteristics
exclusive categories: not involved, romantically involved, cohabited,
Physical victimization [%] 5.6
and married. Fertility history was assessed by whether the child was Emotional victimization [%] 29.4
the first birth (1 = yes, 0 = no). Family structure was measured based Both physical and emotional victimization [%] 3.6
on its citation within the literature as having a significant impact on Race [%]
other outcomes such as lower educational achievement and behav- Non-Hispanic White 21.8
Black 48.7
ioral problems (Amato, 2005; McLanahan & Sandefur, 1994). This Hispanic 25.9
variable was based on a single item, “Were you living with both of Other race 3.6
your biological parents when you were 15?” (1 = yes, 0 = no). The Age at baseline [%]
characteristics of child included gender (1 = boy, 0 = girl) and age, ≤19 18.6
20–29 59.3
measured in months.
≥30 22.1
Educational attainment at baseline [%]
4.3. Analytical approaches Below high school 33.5
High school 30.8
Regression analyses were used to assess the effects of the Above high school 35.7
Relationship status at baseline [%]
independent variables on dependent variables. The model specification Not Involved 12.8
was represented by the following equation, with the βs representing the Romantically Involved 27.2
estimated coefficients, and ε as the error term: Cohabit with Father 37.6
Married 22.4
Y = X1 β1 + X2 β2 + ε First Birth [%] 38.8
Lived in two-parent family at 15 [%] 42.3

Y represents one of mother's health or child's outcomes as described Child's characteristics

above. X1 represents the characteristics of the mother, which include Age at year 1 (Month) 14.9 (3.6)
domestic violence, socioeconomic characteristics, fertility history, and Boy [%] 53.1
N 3961
family background. X2 represents child characteristics such as gender
 S. McMahon et al. / Children and Youth Services Review 33 (2011) 2103–2111 2107

Table 2 during pregnancy. Overall, the majority of the mothers reported

Physical and emotional abuse by mother's characteristics. good health (mean = 3.9 out of 5). About 12% of mothers reported
Physical Emotional Both experiencing depression in the previous year. Significant differences
on maternal health were observed for mothers with different types of
All [%] 5.6 29.4 3.6
Race IPV. Mothers who had experienced physical or emotional victimiza-
Non-Hispanic White 3.4 27.2 2.3 tion were more likely to have poorer health than were mothers who
Black 5.3 30.2 3.3 reported no abuse. Likewise, mothers who reported physical and
Hispanic 7.5 29.0 4.9
emotional victimization were more likely to experience depression
Other race 8.3 34.0 5.6
F-test 5.8⁎⁎⁎ 1.4 3.6⁎ than were mothers who had no physical and emotional victimization.
Age at baseline With respect to children's outcomes, mothers reported generally
≤19 6.6 28.7 4.1 good health of their children (mean = 4.5 out of 5), and modest child
20–29 5.7 27.8 3.6 temperament score (mean = 2.6 out of 5). Significant associations
≥30 4.1 34.1 3.1
between child outcomes and domestic violence were observed.
F-test 2.6+ 6.1⁎⁎ 0.6
Educational attainment at baseline Mothers who reported physical or emotional victimization reported
Below high school 7.9 28.7 4.7 that their children had poorer overall health than did the children of
High school 5.1 30.5 3.5 mothers who had not experienced abuse. Mothers who reported
Above high school 3.4 29.1 2.5
emotional victimization rated their children's temperament as more
F-test 12.1⁎⁎⁎ 0.5 5.1⁎⁎
Relationship status at baseline difficult than did mothers who reported no emotional victimization.
Not involved 12.5 36.0 9.9 There was no relation between child temperament score and physical
Romantically involved 5.6 27.3 3.1 victimization.
Cohabit with mother 5.4 29.2 3.1
Married 1.9 28.4 1.3
F-test 23.2⁎⁎⁎ 4.5⁎⁎ 24.9⁎⁎⁎
First birth
5.3. Predictors of maternal health and child's outcomes
No 6.5 30.8 4.3
Yes 4.1 27.1 2.4 5.3.1. Maternal health outcomes
F-test 10.1⁎⁎ 6.4⁎ 9.7⁎⁎ Table 4 presents the regression estimates for maternal health at year 1,
Lived in two-parent family at 15
as predicted by factors measured at baseline. Looking at mother's overall
No 5.9 30.4 3.8
Yes 5.1 28.0 3.2 health at (Column 1), emotional victimization significantly and negatively
F-test 1.3 2.7 1.3 affected mother's health. For mothers who reported experiencing
Note: N = 3961.
emotional victimization, their overall health would reduce by 0.07 points
⁎ p b .05. compared to mothers who reported no emotional victimization. The
⁎⁎ p b .01. effect of physical victimization was nonsignificant. As for the control
⁎⁎⁎ p b .001. variables, mothers who were Hispanic had poorer health than did white
mothers. Mothers who had a high school education or below were found
Table 2 presents the percentages of physical and emotional to have poorer health than were mothers with a college education.
victimization by the mother's characteristics. Those mothers who Married mothers had better health than mothers who were not involved
were significantly more likely to report physical victimization were with the father of the child. Mothers who reported that the birth was their
those with less than a high school education, who were not involved first also had better health than other mothers. The child's age also had
with the baby's father, for whom the target birth was not their first, positive effects on maternal health.
and who were members of minority groups. For emotional victimi-
zation, mothers who were over 30 years old, not involved with the
baby's father, and beyond their first birth reported more abuse.
Mothers who were more likely to report experiencing both forms of Table 4
Determinants of mother's health at year 1.
victimization were those with less than a high school education, not
involved with the baby's father, beyond their first birth, and who were Overall health Depression
members of minority groups. B S. E. p Odds S. E. p

Mother's characteristics
5.2. Level of maternal health and child's outcomes at year 1 Physical abuse − 0.06 0.07 1.56 0.29 *
Emotional abuse − 0.07 0.03 * 1.34 0.14 **
Table 3 presents the descriptive statistics for maternal health and Non-Hispanic Black − 0.06 0.04 0.95 0.13
child's outcomes at year 1, by emotional and physical aggression Hispanic − 0.23 0.04 *** 0.85 0.13
Other race − 0.20 0.08 * 0.85 0.25
Age b 20 0.06 0.06 0.95 0.18
Table 3 Age 20–29 0.02 0.04 1.03 0.14
Maternal health and child's outcomes by physical and emotional victimization. Below high school − 0.34 0.04 *** 0.92 0.12
High school − 0.16 0.04 *** 0.90 0.12
Mother Child Romantically involved 0.07 0.05 0.88 0.14
Cohabit with mother 0.07 0.05 0.79 0.12
Health Depression Health Temperament
Married 0.18 0.06 ** 0.61 0.11 **
Total sample 3.90 (0.94) 0.12 (0.33) 4.50 (0.79) 2.58 (0.77) First birth 0.12 0.03 *** 0.74 0.09 **
Physical victimization Lived in two-parent family at 15 0.04 0.03 0.84 0.09
No 3.91 (0.94) 0.12 (0.32) 4.51 (0.79) 2.57 (0.76)
Yes 3.72 (0.99) 0.20 (0.40) 4.27 (0.91) 2.66 (0.81) Child's characteristics
F-test 8.9⁎⁎ 13.4⁎⁎⁎ 19.1⁎⁎⁎ 2.8 Age at year 1 (Month) 0.01 0.00 * 1.01 0.01
Emotional victimization Boy − 0.02 0.03 0.96 0.09
No 3.93 (0.94) 0.11 (0.31) 4.53 (0.78) 2.53 (0.76) Constant 3.88 0.09 *** – – –
Yes 3.85 (0.96) 0.15 (0.36) 4.42 (0.83) 2.69 (0.77) Log likelihood – − 1444.0
F-test 6.7⁎⁎ 12.7⁎⁎⁎ 15.2⁎⁎⁎ 32.9⁎⁎⁎ R-square 0.05 –

Note: N = 3961. ⁎p b .05, ⁎⁎p b .01, ⁎⁎⁎p b .001. Note: + p b .10, *p b .05, **p b .01, ***p b .001.
2108 S. McMahon et al. / Children and Youth Services Review 33 (2011) 2103–2111

Table 5 health than did mothers who were white. Teenage mothers tended to
Determinants of children's health at year 1. report better child health than did mothers aged 30 and above. Mothers
Overall health Temperament who had a high school education or below were found to report poorer
child's health than mothers with a college education. Marriage and first
B S. E. p Odds S. E. p
birth tended to have positive effects on child overall health as well. As for
Mother's characteristics
child characteristics, boys were reported to have poorer overall health
Physical abuse − 0.13 0.06 * − 0.05 0.05
Emotional abuse − 0.09 0.03 ** 0.15 0.03 *** than were girls.
Non-Hispanic Black − 0.09 0.04 * 0.15 0.03 *** Emotional victimization also significantly affected child tempera-
Hispanic − 0.22 0.04 *** 0.07 0.04 * ment. For mothers who reported experiencing emotional victimization,
Other race − 0.13 0.07 0.16 0.07 * the score of child's temperament increased by 0.15 points compared to
Age b20 0.11 0.05 * 0.13 0.04 **
Age 20–29 0.03 0.03 0.11 0.03 ***
mothers who reported no emotional victimization. Physical victimiza-
Below high school − 0.22 0.03 *** 0.23 0.03 *** tion, however, had no effects on child's temperament after controlling
High school − 0.07 0.03 * 0.10 0.03 ** for emotional victimization. As for other variables, we observed a
Romantically involved 0.03 0.04 − 0.07 0.04 pattern of results similar to the ones found for child overall health.
Cohabit with mother 0.07 0.04 − 0.07 0.04
Mothers who were a member of minority, young, or with low education
Married 0.12 0.05 * − 0.09 0.05
First birth 0.08 0.03 ** − 0.22 0.03 *** tend to report high child temperament scores than their counterparts. In
Lived in two-parent family at 15 − 0.04 0.03 0.01 0.03 contrast, mothers who were married or had first birth are more likely to
report low child temperament scores than their counterparts. Age of the
Child's characteristics child had positive effects on the temperament score.
Age at year 1 (Month) 0.00 0.00 0.01 0.00 ***
Boy − 0.12 0.02 *** − 0.04 0.02
Constant 4.67 0.08 *** 2.22 0.07 ***
R-square 0.05 0.07 5.3.3. Joint impact of physical and emotional victimization
Note: + p b .10, *p b .05, **p b .01, ***p b .001. In order to examine the joint effects of physical and emotional
victimization on maternal health and child's outcomes, a combined
variable of physical and emotional victimization with four categories
With respect to maternal depression, both physical and emotional (no physical and emotional victimization, no physical but emotional
victimization significantly increased the likelihood of depression at year 1. victimization, physical but no emotional victimization, and both physical
For mothers who reported physical victimization, the odds of depression and emotional victimization) was created and examined in separate
increase by 56% compared to mothers who reported no physical regressions. The results are presented in Fig. 1. For simplicity, Fig. 1 lists
victimization. Likewise, for mothers who had emotional victimization, the estimates of combined physical and emotional victimization variable
the odds of depression increase by 34% compared to mothers who on standardized scores of four outcome variables. We observed evidence
reported no emotional victimization. For other variables, as expected, of the combined effects of physical and emotional victimization on
married mothers had a lower likelihood of depression than mothers who maternal health and child's outcomes. Substantial differences were
were not involved with father of the child. First birth also had an effect on detected in a number of areas. For maternal overall health, the estimated
reducing depression likelihood compared to a second or later birth. score for mothers who had both physical and emotional victimization
(−0.24 [pb .10]) was considerably worse than other groups (range from
5.3.2. Child's health outcomes −0.12 to 0.03). For maternal depression, the standardized scores were
The regression findings of child's outcomes are listed in Table 5. For the worst for mothers experienced only physical victimization (0.25)
child's overall health (column 1), both physical and emotional forms of [pb .01] or had both physical and emotional victimization (0.24) [pb .01],
victimization were significant and negative predictors. For mothers who followed by mothers had only emotional victimization (0.06) [pb .01].
experienced physical victimization, their child's overall health would With respect to child's overall health, the combined effect was also
reduce by 0.13 points compared to mothers who reported no physical evident. For example, the overall health score of children whose mothers
victimization. For mothers who reported emotional victimization, their had both physical and emotional victimization was the worst (−0.31
child's overall health would reduce by 0.09 points compared to mothers [p b .01]), compared to those whose mothers only had physical
who reported no emotional victimization. As for other variables, victimization (0.25 [pb .010]) or only emotional victimization (−0.07
mothers who were Black or Hispanic reported their children had poorer [pb .001]).

0.3

0.2
Standardized Scores

0.1

0 Mother Health

Depression
-0.1
Child Health
-0.2
Temperament

-0.3

-0.4
No Victimization Only Emotional Only Physical Both Victimizations
Victimization Victimization

Fig. 1. Effects of emotional and physical victimizations on maternal and child outcomes.
 S. McMahon et al. / Children and Youth Services Review 33 (2011) 2103–2111
6. Discussion
While we know that IPV during pregnancy is detrimental to mothers
and their children in many ways, there are still a number of areas needing
further exploration. Specifically, we wanted to add to the literature by
looking at the occurrence of not only physical victimization during
pregnancy but also emotional victimization, which is often neglected in
the research literature yet occurs more frequently. Additionally, we
wanted to learn more about the impact of physical and emotional
victimization and their combination on the health of the mother and her
child at one year post partum.
Similar to other studies using large samples, we found a greater
prevalence of emotional victimization (29%) than physical victimization
(6%) among our sample of pregnant women. A total of 4% reported
experiencing both emotional and physical victimization. These percent-
ages are slightly higher than comparable studies, such as Charles and
Perreira's (2007) previous analysis of Fragile Families data, which found
1.7% of women reported physical abuse and 7.0% reported emotional
abuse. However, this may be due to methodological differences, as Charles
and Perreira (2007) utilized only part of the Fragile Families sample, and
did not use Year 1 data to retrospectively obtain data about violence
during pregnancy. Additionally, the measure of physical and emotional
abuse in the Fragile Families battery is quite limited and should be
interpreted with caution. Despite the higher percentages found in our
study, the prevalence of physical and emotional victimization in our study
is still smaller than is found in many community-based samples (e.g.,
Bailey & Daugherty, 2007). Despite these differences, our results indicate
an alarming amount of victimization experienced by women who are
pregnant. This underscores the need for an increased awareness of the
issue and the implementation of effective screening and intervention
techniques, particularly in health care settings or places where pregnant
women may access services both prior to delivery as well as post-partum.
The research and practice literature has consistently called for universal
IPV screening and comprehensive screening for pregnant women in
all healthcare settings (Sharps et al., 2007), and the results of this study
highlight this as an urgent action item for the healthcare agenda. In their
systematic review of the literature, O'Reilly, Beale, and Gillies (2010)
found some evidence that regular and repeated screening of IPV during
pregnancy increases the identification of the issue, and that interventions
may be beneficial to a number of outcomes, including reducing the
amount of violence experienced by victims. However, the authors note
that there is still a great deal of work to be done to identify effective
screening techniques and evidence-based intervention strategies. In
particular, information is needed to determine whether screening for IPV
and interventions are effective in positively impacting long term impacts
on the mother and child's health.
Our results confirm other research findings that IPV prior to and
during pregnancy has a negative impact on both the mother and child
(Sharps et al., 2007), and we extend these findings by including the
child's health at one year post partum. Overall, emotional victimiza-
tion was significantly associated with poorer outcomes in all four
areas (mother's health, mother's depression, child's health and child's
temperament). Physical victimization was negatively associated with
two outcomes, maternal depression and child's health, with larger
effects than emotional victimization in these areas. While complex,
this is an especially important finding, as it indicates that indeed,
emotional victimization significantly contributes to poor maternal
and child health outcomes on its own, and not just coupled with
physical victimization. Combined with the fact that nearly one-third
of the pregnant women in the sample reported emotional victimiza-
tion, this finding highlights the urgent need to more fully understand
its occurrence and impact. Given the dearth of information on
emotional abuse within the literature and practice settings, additional
research is needed to unpack its relationship to short and long term
health, both with pregnant and non-pregnant women and their
children. The larger effects found with physical victimization indicate
2109
that it also remains a critical issue for pregnant women, and that
screening must truly be comprehensive to account for both types.
Another important finding from this study is the combination of
physical and emotional victimization resulted in more negative out-
comes. These findings suggest that occurrence and accumulation of abuse
are important factors to consider when working with pregnant women.
Screening tools must be carefully constructed not only to assess whether
abuse is occurring, but to collect further qualitative information about the
frequency and co-occurrence with other forms of abuse, which may assist
practitioners with interpreting the potential risk. Additionally, interven-
tions designed for pregnant women experiencing IPV need to take
into account the various ways in which abuse manifests itself both with
frequency and type.
Our analyses also revealed a demographic pattern, with worse
outcomes for women who were Black or Hispanic, obtained a high school
education or less, and were young (except for the child's overall health,
which found younger mothers reporting better health). Marriage and first
birth were both positively associated with these outcomes. These results
are consistent with other research that has found low educational level,
young age, non-married status, and racial/ethnic minority membership to
be risk factors for IPV during pregnancy (Taylor & Nabors, 2009). This
highlights the importance of targeted research and interventions designed
to better understand the needs of these groups and the factors that
increase risk for experiencing IPV during pregnancy. In particular, these
findings suggest the role of larger socio-structural factors – such as
poverty, education, and racism – in creating vulnerability to IPV. Further
research should carefully consider the role of these demographic factors,
as well as others that were not included in this study. This also suggests
the need for further research and practice to be culturally sensitive and
modified to address the potential risk and protective factors particular to
various communities.
6.1. Limitations and future research
There are a number of limitations which should be considered when
interpreting the findings from this study. First, the measurement of
emotional and physical abuse in the Fragile Families study was quite
limited and only asked about a few behaviors. In particular, the item
used to measure emotional abuse is far from ideal, and fails to capture
the true range of behaviors that comprise this experience. We know that
abuse manifests in numerous ways and our reliance on only a few
indicators likely excluded a variety of other types of emotional and
physical abuse, as well as other forms of violence such as sexual and
financial. Additionally, our study only asked about abuse occurring
during a short time period (one month), when it is possible that women
experienced abuse outside this timeframe during their pregnancy. This
suggests that the actual prevalence of pregnancy associated abuse may
likely be larger than captured by our study. This type of problem is
common for larger scope studies, which tend to ask fewer questions
about IPV (Bailey & Daugherty, 2007).
An important next step would be for larger scale studies to include a
comprehensive inventory of carefully worded abusive behaviors to
capture the spectrum of abuse as well as including a longer period of time.
Further research can also examine whether the timing of IPV during the
perinatal period is significant, and whether abuse occurring prior to, or
during each of the three trimesters results in different outcomes for the
mother and child. Following participants longitudinally to assess when
the abuse occurred in relationship to the pregnancy is needed. This is
especially important to be able to compare the impact of separate forms of
abuse with cumulative or co-occurring types of abuse.
Selective attrition may have also biased the results. To investigate the
influence of sample attrition on the findings, baseline characteristics of the
final sample and the dropped cases were examined. The results showed
that there were no differences by mother's age or education between
the final sample and the dropped cases; however, the dropped cases
were significantly more likely than the final-sample cases to be African
2110 S. McMahon et al. / Children and Youth Services Review 33 (2011) 2103–2111
American. Given that in the extant literature, this group typically has
reported different rates of domestic violence rates compared to other
racial/ethnic groups, this selective attrition might have effects on
the estimates of the prevalence of domestic violence reported here.
Additionally, our study was limited in measuring only a few degrees of the
frequency and severity of victimization. While our findings indicate
that these may be important factors, the limited scope of our assess-
ment warrants future work to attempt to more clearly analyze these
distinctions.
Our study provides a foundation for understanding the impact of
emotional and physical abuse on the health and well being of mothers
and their children after one year past birth. An important extension of
this work would be to conduct longitudinal research to determine if the
negative impact on mothers and children's health is sustained over an
even longer period of time, as well as exploring possible mediating and
moderating variables. Expanding the outcomes used to measure physical
and mental health for mothers is important as well. For example, post-
partum depression (PPD) is common among women in general, and
further exploring the link between IPV during pregnancy and PPD is
needed (Valentine, Rodriguez, Lapeyrouse, & Muyu, 2011).Additionally,
further understanding the direction of the relationship among negative
health and mental health, IPV, and pregnancy needs further attention,
as establishing causality is challenging. Further, while there is some
evidence that poor health of the mother can result in problematic
relationships with infants and caretaking, additional studies are needed
to examine this issue and its complexities.
Lastly, this study focused largely on characteristics of the mother that
may be related to increased risk of IPV during pregnancy and negative
outcomes for the health of herself and her child. While it is important to
better understand factors that put women at risk of experiencing IPV, it
is also critical to understand the factors that increase the abuser's risk of
perpetration during this time. From a prevention standpoint, it is critical
to identify pathways that lead to perpetration and to design appropriate
intervention strategies to address these needs.
7. Conclusions
Despite the limitations, this study provides important information
about the detrimental impact of both emotional and physical violence
during pregnancy on the health of mothers and children at one year
post-partum. Our findings highlight the need to broaden our consider-
ation of IPV beyond just physical abuse to understand the effects of
emotional abuse as well.
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