ANEXO 4

PAPER 1

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286

Violence during Pregnancy Presence and Severity among Women in Matosinhos - Oporto, Portugal

Abstract
Objective: The objective of this study was to explore and characterize domestic violence perpetrated
against pregnant women in Matosinhos, Portugal.
Method: A cross-sectional study to assess risk factors, health habits, psychopathology, self-esteem and
anxiety, as well the severity of domestic violence during pregnancy, was conducted on 204 women in
their third trimester of pregnancy. These women were outpatients of the Obstetrics and Gynecology
Department of Pedro Hispano Hospital, Matosinhos/Oporto, Portugal, from March of 2008 to January
2009.
Results: The study showed that one hundred and seven (58.2%) pregnant women suffered some acts of
violence during pregnancy. The prevalence of emotional, physical and sexual abuse during pregnancy
was 59.3%, 15.8% and 24.6% respectively. It was also found that women abused by their partners had
lower self-esteem and higher anxiety levels when compared with non abused pregnant.
Conclusion: From these results we concluded that a systematic involvement of all antenatal health
professionals would be necessary to effectively screen for the prevalence of violence against pregnant.
Screening would include proper psychological and medical follow-up for the women and their babies.
Keywords: anxiety. domestic violence, pregnancy, psychopathology, self-esteem.

Domestic violence is one of the most common forms of abuse against women. It is violence
perpetrated by people who have or had a relationship of kinship or affection with the women, and
generally by the current or former male intimate partner (World Health Organization (WHO), World
Report and health, 2002).
Domestic violence represents a pattern of coercive conduct towards women,(Nuez-Rivas, Monge-Rojas,
Gros-Dvila, Elizondo-Urea, & Rojas-Chavarra, 2003) which may be present in an active manner
through direct violent behaviors or passively manifested by neglecting care and affection (Magalhes,
2004).
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This coercive conduct is expressed more frequently by physical assault, psychological abuse and sexual
behaviors (Bogat, Levendosky, & Eye, 2005; Simpsa, Isabel, Cerrato, & Everaed, 2000). The physical
assault is defined by Straus (1996) as an act carried out with the intention, or perceived intention of
causing physical pain, or injury to another person. The psychological aggression consists in verbal and
nonverbal acts with intuit to hurt the other.
The sexual coercion is a behavior that is intended to compel the partner to engage in unwanted sexual
activity (vaginal, oral or anal), encompassing coercive acts ranging from verbal insistence, threats and
physical force (Straus et al. 1996).
In addition to the physical consequences, abuse during pregnancy also triggers psychological
consequences. Pregnant women who suffered domestic violence are more likely to suffer from stress,
depression and several addictions such as tobacco, alcohol and other drugs (Campbell, Garcia-Moreno, &
Sharp, 2004). Sometimes abused pregnant women may show general loss of interest in them and in their
babies, as well as in their health, either during pregnancy or after the baby is born (Campbell, Jones, &
Dienemann, 2002).
Aggression can be minor or severe. Severe was defined in the sense that they pose a greater risk of injury
that would require medical attention than the minor aggression (Straus, 2004).

Some traits of the mother or of the pregnancy have been considered as major risk factors for
violence during pregnancy. Factors such as age, race/ethnicity, low socioeconomic status, low level of
social support, prenatal care, smoking, alcohol and drug abuse, unexpected or unwanted pregnancy and
emotional instability have been identified as the most prevalent factors (Coker, Sanderson, & Dong,
2004; Cox, Kotch, & Everson, 2003; Fawole, Ajuwon, Osungbade, & Faweya, 2003; Jasinski, 2004;
Martin, Harris-Britt, Li, Moracco, Kupper, & Campbell, 2004; Stuve & O'Donnel, 2008;).
The prevalence of abuse in pregnant women ranges from 0.9% to 31.7%, according to several
international studies in both industrialized and developing countries (Campbell et al., 2004; El-Zanaty,
Hussein, Shawky, Way, & Kishor, 1996; Gazmararian, Lazorick, Ballad, Saltzman, & Marks, 1996;
Jasinski, 2004).
In Portugal, the available studies on this phenomenon suggest a prevalence between 5.6% and
9.7% (Rocha, 2006, Agrupamento de Centros de Sade do Nordeste, Domestic Violence and Pregnancy,
2011).
Literature suggests that women victims of domestic violence often do not reveal the acts of
violence to members of their own family and support/health care network, making the act that much more
difficult to be detected. This scenario also delays the aid to these women and may prolong the abuse over
time (Levendosky, Bogat, Theran, Trotter, Eye, & Davidson, 2004).We believe this is exactly the
situation happening in Portugal, despite domestic violence receiving increased visibility over the years
and also being subject to a new legal framework.
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Our investigation aimed was characterize the presence, severity, chronicity, health habits, the selfesteem and the anxiety in pregnant women victims of domestic violence in Oporto, Portugal.
Method
Participants
It was a convenience sample composed of two hundred and four pregnant, with 29 SD years old
and in their third trimester of pregnancy, outpatients in their routine prenatal appointments at the
Obstetrics and Gynecologic Department of Pedro Hispano Hospital, in Matosinhos, Oporto, Portugal
participated in this study (Table 1).
The following inclusion criteria were used to determine the constituents of the sample group:
women older than 16 years of age, in their third trimester and of Portuguese nationality. The sample
group was divided into two segments: one consisting of non-abused pregnant women and another with
the pregnant women victims of domestic violence. The latter included all women who suffered any act of
abuse during pregnancy in Conflict Tactic Scale 2.
Methology
Socio-demographic questionnaire.
The socio-demographic questionnaire is intended to characterize the participants in terms of age,
profession, education level, marital status, physical exercise, smoking, alcohol or drugs consumption
before and/or during pregnancy as well as folic acid consumption.
Conflict Tactic Scale 2 (CTS2, Straus, 1996 Portuguese version, Figueiredo, 2006).
In this study we used the Conflict Tactic Scale 2 (CTS2, Straus, 1996). The scale comprises 39
items grouped together for a total of 78 questions, designed to assess experiences of psychological,
physical, and sexual domestic violence as well as violence causing injury from a partner; 33 items assess
perpetration and 33 items assess victimization. Furthermore, 12 items (6 for self and 6 for partner) assess
conflict negotiation. For the purpose of this study, only the 33 items that assess experiences of
victimization were used. Higher scores indicate greater severity of partner violence and abuse. To
determine the severity of the acts, the psychological, physical, and sexual subscales include items that can
be classified as minor (Made my partner have sex without a condom; Had a sprain, bruise, or small cut
because of a fight with my partner; Shouted or yelled at my partner) or severe Used force (like
hitting, holding down, or using a weapon) to make my partner have oral or anal sex); Destroyed
something belonging to my partner.
In Portuguese version CTS2 shows a high coefficient of internal consistency ( =.80).
RosenbergScale

(Rosenberg,

1965

Portuguese

version,

Romano,

Negreiros

&

Martins,2007).
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The questionnaire consists of ten statements related to feelings about oneself. The response scale
is Likert type and ranges from 1 (totally agree) and 4 (very strongly disagree). The range of answers
varies between 10 and 40 with a higher rating indicating the subject feels more self-esteem. Rosenberg
scales show a high coefficient of internal consistency ( =.95) to the portuguese population.
Brief Symptom Inventory Anxiety (BSIA: Derogatis& Leonard, 1993 Portuguese version,
Canavarro, 1999).
The BISIA is composed of six items (1, 12, 19, 38, 45 and 49) drawn from the Brief Symptom
Inventory that assesses current anxiety and nervousness, tension, generalized anxiety and panic attack
symptomatology during the previous two weeks.
The answer is Likert ranging from 0 (never happened) and 4 (always happens). The
coefficient of this sub-scale is 0.76, demonstrating that it has internal consistency in portuguese
population.
Procedure
We conducted a cross-sectional study that examines the presence of domestic violence during
pregnancy. Participants were recruited from the Obstetrics and Gynecology Department at Hospital Pedro
Hispano, Matosinhos, Oporto, Portugal. Data collection took place between March 2008 and January
2009.
It was a convenience sample, collected in the Obstetrics and Gynecology Department during
routine appointments. To be part of the sample, the following inclusion criteria would have had to be met:
older than 16 years of age, in their third trimester of pregnancy and to be of Portuguese nationality.
Participants were invited to participate by a nurse or obstetrician who briefed them about the
study. The women who agreed to participate introduced to the psychologist/investigator who provided the
details of the study.
Participants were given a set of instructions by two psychologists previously trained to administer
the questionnaires who also assisted the participants while they were self-completing the forms. Each
participant signed an informed consent form (Helsinki declaration), (World Medical Association, 2000).
Questionnaires were anonymous and participants were told that they could withdraw from the study at
anytime if they wished to. This study was approved by the ethical commission of the Pedro Hispano
Hospital.
Descriptive statistics including means and standard deviations were calculated for the continuous
variables and independent samples; t-test was used to compare means between groups. Frequencies were
calculated for the categorical variables and Chi square test was used to compare frequencies between
groups and test the association between the variables.

290

P-Values <0 .05 were considered statistically signicant. All data was analyzed with the Statistical
Package for Social Sciences (SPSS version 19).
Two groups were created, one of non-abused pregnant women and another of pregnant women
victims of domestic violence. To assess violence during pregnancy, the CTS2 was used as a diagnostic
instrument. The abused pregnant women group included all women who reported having suffered any act
of abuse during pregnancy in CTS2.
Results
In our work, we found one hundred and seven (58.2%) pregnant women who suffered domestic
violence and seventy-seven (41.8%) pregnant women who were not abused.
In the group of pregnant women abused, it was found most were married (51.1%), worked in the
area of trade and services (43.2%) and completed ninth grade (30.7%) (Table 1).
We have done the Chi square test to find out if any of these factors such as marital status,
schooling, professional and a age stood out as being associated with the presence of violence, but no
statistically significant values were found.
In respect to the pregnant women who suffered domestic violence data collected in the CTS 2
revealed that in the last year, eighty seven (46.6%) women suffered from minor psychological aggression
(e.g.: Insulted or swore at my partner) and twenty-four (12.7%) from severe psychological aggression
(e.g.: Threatened to hit or throw something at my partner).
It was found that twenty one (11.1%) women suffered from minor physical assault (e.g.: Twisted
my partner's armor pulled the hair). Nine (4.7%) women suffered severe physical assault (e.g.: Slammed
my partner against a wall). Three (1.6%) women reported having suffered minor injury (e.g.: Had a
sprain, bruise or small cut because of a fight with my partner). One woman reported having suffered
severe injury (e.g.: Went to a doctor because of a fight with my partner).
It was verified the existence of forty two (22.4%) victims of minor sexual coercion (e.g.: Made
my partner have sex without a condom), four women (2.2%) suffered from severe sexual coercion (e.g.:
Used threats to make my partner have sex) in the last year (Table 2).
Violence chronicity measures how many times any of the acts of violence portrayed in the scale
occurred among those who practiced at least one of those acts of violence.
In the last year, pregnant women suffered on average 1.15 times (SD=0.81) from minor
psychological aggression and suffered severe psychological aggression on average 0.15 times (SD=0.14).
Regarding minor physical assault women suffered on average 0.23 times (SD=0.21) while women
suffered severe physical assault on average 0.06 times (SD=0.06). Minor and severe injury was suffered
by women on average 0.03 times (SD=0.03).Regarding minor sexual coercion it was observed that on

291

average women suffered 0.25 times (SD=0.23) and severe sexual coercion on average 0.02 times
(SD=0.02) (Table 3).
Sixteen and half percent of pregnant women victims of domestic violence reported physical
exercise during pregnancy, 37.5% of women affirmed smoking before getting pregnant, however this
percentage decreased to 25% of smokers during pregnancy. With regard to the consumption of alcoholic
beverages, 10% of the abused women consumed before getting pregnant women but this percentage
decreased to 2.8% of alcohol consumption during pregnancy. With regard to drug use among the abused
women, a percentage of 0.9 was maintained before and during pregnancy. 24.5% of the women belonging
to the abused group have had some psychiatric or psychological illness (Table 4).
When analyzing the self-esteem it was use descriptive statistics. In the group of pregnant women
victims of domestic violence, statistical significant values were observed (p= 0.005). Twenty three
(21.5%) women had low self-esteem, seventy three (68.2%) with normal self-esteem and eleven (10.3%)
with high self-esteem.
The study revealed higher levels of anxiety for pregnant women victims of violence compared
with women non victims. This value was statistically significant (p < .005).
Discussion

The aim of this study was to characterize the pregnant women victims of domestic violence in the
Portuguese population.
In our study, we found that most women (58.2%) who participated in this study had experienced
abuse from moderate to severe, both physically and psychologically. This number is an unexpectedly high
number of victims of domestic violence, which may explain to cultural issues where some abusive
behaviours are still seen as a normal pattern in marital relationships.
We did not find statistically significant differences when comparing the two groups on their age,
marital status, schooling or profession suggesting that violence during pregnancy is widespread over a
population with not one single factor that signals its presence.
Nonetheless, our study reinforces the literature which indicates that pregnant women who are
victims of domestic violence are likely to have a low education, (Bailey, 2010; Chung, Lau, Yip, Chiu, &
Lee, 2001; Coker et al., 2004), and that violence during pregnancy is associated with several negative
behaviors (Bailey, 2010) and inadequate health habits such as smoking, alcohol and drugs consumption.
Assessing these negative behaviors before and during pregnancy among pregnant women victims and non
victims of domestic violence, we found that the former demonstrated that they were more frequent users
of alcohol and drugs than non victims, corroborating the idea that there is an association between
292

consumption and victimization. There were no discrepancies in the consumption of alcohol before and
during pregnancy among pregnant women victims and non victims of abuse.
An important finding of this study, concerns the association of violence and high anxiety and low
self-esteem. Those pregnant women who belonged to the abused group showed higher levels of anxiety
and lower self-esteem when compared to pregnant women who were not victims of domestic violence.
These differences were statistically significant in line with what research has been describing as the
consequences for pregnant women who suffered domestic violence such as generalized anxiety, stress,
multiple addictions (tobacco, alcohol and other drugs) with depression and general loss of interest in
themselves or the infants, as well as their health, either during pregnancy or after the babies are born
(Campbell et al., 2002).
Our findings might have been affected by some limitations. The sample size resulted in a design
that may have underpowered the findings. Since this study was based on a convenience sample, the
results may not necessarily be applicable to other groups of women, but the findings reinforce the need to
extend these types of studies to other socio-demographic characteristics that may be relevant to the
presence of violence.
Another potential limitation of this study might have been the unwillingness of the women to
divulge information relating to their own experiences of domestic violence. Other major limitation was
the fact that the study did not assess maternal mental health or maternal social support and these might be
important factors to mediate the consequences of violence during pregnancy, as other studies have already
indicated (Huth-Bocks, Levendosky, Bogat, & Van Eye, 2004).
This study did not investigate the presence of violence in the newborn, so in a future investigation
it would be important to study the co-occurrence of violence in babies and their parents.
Limitations a side, what this study did show was that domestic violence during pregnancy does
exist and at both the physical and psychological levels. It also corroborates the urgent need for the
implementation of procedures to detect the signals of domestic violence and therefore, create the
conditions for an early intervention, before the emotional and physical stability of the household is totally
disrupted, with serious consequences for all the involved parties
In the future it will be an important effort to develop training programs and intervention protocols
involving different health professionals where the screening of domestic violence will be considered a
routine procedure for pregnant women.

293

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ANEXO 5
PAPER 2

297

Domestic violence during pregnancy and babies development in the first year

Abstract
Objective: The objective of this study was to evaluate how violence during pregnancy might affect the
mental and socio-emotional developments of infants during the first year of their lives.
Method: This study had the participation of 184 women in their third trimester of pregnancy and their
babies. We used the following tools: Conflict Tactic Scale 2 (CTS2), Griffiths Mental Scale (0-2) and
Brief Infant Social Emotional Assessment (BITSEA).
Results: One hundred and seven (58.2%) pregnant women were victims of domestic violence.
Conclusion: Our results demonstrated a trend indicating that virtually all babies born to women victims
of violence had lower results in the metal development.
Keywords: violence, pregnancy, social-emotional, mental, development.

298

Abstrat
Objetivo: O objetivo deste estudo foi avaliar como a violncia durante a gravidez pode afetar os
desenvolvimentos mentais e scio-emocional das crianas durante o primeiro ano das suas vidas.
Mtodo: Este estudo teve a participao de 184 mulheres no seu terceiro trimestre da gravidez e os seus
bebs. Foram utilizados os seguintes instrumentos: Escala de Ttica de Conflitos 2 (CTS2), Escala Mental
Griffiths (0-2) e a Escala Breve de Avaliao Emocional - Social Infantil (BITSEA).
Resultados: Cento e sete (58,2%) das mulheres grvidas foram vtimas de violncia domstica.
Concluso: Nossos resultados demonstraram uma tendncia indicando que praticamente todos os bebs
nascidos de mulheres vtimas de violncia tiveram resultados mais baixos no desenvolvimento metal.
Palavras-chave: violncia, gravidez, scio-emocional, mental, desenvolvimento.

Resumen
Objetivo: El objetivo de este estudio fue evaluar cmo la violencia durante el embarazo puede afectar el
desarrollo mental y el desarrollo socio-emocional de los nios durante el primer ao de su vida.
Mtodos: En este estudio se cont con la participacin de 184 mujeres en su tercer trimestre de
embarazo y sus bebs. Se utilizaron los siguientes instrumentos: Conflict Tactics Scale 2 (CTS2), Escala
Mental Griffiths (0-2) y la Escala Breve de Evaluacin Emocional - Social Infantil (BITSEA).
Resultados: Ciento siete (58,2%) de las mujeres embarazadas que fueron vctimas de la violencia
domstica.
Conclusin: Nuestros resultados muestran una tendencia que indica que prcticamente todos los nios
nacidos de mujeres vctimas de la violencia tuvieron menores resultados en la elaboracin de metal.
Palabras clave: violencia, embarazo, socio-emocional, desarrollo mental.

299

Domestic violence during pregnancy and babies development in the first year
Abuse during pregnancy is a serious prenatal problem that has received increasing attention
(Campbell, 1995). Domestic violence during pregnancy refers to the repeated psychological, physical or
sexual aggression through that period of time in a context of coercive control. Such violence is
characterized by physical abuse (strikes, burns, stabs or firearm wounds), psychological and emotional
abuse (threats, humiliation, neglect or abandonment) and sexual abuse (forced sexual practices) (NuezRivas, Monge-Rojas, Gros-Dvila, Elizondo- Urea, & Rojas-Chavarra, 2003).
Statistical data from several studies show that the prevalence of abuse during pregnancy varies
widely between 1 and 20% (Martins, Griffin, Kupper, Petersen, Beck-Warden, Buescher, 2001).
Consequences of abuse during pregnancy are associated with negative outcomes for the maternal,
fetal and neonatal physical health (Kady, Gilbert, Xing, & Smith, 2005; Rachana, Suraiya, Hisham,
Abdulaziz, & Hai, 2002).
Beyond the physical consequences, abuse during pregnancy also generates psychological
consequences. Pregnant women who are abused by their partners are at higher risk of suffering from
stress, depression and addiction to tobacco, alcohol and other drugs (Carlson, McNutt, & Choi, 2003;
Curry & Wall, 1998).
Violence during this period can result in inadequate prenatal care (Curry & Wall, 1998; Goodwin,
Gazmararian, Johnson, Gilbert, & Saltzaman, 2001). Additionally, abused pregnant might face a loss of
interest in the health and well-being of herself and her baby either during pregnancy or after the baby is
born (Campbell, Jones, & Dienemann, 2002; Piontelli, 1995) and can trigger maternal responses that are
quite often inadequate to meet the needs of her offspring. This lack of adequate response can result in a
higher prevalence of sleep disorders, dysfunctional patterns of behavior and increased aggression and
irritability(Somer, 1999).
Domestic violence during and after pregnancy can adversely affect baby health and socialemotional development (Edelson, 1999; Kitzman et al. 2003; Rachana et al. 2002).A healthy newborn is
already able to regulate stress responses, but this ability is being shaped by the intensity and frequency of
the experiences to which the baby is exposed. Recent investigations suggest that responses to stressors
enhance a humans emotional functioning. However, if this exposure occurs too frequently or too
intensely over time, it can impact the babys health and development (Weiner et al, 2003).
Literature suggests a significant positive relationship between infant socio-emotional difficulties
at 3 months of age and infant socio-emotional difficulties at 1 year of age and studies reveal that this
association is both moderated and mediated by different maternal risk factors. Specifically, some authors
claim that domestic violence experienced during pregnancy and during the infants first year of life
moderates the association between present and future infant difficulties (Ahlfs-Dunn, 2010; Edelson,
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1999; Jouriles, Norwood, McDonald, & Vincent, 1996, Kitzman, Gaylord, Holt, & Kenny, 2003;
Rachana et al., 2002).
The objective of this investigation was to study the mental and socio-emotional development of
infants, during their first year of life, born to a group of women abused by their partners during pregnancy
and to compare them with a group of babies born to non-abused women.
Method
Participants
The participants in the study were 184 women in their third trimester of pregnancy enrolled in a
larger longitudinal study (N=204), these women were outpatients in their routine prenatal appointments at
the Obstetrics and Gynecologic Department of Pedro Hispano Hospital, Matosinhos/Oporto, Portugal.
In the whole sample, pregnant women had a mean age of twenty nine years (SD= 5.8).
Thirty six (23.5%) of the abused women during pregnancy engaged in some sort of physical
exercise, thirty three (21.4%) smoked and six (3%) drank alcohol.
Materials
Socio-demographic questionnaire.
The socio-demographic questionnaire consists of questions intended to characterize the
participants in terms of age, profession, education level, marital status, whether or not they did some
physical exercise, smoking, alcohol or drugs consumption before and/or during pregnancy and folic acid
consumption.
Conflict Tactic Scale 2 (CTS2, Straus, 1996 Portuguese version Figueiredo, 2006).
In this study we used the Conflict Tactic Scale 2 (CTS2, Straus, 1996). This scale assesses the
experience of domestic violence in its several forms: psychological, physical and sexual. It comprises 39
items grouped together for a total of 78 questions, 33 of them assess perpetration, 33 assess victimization
and 12 questions (6 for self and 6 for partner) assess conflict negotiation. According to the nature and
objectives of the studies, it is common practice that only certain subscales of the CTS2 are used. In this
case and due to the purpose of the study which was more focused on victimization, only the 33 items that
assess experiences of victimization were used. (Bogat, Levendosky, Theran, Von Eye, & Davidson, 2003;
Hughes & Huth-Bocks, 2007; Johnson & Lieberman, 2007), and this is welcomed by the authors of the
Scale (Straus, Hamby, Boney-McCoy, & Sugarman, 1996). The response format includes eight
hypotheses, 0 (never), 1 (once), 2 (twice), 3 (3-5 times), 4 (6-125 10 times), 5 (11-20 times), 6 (more than
20 times), and 7 (not during these time periods, but it happened previously), with the first six determining
the prevalence and chronicity in the last year. The CTS2 is scored by using a weighted system in which
the values are recoded (1 = 1, 2 = 2, 3 =4, 4 = 8, 5 = 15, and 6 = 25).
Higher score indicate a greater severity of partner violence and abuse. To determine the severity
of the acts, the psychological, physical, and sexual subscales include items that can be classified as minor
301

(Made my partner have sex without a condom; Had a sprain, bruise, or small cut because of a fight
with my partner; Shouted or yelled at my partner) or classified as severe (Used force like hitting,
holding down, or using a weapon to make my partner have oral or anal sex; Destroyed something
belonging to my partner). In this study CTS2 showed a high coefficient of internal consistency ( =.86).
Griffiths Mental Scale (0-2) (Griffiths 0-2: Griffiths, 1996 Portuguese version Castro & Gomes,
1996).
Griffiths Mental Scales (0-2) measure the mental development in babies and young infants from
birth to a developmental age of two years. It is composed of five subscales: A - Locomotion; B Personal-Social; C - Language; D - Eye and Hand Coordination; E Performance. Each sub-scale is
composed of 35 items. The score is obtained by adding up the number of items that the baby successfully
performed in each of the sub-scales. Then the raw scores for each individual sub-scale can be converted
to standard scores.
The Griffiths had adequate internal consistency (= .89).
Brief Infant Toddler Social Emotional Assessment (BITSEA: Briggs-Gowan &Carter, 2004).
The BITSEA consists of a screening of the development of socio-emotional behavior and
competencies of babies from 12 to 35 months 30 days with possible socio-emotional behavior problems
and/or possible delays or deficits in socio-emotional competencies. It is composed of 42 items with
Lickert-type responses ranging from 148 0 (false/rarely) to 2 (true/often). Lower scores indicate fewer
problems and lower competence. In this study the BITSEA had adequate internal consistency ( = .79).
Procedure
A convenience sample was collected in the Obstetrics and Gynecology Department during routine
appointments. In order to be eligible for the study the women had to be more than 16 years of age,
Portuguese nationality and at least 25 weeks in gestation. After a potential participant was approached
and identified as meeting the criteria to be considered for the study, she received a set of instructions and
the assistance of two psychologists specifically trained for the purpose of filling out the questionnaires.
Data collection took place between March 2008 and January 2009 and was conducted in three separate
periods. The first period (P1) took place with pregnant women in their third trimester of pregnancy using
CTS2. Any pregnant who had experienced at least one incident of violence was classified as belonging to
the group of abused women. The second (P2) and third (P3) periods of data collection were done,
respectively, when the infants were 3.5 and 12 month old, both using the Griffiths Mental Scale (0-2). In
P3 the BITSEA was also used to ascertain the babies socio-emotional state.
Participants were told that all the information revealed by them would remain confidential and
they could withdraw form the project for any reason at any time during the procedure. They signed a
consent form (Helsinki declaration) (World Medical Association, 2000), for both themselves at P1 and
their infants at P2 and P3.
302

The ethical commission of the Pedro Hispano Hospital gave their approval for this study.
Descriptive analysis of the sample was done with the appropriate summary statistics. Categorical
variables were described using absolute (n) and relative (%) frequencies. Continuous variables were
described using the mean and the standard deviation or median, the 25th percentile and 75th percentile depending on their distribution being symmetric or asymmetric, respectively. A chi-square independence
test was used to analyze the association between categorical variables. The Mann-Whitney Test was used
to test hypotheses concerning continuous variables with skewed distribution. Was calculated the odds
ratio measure of risk, and its range with 95% confidence when appropriate.
In all tests of hypotheses at a significance level of 0.05 was considered. All data was analyzed
with the Statistical Package for Social Sciences (SPSS version 19), for MacOS.
Results
In the course of P1, two groups were formed; one with seventy-seven (41.8%) non-abused
pregnant and the other with one hundred and seven (58.2%) pregnant victims of domestic violence.
In the group of abused women, and during the last year, it was found that eighty seven (46.6%) of
them suffered from minor psychological aggression, twenty-four (12.7%) suffered from severe
psychological aggression, forty five (11.1%) suffered from minor physical assault and nine (4.7%)
suffered from severe physical assault. With regards to sexual coercion, forty-two (22.4%) of the victims
suffered minor sexual coercion, and four (2.25%) suffered severe sexual coercion. Three (1.6%) women
reported having suffered minor injury and one (.5%) woman confirmed to have suffered severe injury
(Table 2).
Statistical analysis was performed to investigate if any factors such as marital status, schooling,
occupation and age would stand out as being associated with the presence of violence, but no statistically
significant values were observed.
With respect to birth weight, we found that babies born to women victims of violence had a higher
mean value weight (M= 3365; SD= 388.2) than babies born to women who were not abused (M= 3156;
SD= 424.4) and this difference was statistically significant.
However, the minimum birth weight was found in the group of babies born to abused women
(1885 g) and it is significantly lower than the minimum birth weight of babies born to non abused women
(2335 g.).
Considering mental development, babies born to non-abused women had a mean value of 100.1
(SD = 15.8) for the global scale, while babies born to abused women had a mean value of 99.8 (SD =
13.7) at P2, although these results did not show statistical significant differences (Table 3).
When we compared the mental global development of these babies at 12 months of age (P3), the
same non statistical trend was found. Babies born to non-abused women had a mean value of 108.1 (SD =
11.3) while babies born to abused women had a mean value of 105.8 (SD = 11.6). Mental development in
303

babies born to non-abused women continued to score higher (Table 4).

When analyzing the mental development of babies born to abused pregnant, in different forms
(physical, psychological and sexual), we only verified statistically significant differences on
psychological victims (p= .013) in the language sub-scale in which babies born to non-abused women
scored higher.
Considering the different types of violence as a risk factor for cognitive differences in babies at
12 moths, we found that those whom mothers suffered severe psychological aggression during pregnancy,
showed .250 times less risk (95% CI Between .184 and 1.538) to have problems at global development.
The fact that the mother had suffered severe psychological aggression seems to be a protector factor to the
global development in babies, at twelve months old.
Babies at 12 moths whose mothers had suffered physical assault without light sequel during
pregnancy shows .214 times less risk (95% CI Between .063 and .731) to develop problems at subscale
language. So the fact that the mother had suffered physical assault without light sequel is a protector
factor of language development in babies at one year of age. As regards babies at P3, whose mothers
suffered severe physical assault without severe sequel during pregnancy show .103 times less risk (95%
CI between .011 and .948) to develop problems at subscale performance. So the act that the mother had
suffered severe physical assault without severe sequel is a protector factor for the performance
development in babies at twelve months old.
Through the analysis of the results of BITSEA (P3) we found 17 babies born to abused women
who had a positive screen for BITSEA compared to 9 babies with a positive screen in the group of nonabused women. Still, this difference was not statistically significant.
We verified that babies showed differences at the gender level. For example, in the group of
babies born to abused women, baby girls had a positive screen at problem domain and a positive screen at
competence domain, while boys scored high at both domains. There were, however, no statistically
significant differences between the group of babies born to mothers abused during pregnancy and babies
born to non-abused mothers during pregnancy.
When we examined the BITSEA's domains, we found that the baby girls born to abused women
had a mean value of 1.5 (SD = 1.2) for internalizing and baby girls born to non-abused women had a
mean value of 0.8 (SD = 1.1) for the same domain. These results were statistically significant. So, baby
girls born to abused women had more symptoms of generalized anxiety, separation anxiety and novelty
inhibition.
Discussion
The objective of this study was to investigate the impact of violence during pregnancy and the
mental development and in the socio-emotional state of the babies.
We know from research that the placenta embodies the genes that are influenced by the maternal
304

hormone levels. In turn, these maternal levels are influenced by the mothers' day-to-day life experiences
and by the way they deal with them. All these circumstances alter the development of the baby's stress
regulation system and contribute towards the organization of the baby's temperament in the postnatal
period. Studies on the presence of cortisol, which is a hormone that is involved in stress response
processes, show that exposure to high levels of this hormone in the preterm will promote delays in the
baby's exploratory behavior, motor development and temperament difficulties (Buitelaar, Huizink,
Mulder, Medina, & Visser, 2003).
Given the fact that domestic violence during pregnancy enhances the experiencing of high levels
of anxiety by the mother and, consequently, by the fetus, and that stress can contribute to the onset or
aggravation of several somatic and psychological health problems of the mother, we may conclude that
the fetus is also at risk of being affected by the mothers physical and mental health which are
exacerbated by the occurrence of domestic violence (Stenson, 2004). Studies have shown that pregnancy
can be a factor which favors the occurrence of abuse during this period or the escalation of pre-existing
abuse prior to the pregnancy (Rachana et al., 2002).
Some authors consider domestic violence as a significant risk factor for the birth of babies with
low birth weight (Parker, McFlarane, & Soeken, 1994; McFarlane, J., Parker, & Soeken, 1996; Bullock &
McFarlane, 1990). Wither others do not (Bereson, Wiemann, Wilkinson, Jones, & Anderson, 1994). In
our study, babies of abused women had a higher mean weight compared to babies of non-abused women;
nevertheless, we found the lowest weights within the group of babies born to battered women.
We found the violence during pregnancy has a direct effect on babies' mental skills, we could
demonstrate a trend in all babies born to battered mothers having lower results in global scale at three and
half moths (p2) and twelve moths (P3), with statistically significant difference, except in the language
sub-scale.
Furthermore, when we consider the mental development progression from P2 to P3 we concluded
that, although there were positive improvements in the two groups for the global scale and all subscales
(except for the locomotion), babies born to battered women exhibited delayed development when
compared with babies born to non-battered women.
Girls are known for internalizing problems more than boys in every culture (Crijnen, Achenbach,
& Verhulst, 1997). Studies point to the fact that specific traits such as gender, developmental level and
temperament may have an important role in behavioral issues. For example, boys exhibit more
externalizing behaviors (aggression) and girls exhibit more internalizing behaviors (depression)
(Campbell, 1995). Parenting styles and parental characteristics have an effect on a childs 260 behavior,
specifically problematic behaviors (Barry, Dunlap, Cotten, Lochman, & Wells, 2005; Gadeyne,
Ghesquire, & Onghena, 2004).
Women who have been victims of domestic violence and feel traumatized by these occurrences
305

will probably have problems acknowledging what their babies need. This may happen because they are
concerned with their survival, feel afraid and/or dissociated from others, which jeopardizes their behavior
as mothers and care givers (Levendosky & Graham-Bermann, 2001).
Our results were in line with this since with respect to the babies socio-emotional state at one
year of age, we found a greater number of positive screens among babies born to women victims of
domestic violence when compared to babies born to non-abused women, so it can be argued that violence
during pregnancy will hamper babies socio-emotional development and put them at risk of developing
some mental disturbance at future stages. Violence during pregnancy may cause social and emotional
wounds in babies making them unable to cope with future problems due to the lack of healthy
psychological competences (Ahlfs-Dunn, 2010).
We know that children who witnessed domestic violence display more externalizing behaviors at
ages 2 and 3 when compared to children who did not. Curiously, and according to our results, when we
analyzed infants at 12 months old, they showed that baby girls presented more internalizing behaviors.
Even though we can not presume that violence continued after the birth, we can assume that possibility
taking into account the cultural issue which seems to consider some violent behaviors as part of the
normal couple functioning (DeJonghe, Von Eye, Bogat, & Levendosky, 2011).
Our data reinforces the knowledge that when a pregnant is a victim of violence there are two
individuals who are in danger: the mother and the fetus. These findings, suggest developmental
improvements in all babies from the first evaluation to the second, nevertheless, babies born to women
who experienced violence during pregnancy consistently scored at levels slightly lower, when compared
to those babies born from women with no experience of violence during pregnancy, implying that
although prenatal violence does not directly affect either the mental or the socio-emotional development
of babies, it is a factor that can hamper the babies development to their full potential.
Several limitations may have affected these findings. Despite the large number of the initial
sample, it diminished in P2 and than again in P3, resulting in a design that may have underpowered the
findings.
Another major limitation relates to the behavior measures. Although Griffiths Scale (0-2) was
applied on two different periods with the psychologists supervision, the BITSEA information was a
verbal report by the mother, and therefore, may reflect her own opinion or her own perception of how a
good mother should behave. Another limiting factor was that the study did not assess the maternal mental
health or the maternal social support, and these might be important factors to mediate the consequences of
violence during pregnancy, on infants mental development and socio-emotional states, since other studies
have demonstrated that, for example, maternal social support was found to act as a protective 374 shield
against the effects of violence in several health outcomes (Hutch-Bocks et al., 2001).
The findings in this study are not necessarily applicable to other groups of women since it was
306

based on a convenience sample, but it does reinforce the need to extend these types of studies to later ages
in order to clarify the extent of these developmental changes.
Taking into account the results obtained, it is urgent that measures are implemented to signal the
risk of domestic violence so that we can intervene as early as possible and thereby avoid further damage
to the level of emotional and physical stability of the household.
Thus, and despite being well known that adult behavior is the result of a developmental history, it
has become clear that because the nervous system begins its development long before birth, human
behavior is directly related to the pre and postnatal environment (Hall & Oppenheim, 1987). The mother
is the most important mediator between the baby and the internal and external stimuli, so it is easy to
understand that if she fails in her protective ability and adequate regulation, the risk of damage in the
neurobiological and psychological development of the baby increases and may have negative
consequences for life. Affectivity and its development is linked to the subjective and communicative
experiences with each other, that is, besides the physical abuse that the fetus/baby may experience with
the consequential damage to its development, these conditions represent as well an important risk factor
to the babies psychological development.

307

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Table 1
Socio-demographic Specificacions
Total Population
N
(%)

Victim
N

(%)

Non- Victim
N
(%)

Single

38

(20,8%)

26

(26.3)

10

(14.9)

Married

100

(54,6%)

51

(51.5)

38

(56.7)

Living with a 31
partner
Divorced or 14
separated

(16,9%)

16

(16.2)

12

(17.9)

(7,7%)

(6.1)

(10.4)

Student

(2,2%)

(3.2)

(1.4)

Housewives

40

(22,1%)

22

(23.2)

15

(21.4)

Health

12

(6,6%)

(8.4)

(4.3)

Area of trade 84
and services
Education
12

(46,4%)

41

(43.2)

35

(50)

(6,6%)

(6.3)

(8.6)

Banking

(2,8%)

(2.1)

(2.9)

Another area

24

(13,3%)

13

(13.7)

(11.4)

Marital
Status

Profession

Schooling
311

First cycle

39

(20,2%)

24

(23.8)

12

(16)

Second cycle

60

(31,1%)

31

(30.7)

27

(36)

Secondary
46
education
Undergraduate 46
degree
Graduate
2
degree

(23,8%)

20

(19.8)

19

(25.3)

(23,8%)

25

(24.8)

16

(21.3)

(1,0%)

(1)

(1.3)

Table 2
Violence Severity
N

(%)

Minor
Severe

87
24

(46.6)
(12.7)

Minor
Severe

21
9

(11.1)
(4.7)

Minor
Severe

42
4

(22.4)
(2.2)

Minor
Severe

3
1

(1.6)
(.5)

Psychological Agression
Phisical Assault
Sexual Coercion
Injury

Table 3
Comparison of babies development, with the Griffiths Scale at T2 (comparing children of victims and
children of non-victims).
Non-Victim
M
SD

312

Victim
M

p
SD

Locomotor

106.6

17.8

106.5

17.7

.445

PersonalSocial

96.1

21.4

96.9

20.9

.777

Language

99.5

19.2

100.2

14.6

.697

Eye_
Hand
Coordination

99.8

17.8

99.7

17.8

.290

Performance

98.0

18.3

97.2

16.5

.740

Global

100.1

15.8

99.8

13.7

.303

Table 4
Comparison of babies development, with the Griffiths Scale at T3 (comparing children of victims and
children of non-victims).
Non-Victim
Victim
p
M

SD

Locomotor

100.9

13.6

98.8

13.7

.738

PersonalSocial

107.6

18.5

103.3

14.6

.229

Language

115.1

13.0

113.1

11.2

.297

Eye Hand
Coordination

111.8

12.0

111.9

15.8

.410

13.9

102.9

12.5

.826

11.3

105.8

11.6

Performance
Global

104.2
108.1

SD

1.000

313

314

ANEXO 6
PAPER 3

315

Common mental disorders during pregnancy and babys development in the first year of life.

Abstract
Evidence shows that pregnancy and early postpartum periods are crucial to the development of the
mother-baby relationship.
Objective: The aim of this study was to evaluate the impact of Common Mental Disorders (CMD) during
pregnancy on childs mental development during the first year.
A prospective study was carried out with 204 pregnant women in the third trimester of pregnancy and
continuing with their babies to 3.5 and 12 months of age.
Method: To assess the presence of CMD, the Brief Symptom Inventory (BSI) and the Inventory of the
Clinical Evaluation of Depression (IACLIDE) were used. Evaluation of the babies mental development
and the socio-emotional state was carried out using the Griffiths Mental Scale (0-2) and the Brief Infant
Toddler Social and Emotional Assessment (BITSEA).
Results: We observed 20 babies born to women with a positive diagnose for CMD and who presented a
positive screen in the BITSEA. We also observed a statistically significant relationship regarding the
diminished development in certain Griffiths sub-Scales of babies whose mothers showed presence of
psychotic, anxiety, hostility and depressive symptoms, during pregnancy.
Conclusion: We conclude that the presence of CMD influences the mental, social and emotional
development levels of infants in their first year.
Keywords: Common Mental Disorders; pregnancy; infant mental development; infant social-emotional
development.
Common mental disorders during pregnancy and babys development in the first year of life.

316

Pregnancy has been considered to be a stressful period for some women (Martin, Harris-Britt, Li,
Moracco, Kupper, & Campbell, 2004) during in which they have to deal with many physical, hormonal
and/or psychopathological changes (Fatoye, Adeyemi, & Oladimeji, 2004).
Empirical studies have recorded the presence of symptoms of depression and anxiety at a clinical
level and their comorbidity in certain periods of a woman's life and in relation to the transition to
motherhood (Ross, Evans, Sellers, & Romach, 2003).Several studies point to an increased risk for
psychopathological disorders, (Ross, Evans, Sellers, & Romach, 2003, Halbreich, 2004; Gavin, Gaynes,
Lohr, Meltzer-Brody, Gartlehner, &Swinson, 2005; Grant, McMahon, & Austin, 2008; Van Bussel, Spitz,
&Demyttenaere, 2006), and some even indicate that the prevalence of these symptoms may be higher
during the pregnancy and in the puerperium than later in the postpartum period
(Limlowongse&Laibsuetrakul, 2006; Rich- Edwards, Kleinman, &Abrams, 2006; Wissar, Parshad,
&Kulkrni, 2005).
Psychopathological symptoms, if present in a womans clinical history, maybe further
experienced during pregnancy due to hormonal changes (Marcus, Flynn, Bow, & Barry, 2003;
Figueiredo, 2005). These are commonly known as perinatal Common Mental Disorders (CMD) and what
characterizes them are high levels of depressive, anxiety, panic and/or somatic symptoms occurring
during pregnancy after birth. They are important predictors of subsequent postpartum depression and
postpartum anxiety (Grant, McMahon, & Austin, 2008; Heron, O'Conno, & Glover, 2004; Lee, Lam, Sze,
Chong, Chui, & Fong, 2007).
Risk factors associated with CMD in the perinatal period are likely to be related to biological
factors (history of previous humour disorders, history of previous postpartum depression, family history
of psychiatric illness) and psychosocial factors (history of being abused during the childhood, being an
unmarried mother, experiencing domestic violence, drug abuse and being a smoker) (Ryan, Milis,
&Misri, 2005).
The physical and emotional state of mothers during pregnancy is thought to affect the well-being
and equilibrium of the baby. Difficulties experienced during this period may be associated with lasting
effects on babies as far as their emotional, behavioural and cognitive levels are concerned (O'Connor,
Heron, & Gover, 2002).
The aim of this study was to understand more about the impact of Common Mental Disorders
during pregnancy on babies mental and social-emotional development in the first year of their lives.
Method
Participants
The participants in this study were 204 pregnant women in their third trimester of pregnancy and
their babies at 3.5 and 12 months old.
317

In the sample, these women had a mean age of twenty nine years (SD= 5.8) (Table1).
During pregnancy 36 (23.5%) of the women engaged in some sort of physical exercise, 33
(21.4%) smoked and 6 (3%) drank alcohol.
Materials
In order to describe the characteristics of the participants in terms of age, profession, education
level, marital status, whether or not they did some physical exercise, smoking, alcohol or drugs
consumption before and/or during pregnancy, and folic acid consumption socio-demographic
questionnaire was used.
The presence of Common Mental Disorders was measured using the Brief Symptom Inventory (BSI)and
the Inventory of the Clinical Evaluation of Depression (IACLIDE).Infant mental and social-emotional
development was assessed using the Griffiths Mental Scale 0-2 (Griffiths 0-2) and the Brief InfantToddler Social and Emotional Assessment (BITSEA).
Brief Symptom Inventory (BSI: Derogatis & Leonard, 1993 Portuguese version, Canavarro,
1999).
The BSI consists of 53 symptoms drawn from the Symptom Checklist-90-R and assesses current
psychological symptomatology. It is composed of nine primary symptom dimensions and three global
indices which provide a summary assessment of emotional distress. The BSIs Likert type responses
range from 0 (never happened) to 4 (always happened).
The primary symptoms relate to: Somatization; Obsession-Compulsion; Interpersonal Sensitivity;
Depression; Anxiety; Hostility; Phobic Anxiety; Paranoid Ideation and Psychoticism.
The BSI scale in this study had a high coefficient of internal consistency for all subscales:
Somatization ( =.78), Obsession-Compulsion ( =.77), Interpersonal Sensitivity ( =.82), Depression (
=.84), Anxiety ( =.82), Hostility ( =.82), Phobic Anxiety ( =.77), Paranoid Ideation ( =.79);
Psychoticism (=.79).
The three indices are: General Symptom Index (GSI), calculated by taking the mean of the items
dimensions. Positive Symptom Totalis derived by counting the number of items endorsed with a positive
response; Total of the Positive Symptoms, derived by counting the number of items endorsed with a
positive response and the Indices of Positive Symptoms (PSD), derived by summing across the items and
then dividing by the Positive Symptom Total. Again, the Fast Track version is then multiplied by 53/31 to
account for the difference in the number of items included in the measure.
The following two criteria were established for designating a BSI protocol as being positive for
diagnosable psychopathology based on female adult, non-patient norms: a) T-score for GSI of 63 or
greater, or b) T-score of 63 or greater on two or more subscales (Derogatis, 1993).
318

Inventory of the Clinical Evaluation of Depression (IACLIDE: Vaz Serra, 1994)

The IACLIDE is a Portuguese Inventory of the Clinical Evaluation of Depression, consisting of
23 questions with Likert type responses covering four types of disturbances: in work, cognition,
interpersonal relationship and biological changes. These reflect the relationship that an individual has
with their body, as a person, with others and with work. The scale has four severity levels of the
depressive symptom states, which are: none, mild, moderate and severe. The IACLIDE scales in this
study showed internal consistency coefficients ( =.76).

Griffiths Mental Scale 0-2 (Griffiths 0-2 Griffths, 1996 Portuguese version Castro & Gomes,
1996).
Griffiths Mental Scales (0-2), assess mental and motor development in babies and young children
from birth to a developmental age of two years. It is composed of five subscales: A - Locomotor; B Personal-Social; C - Language; D - Eye and Hand Coordination; E - Performance. Each sub-scale is
composed of 35 items. The score is obtained by adding up the number of items that the baby successfully
performed in each of the sub-scales, and then the raw scores for each individual sub-scale can be
converted to standard scores.T he Griffiths had adequate internal consistency in this study (=.89).
Brief Infant-Toddler Social and Emotional Assessment (BITSEA: Briggs-Gowan&Carter, 2004)
The BITSEA is a screening instrument for social-emotional behavioural development and
competencies for babies from 12 to 35 months 30 days, with possible social-emotional and behavioural
problems and/or possible delays or deficits in social-emotional competencies. A positive screen in
BITSEA reflects the presence of problems in social-emotional development.
The BITSEA was derived from the longer instrument, the Infant Toddler Social Emotional
Assessment (ITSEA) (Carter & Briggs-Gowan, 2003).
It consists of 42 items with Lickert type response ranging from 0 (false/rarely) and 2
(true/often).The BITSEA in this study had adequate internal consistency (=.79).
Procedure
A convenience sample of participants was collected in the obstetrics service of the Obstetrics and
Gynaecology Departments, at Hospital Pedro Hispano, Matosinhos, Oporto, Portugal during routine
appointments. Participants were approached by the nurse or the obstetrician, who briefed them about the
study and asked if they wanted to participate. The women who responded affirmatively were then
introduced to the psychologist/investigator who explained the details of the study. The following
inclusion criteria were used: older than 16 years of age, to have reached at least 25 weeks of gestation and
to be of Portuguese nationality

319

Participants were given a set of instructions by two psychologists, previously trained to administer
those questionnaires, and who assisted the participants clarifying any points raised by women. All
participants signed a consent form (Helsinki form World Medical Association , 2000) and were informed
that the questionnaire data would be treated anonymously and that they could withdraw from it at any
time during the study if they so wished. The ethical commission of the Hospital Pedro Hispano approved
this study. Data collection took place between 2008 and 2010.
A cohort study was conducted at three time points. Data collection began during the third
trimester of pregnancy (P1), with the participation of 204 pregnant women where we examined the
presence of common mental disorders with the objective of creating a group of participants presenting
psychopathology and a group without psychopathology. At that time, a short socio-demographic
questionnaire was used.
After the babys birth, an assessment of their overall mental development at 3,5 months was
carried out (P2). At 12 months an assessment of their mental development and also of their socioemotional state was carried out (P3) using the Griffiths Scale (0-2) and the BITSEA. Data on behaviours
that could not be directly observed relied on maternal report. All evaluation was blind to any symptoms of
maternal psychopathology in the antenatal period.
All assessments were scored in a standard way. In the descriptive analysis of the sample,
appropriate summary statistics were applied. Categorical variables were described using absolute (N) and
relative (%) frequencies. Continuous variables were described using the mean and standard deviation. The
test for independence of chi-square to analyze the association between categorical variables was used.
When the expected frequency in any cell of the contingency table regarding the analysis of association of
two categories was less than 5, we used the Fisher exact test. The Mann-Whitney test was used to test
hypotheses concerning continuous variables with skewed distribution.
In all tests of hypotheses a significance level of 0.05 was used. All data were analysed with the
Statistical Package for Social Sciences (SPSS version 19) to MacOS.
Results
Regarding the presence of Common Mental Disorders (CMD) in pregnant at least of 25 weeks of
gestation, it was found that 53 (27.5%) pregnant women were positive for diagnosable psychopathology.
It was also found that 68 (79.1%) presented with symptoms of hostility, 66 (33.5%) paranoid ideation, 34
(17.2%) anxiety and 42 (21.2%) depression (Table 2).
When we analysed the presence of depression in IACLIDE, we found 37 (19.1%) participants
who were depressed (Table 3).
Regarding infants Global mental development, it was found that at P2 and at P3 the results did
not show any statistical difference and are presented in Table 4 and 5.
320

When analyzing each BSI subscales individually, some statistically significant differences were
found. In the analysis at P2 of babies born to women with positive diagnose in BSI's Anxiety subscale,
statistically significant differences in Personal-Social (p=.004), Performance (p=.004) and Global
(p=.008) subscales were found between the two groups of babies. In the Personal-Social Performance
subscale and Global scale, babies born to women with positive diagnose in BSI's Anxiety subscale scored
lower. Babies born to women with positive diagnose in the BSI's Obsessive-Compulsive subscale,
showed lower mean values on all the Griffiths 0-2 subscales (p=.102), and there were significant
differences in the Hand-Eye Coordination (p=.051) subscale.
Babies born to women with positive diagnose on BSI's Depression subscale had a statistically
significant (p=.018) higher mean score (M = 106.8, SD = 21.7) than babies born to non-depressed women
(M = 105.9, SD = 17.0) in the Locomotor subscale. Babies born to women with positive diagnose in BSI's
Psychoticism subscale showed significant differences on the Hand-Eye Coordination and Performance
subscales, whereas babies born to women with Psychotic symptoms showed lower mean scores. Although
statistically significant, it is important to note that the results might have been impacted by the small
sample sizes of each group and multiple testing segments (Table 6).
At 12 months (P3) significant differences were also observed: babies born to women with a
positive diagnose on BSI's Depression subscale had a lower mean score in Global mental development (M
= 102.7, SD = 12.9) than babies born to women who did not have depressive symptoms (M=107.6;
SD=10.7); these same babies had a lower mean score (M = 98.8;SD = 17.5) on the Personal-Social
subscale when compared with babies born to non-depressed women (M = 106.5; SD = 15.5) (p=.021) and
babies born to women who showed Hostility symptoms had a lower mean value (M = 103.5; SD = 11.5)
in the Global mental development than babies born to women who did not show such symptoms
(M=111,2; DP=9.1) (p=.030)(Table 7).
Using the IACLIDE data some statistically significant differences were found in mental
development between the groups of babies born to women with and without depression during pregnancy
(Table 8).
When the baby's social-emotional development was analysed, no statistically significant
differences were found between the groups of babies born to women with or without positive diagnose in
BSI. Nevertheless, 20 babies born to women with positive diagnose in the BSI presented a positive screen
in the BITSEA (Table 9).
Discussion
The aim of this study was to understand if CMD during pregnancy had a measurable effect on the
mental and social-emotional development of babies in the very early stages of their development, at 3.5
and 12 months old.
321

The study showed high levels of psychopathology during pregnancy, suggesting a possibly
widespread problem for which women are not routinely screened in Portugal. This finding did not reflect
the views or current practice of health professionals who were working with these women. In response to
the study findings antenatal screening for CMD has been introduced.
Some researchers have suggested a possible association between early infant experiences of an
absence of touch and handling (since depressed mothers seem to handle their babies less) and the
occurrence of depression, anxiety and drug abuse in both the child and the adult (Kaufman, 1991) and
borderline personality disorder in adulthood (Plotasky, Owens, & Nemeroff, 1998).
In regard to infant mental development, our findings also suggest that CMD in the third trimester
of pregnancy is associated with lower scores of mental development in babies of 3.5 months and one year
and that there was a delay in processes related to specific cognitive abilities.
Is important to note that, the results may have suffered some impact by the small sample size.
Globally, our study suggested that babies born to mothers with no evidence of
psychopathological symptoms during pregnancy scored higher in mental development on most subscales,
to that it might contribute the fact that mothers without psychopathology seem to be more sensitive and
tuned in with their baby, thus facilitating development (Koren-Karie, Oppenheim, & Getzler-Yosef,
2008; Thompson, 2007).
In contrast, we found a statistically significant relationship between the presence of CMD during
pregnancy and poorer development in some specific areas, in particular hand-eye coordination, personalsocial, locomotor and performance among babies whose mothers showed obsessive-compulsive,
psychotic, anxiety, hostility and depressive symptoms.
These findings appear to be consistent with existing literature in which children raised by mothers
who have been highly anxious during pregnancy are more likely to exhibit lower performance in mental
development and emotional adjustment tests (Davids, Holden, & Gray, 1963).
Many studies have shown that maternal depression may have a significant negative effect on
cognitive and emotional development (Austin & Leader, 2000; Tiet, Bird, Hoven, Wu, Moore, & Davies,
2001). In our study we found higher scores for locomotor skills in babies at 3.5 months born to women
with depressive symptoms, compared with babies born to women without such symptoms. The study also
showed that mothers depressive symptoms appeared to have a negative effect on babies interpersonal
and social skills.
In our study we found 20 babies born to women with positive antenatal diagnoses, who presented
a positive screen in their social-emotional functioning. These results were consistent with others that have
related prenatal stress or anxiety to reduced motor maturity in children (DiPietro, 2002). Babies socialemotional difficulties are also thought to have a significant positive relationship with high levels of
anxiety by the end of the pregnancy (Van de Bergh, 1990).
322

The psychopathology of the mother during pregnancy is thought to cause long-term effects on the
neurological development of the baby which can include a greater predisposition to depression in
adulthood. Anxiety, shyness and passivity are also possible consequences of prenatal chronic stress,
especially when the stress persists after birth (Glover, 1997).
With between 10% and 14% of women affected by perinatal distress and depression, resulting in
short and long term consequences for the family (Buist, Barnett, Milgrom, Pope, Condon, Ellwood,
Boyce, Austin, & Hayes, 2002) measures for early detection are crucial, because if these women s
mental health problems go un identified, there may be long term consequences. Timely investigation and
detection of these symptoms could reduce the negative impact on the mothers and on their children, and
will help to create best practice that can be used with a whole population of women (Buist, Barnett,
Milgrom, Pope, Condon, Ellwood, Boyce, Austin, & Hayes, 2002).
It is an unfortunate fact is that, in the prenatal appointments, most of the interaction between the
obstetrician and the patient is mainly medically related and the social and psychosocial aspects are very
often forgotten (Roter, Geller, & Bernhard, 1999),which means that even if these symptoms are already
present they may not be noticed by the health care professionals (Wiley, Burke, Gill, & Law, 2004;
Sleath, Thomas, Jackson, West, & Gaynes, 2007)
Several limitations may have affected the results of this study. One of these was that the presence
of psychopathology in women before pregnancy was not evaluated and this information could have
altered the findings and conclusions of the study. Another limitation of our study was the way the baby's
development and behavior was evaluated. While the Griffiths 0-2 was applied twice by two psychologists
during the study and through direct observation, the information collected through the BITSEA was done
through the oral maternal report and may have been influenced by their perception of appropriate
behavior. An additional limitation was the absence of information about maternal social support and
postnatal mental health. Further, since the study was based on a convenience, rather than a population
sample there is a need for further, more broadly based research on common mental disorders and how
they may affect the social, emotional and intellectual developments at ages beyond one year.
The results of this study are consistent with the published literature. However, there is a need to
extend such studies until later ages, in order to investigate long term developmental effects. The
identification of patterns of psychopathology in women during pregnancy may provide an important
opportunity to begin a program of support for these women in order to optimize the mother-baby
relationship and, consequently, the mental development of their children. Many mothers, especially those
having a baby for the first time, feel that they are not ready or well enough prepared to provide for their
babies (Heneghan, Mercer, & Deleone, 2004) and are, therefore, eager to talk to health professionals
about parenting and thus there is a real opportunity to intervene at this time.

323

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Table 1. Characterization of the sample

Profession

(%)

Students

(2,2%)

Housewives

40

(22,1%)

Health

12

(6,6%)

Area of trade and

84

(46,4%)

Education

12

(6,6%)

Banking

(2,8%)

Another area

24

(13,3%)

1st cycle

39

(20,2%)

Second cycle

60

(31,1%)

Secondary
education

46

(23,8%)

services

Schooling

326

Undergraduate
degree
Graduate degree

46

(23,8%)

(1,0%)

Single

38

(20,8%)

Married

100

(54,6%)

Living with a
partner
Divorced or
separated

31

(16,9%)

14

(7,7%)

Maritial status

Table 2. Characterization of BSI - Pathology frequency

Somatization
Obsessive Compulsive
Interpersonal sensitivity
Depression
Anxietyy
Hostility
Phobic anxiety
Paranoid ideation
Psychoticism
GSI
PST
PSDI

N
51
51
46
42
34
68
54
66
55
53
33
63

(%)
(25,6)
(25,6)
(23,4)
(21,2)
(17,2)
(79,1)
(27,4)
(33,5)
(27,8)
(27,5)
(17,1)
(32,6)

Table 3. Characterization of IACLIDE - Depression frequency

N
(%)
Non Depression
156
(80,8)
MildDepression
28
(14,5)
ModerateDepression
7
(3,6)
SevereDepresssion
2
(1,0)

Table 4. Characterization of the values in the Griffiths Mental Development Scale (0-2) using the BSI
P2
No Pathology
With pathology
327

Locomotor
Personal Social
Hearing and Speech
Eye-Hand
Coordination
Performance
Global Scale
* p< .05 **p< .01 ***p< .001

M
101,2
101,4
97,6
103,1

(SD)
(20,9)
(24,8)
(17,0)
(16,0)

M
108,6
94,3
99,8
95,8

(SD)
(19,4)
(24,4)
(15,1)
(19,6)

p
0,140
0,248
0,586
0,108

99,1
100,4

(15,6)
(14,9)

94,5
98,3

(19,8)
(15,8)

0,298
0,576

Table 5. Characterization of the values in the Griffiths Mental Development Scale (0-2) using the BSI P3
No Pathology
With pathology
M
(SD)
M
(SD)
p
Locomotor
100,2
(16,4)
93,6
(14,3)
0,107
Personal Social
106,7
(15,9)
99,8
(19,2)
0,135
Hearing and Speech
113,9
(9,4)
110,2
(12,7)
0,207
Eye-Hand
111,5
(13,8)
107,7
(14,1)
0,292
Coordination
Performance
102,9
(10,8)
102,2
(10,6)
0,815
Global Scale
107,2
(10,3)
102,0
(11,4)
0,070
* p< .05 **p< .01 ***p< .001

Table 6. Characterization of the values in the Griffiths Mental Development Scale using BSIs
subscales P2
Negative Diagnose
Positive Diagnose
N
M
SD
N
M
SD
Anxiety
170
34
Personal - Social
98,7
(20,8)
86,1
(20,8)
Performance
99,2
(16,5)
88,8
(20,3)
Global Scale
101,2
(14, )
93,3
(15,9)
Obsessive153
51
Compulsive
Hand101,0
(17,4)
94,8
(19,0)
EyeCoordination
Depression
162
42
Locomotor
105,9
(17,0)
106,8
(21,7)
Psychoticism
55
149
Hand101,4
(17,4)
93,9
(18,8)
EyeCoordination
328

p
0,004**
0,004**
0,008**
0,051
0,018*
0,017*

Performance
* p< .05 **p< .01 ***p< .001

99,3

(15,9)

92,4

(20,9)

0,024*

Table 7. Characterization of the values in the Griffiths Mental Development Scale using BSIs
subscales P3
Negative Diagnose
Positive Diagnose
p
M
SD
M
SD
Depression
Personal-Social
106,5
(15.5)
98.8
(17.5)
0.021*
Global Scale
107.6
(10.7)
102.7
(12.9)
0,038*
Hostility
Global Scale
111.2
(91.1)
103.5
(11.5)
0.030*
* p< .05 **p< .01 ***p< .001

Table 8. Characterization of the values in the Griffiths Mental Development Scale using IACLIDE T2
No
pathology

Locomotor
Hand-Eye Coordination
Performance
Total Score

With
pathology

(SD)

(SD)

108
101
99
101

(15,8)
(16,5)
(16,2)
(13,4)

99
93
89
93

(22,9)
(23,5)
(21,6)
(18,3)

Table 9. Association between BSI and BITSEA

Negative BITSEA
N
(%)
BSI Negative Diagnose
2
9
BSI Positive Diagnose
25
90.9

0,006
0,041
0,003
0,006

Positive BITSEA
N
(%)
0
0
20
100

329

330

ANEXO 7
PAPER 4

331

Mother-infant relationship during pregnancy and babies development in the first year

Abstract

The need to establish emotional ties is vital to the human being. As we create our relationship with the
world, we do so by developing an emotional bond with those who care for us, thus creating and
developing our internal working models. This process starts long before birth with the development of the
maternal-fetal relationship (Cirulli, Berry, & Alleva, 2003).
Our objective with this study was to gauge how, in Portuguese pregnant women, the mother-baby
relationship during the pregnancy affects babies Mental and Social-Emotional Development.
Two hundred and four pregnant women and their babies, outpatients of the Obstetrics and Gynecology
and Peadriatics Departments of the Hospital Pedro Hispano in Matosinhos, Oporto, Portugal, were the
subjects of this study.
Our results demonstrated a statistical significance in the Locomotor subscale, babies born to women who
have a high MFA during pregnancy have a hight mean value.

Keywords: Mother-infant relationship, maternal-fetal attachment, infant mental development,

infant social-emotional development.

Mother-infant relationship during pregnancy and babies development

Research has shown us the great role that the mother-infant relationship plays in the
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neurobiological and psychological development of the babies. When born, the babies are totally
dependent on the adults for survival and the mother-baby relationship is of extreme importance in
regulating their internal and external states.
It is now known that this relationship begins long before birth; it starts when a woman gets
pregnant and the child is only a fetus (Laxton-Kane, 2002; Piontelli, 1995; Caron, 2002), as demonstrated
in a procedure in which a pregnant womans libidinal energy is cathected into the fetus (Deutch, 1945;
Benedek, 1959) and what we witness is known as the Maternal-Fetal Attachment (MFA).
The Maternal-Fetal Attachment refers to an initial phase of a continuum process of mother-infant
attachment that extends itself into the postnatal period (Grace, 1989; Muller & Ferketich, 1993; Piontelli,
1995) defined as the extent to which women engage in behaviors that represent an affiliation and
interaction with their unborn child (Cranley, 1981) as a unique relationship between a women and her
unborn fetus (Muller & Ferketich, 1993).
The MFA describes the behaviors and attitudes of pregnant, being these behaviors based on
cognitive representations that include imagery of the mother as well as the representations of the physical
and emotional characteristics of the fetus (Siddiqui & Hagglof, 2000), which are related to cognitive and
emotional abilities to conceptualize another human being and develops within an ecological system (Doan
& Zimerman, 2003).
Studies have confirmed that the attachment with the fetus is generally developed upon the basis of
an internal representation which is more and more elaborate and personified of the fetus as pregnancy
develops (Lumley, 1972), expressed in behaviors that demonstrate care and commitment to the fetus
(Hart & McHahon, 2006).
During pregnancy both parents usually acquire an internal and increasingly elaborate
representation of the fetus. This comprises a curious mixture of fantasy and reality, being on this internal
image that the emotional bond develops (Condon, 1993).

333

The intrauterine life and experiences of the baby will be influenced by the experiences of the
mother (Wilheim, 2000). A positive association between attachment during pregnancy and the presence
of fetal activity has been demonstrated by Heidrich and Cranley (1989).
MFA also has significant implications for maternal-infant bonding in the postpartum period and
can be positively correlated with the mother-child relationship and the social, emotional and cognitive
developments (Muller & Ferketich, 1993). Findings suggest that mothers with higher prenatal levels of
MFA are more likely to score higher on the subsequent measures of infant attachment (Fuller, 1990).
We know from the attachment theory how important the quality of the attachment between child
and mother is and of the important implications it has for the development of self-confidence, selfesteem, sociability and other developmental aspects of the child (Verssimo, Moteiro, Vaughn, & Santos,
2003).
Several studies (Kirsh & Cassidy, 1997; Belsky, Spritz, & Crnic, 1996) emphasize the connection
between quality of attachment in infancy (Mendes, 2002) and the areas of social, cognitive, and emotional
development (Thompson, 1998).
Tampering with the infants surrounds may affect the ongoing development of the nervous system
which will concur in determining the individual differences in physiological and behavioral responses to
environmental challenges (Cirulli, Berry, & Alleva, 2003).
Disruptions in the mother-infant relationship has been shown to cause neuroendocrine,
neurochemical and behavioral alterations in the adult organism, even though the exact causes for these
changes have not yet been completely understood (Cirulli, Berry, & Alleva, 2003). Early disruption of the
mother-infant relationship has effects on brain plasticity and implications for psychopathology in the
baby (Cirulli, Berry, & Alleva, 2003).
The capacity of the babies have to regulate their own emotions is an important early
developmental milestone with significant implications in many areas of the babys development.
Nevertheless, emotion regulation during infancy is a dyadic process because the caregiver is crucial in
providing the guidelines that the child needs, which in turn will contribute for a much easier growth of an
334

autonomous child regulation (Kopp, 1989).

The baby's inborn capacity of imitation and regulation of visual/auditory stimulation is gradually
patterned and supported by the mother's empathetic response (Lier, 1988).
The quality of the initial interaction is considered an important mediator between prenatal events
and their further development, particularly with regard to communication, socialization and cognition
(Siddiqui & Hagglof, 2000).
The results of studies conducted in the area relating maternal characteristics and present and future
development of the child show links between maternal sensitivity, quality of the connection established
and the posterior emotional and cognitive development (Oppenhein & Lamb, 1988).
It has been shown that maternal behaviors of attachment promotion correlate with factors such as
positive attitudes and adaptation during pregnancy (Zimerman, 2003).
The aim of this study was to assess the Mental Development and Socio-Emotional status of
infants during their first year of life, taking into account the Maternal-Fetal Attachment and the Maternal
Adjustment and Maternal Atitudes during pregnancy.

Method
Participants
The participants in this study were 204 pregnant women in their third trimester of pregnancy (P1)
and their babies at 3.5 (P2) and 12 months old (P3).
Regarding socio-demographic data in P1, the marital status of the women was that 38 (20.8%)
were single, 100 (54.6%) were married and 31 (16.9%) were unmarried but lived with a partner and 14
(7.7%) separated or divorced. As for the occupation 84 (46.4%) reported working in the area of trade and
services, 40 (22.1%) were domestic, 12 (6.6%) worked in health care and the same percentage in
education, 5 (2.8%) worked in the area of banking, 4 (2.2%) were students and 24 (13.3%) of the women
surveyed worked in another area other than those mentioned above. With regards to education, 39
(20.2%) of the participants finished grade six, 60 (31.1%) had finished grade 9, 36 (23.8%) completed
335

high school education and the same percentage had a bachelors degree and 2 (1%) of the respondents had
a post-graduation.
During pregnancy 36 (23.5%) of the women engaged in some sort of physical exercise, 33
(21.4%) smoked and 6 (3%) drank alcohol.
Materials
Socio-demographic questionnaire.
The socio-demographic questionnaire consists of questions intended to characterize the
participants in terms of age, profession, education level, marital status, whether or not they do some
physical exercise, smoking, alcohol or drugs consumption before and/or during pregnancy, folic acid
consumption and the existence of prior psychiatric or psychological diseases.
Maternal Fetal Attachment Scale (MFAS: Cranley, 1981 - Portuguese version, Mendes,
1998).
Maternal-Fetal Attachment was measured using the Maternal-Fetal Attachment Scale (MFAS).
MFAS measures the extent to which pregnant women engage in behaviors that represent an affiliation
and interaction with their unborn child (Cranley, 1981).
This scale is composed of 24 items divided into five subscales: Differentiation of self from the
fetus; Interaction with the fetus; Attributing characteristics and intentions to the fetus; Giving of self and
role-taking. The MFAS 5-point Likert scale range from Definitely Yes to Definitely No and are
scored from 1-5, with 5 being the most positive statement. A mean score is then calculated by dividing
the sum of the items scored by the number of items answered, resulting in potential scores for the scale
ranging from 24-120, with high scores indicating a high level of Maternal-Fetal Attachment (Cranley,
1981). In this study only the Global Scale was used disregarding the subscales.
The MFAS had adequate internal consistency in this study (Cronbachs .76).
Maternal Adjustment and Maternal Atitudes (MAMA: Kumar, Robson & Smith, 1984
Portuguese version Figeiredo, Mendona, & Sousa, 2004).

336

The MAMA questionnaire is a 60-item self report to measure maternal adjustments and attitudes
during the pregnancy and towards the baby. The complete questionnaire consists of five subscales: Body
Image; Somatic Symptoms; Marital Relationships; Attitudes to Sex and Attitudes to Pregnancy/Baby.
The answering format is likert type, fluctuating between 1 (never / not at all) and 4 (very often / very
much during the last month). The scoring of the items is done on a 4-point scale, with the most desirable
option listed as 1 and 4 for the less desirable, thus, the higher the score the least desirable is the
atitude.The sum of scores is calculated for the whole sub-scale ranging from 12 to 48 and for the Global
scale ranging from 60 to 240. The MAMA had adequate internal consistency in this study (Cronbachs
.82).
Griffiths Mental Scale 0-2 (Griffiths 0-2: Griffths, 1996 Portuguese version Castro & Gomes,
1996).

Griffiths Mental Scale (0-2), measures the development trends which are significant for
intelligence or indicative of functional mental growth in babies and young children from birth to a
developmental age of two years.
It is composed of five subscales: A - Locomotor; B - Personal-Social; C - Language; D - Eye and
Hand Coordination; E - Performance. The raw score for each child is transformed to produce an agestandardized Mental Development Index.
The Griffiths had adequate internal consistency in this study (Cronbachs .89).
Brief Infant-Toddler Social and Emotional Assessment (BITSEA: Briggs-Gowan&Carter,
2004).
The BITSEA consists in a screening for Social-Emotional behavior development and
competencies of babies from 12 to 35 months 30 days, with possible Social-Emotional and problem
behaviors and/or possible delays or deficits in Socio-Emotional competencies, including autism spectrum
disorders. The BITSEA was derived from the longer ITSEA. It consists of 42 items with Lickert-type
responses ranging from 0 (false/rarely) to 2 (true/often). The BITSEA produces two scores: a Problem
Scale score and a Competence Scale score, with higher scores representing greater problems and greater
competences, respectively.
337

A baby, who at 12 months old scores a value equal or higher than 13 in the problem domain or a
value equal or lower than 11 in the competencies domain is considered as having a positive screen on
BITSEA.
In this study the BITSEA had adequate internal consistency (Cronbachs .79).
Procedure
It was a convenience sample having been randomly collected in the Obstetrics and Gynecology
Department, at Hospital Pedro Hispano, Matosinhos, Portugal, during routine appointments. Participants
were approached by the nurse or the obstetrician, who briefed them about the study and asked if they
wanted to participate. To be part of the sample, the following inclusion criteria would have to be met:
older than 16 years of age, to have at least 25 weeks of gestation and to be of Portuguese nationality. All
participants signed a consent form (Helsinki declaration), (World Medical Association, 2000) and were
told that the questionnaire would be treated anonymously and that they could withdraw from it at any
time during the study if they so wished. The ethical commission of the Hospital Pedro Hispano approved
this study. Data collection took place between 2008 and 2010.
A cohort study was conducted in three distinct periods. Data collection began during the third
trimester of pregnancy (P1), where we examined the maternal-infant relationship and the maternal
attitudes towards the fetus (MAMA and MFAS). At that time it was also applied a small sociodemographic questionnaire.
After the babies birth, one assessment of their overall mental development at 3.5 months (P2)
was performed using the Griffiths (0-3) and at 12 months (P3) an assessment of their mental development
and also of their socio-emotional state was carried on, respectively with the Griffiths Scale (0-2) and the
BITSEA. Data that could not be directly observed was, as contemplated in the scales, asked to the
mothers.
Statistical-analysis. Through descriptive analysis, categorical variables were described by absolute (n)
and relative (%) frequencies. The analysis was performed using the Student t test for independent

338

samples, chi-square and Fischer exact test. In all the hypothesis tests a level of significance of 0.05 was
considered. All data was analyzed with the Statistical Package for Social Sciences (SPSS version 19).
Results
Through the analysis of Maternal-Fetal Attachment (MFA) during pregnancy and Mental
Development of infants at 3.5 months old, it was found that babies born to women who scored as having
a low MFA had a lower Global Mental Development mean value in the Global Griffiths Scale than
babies born to women who showed a High MFA nevertheless, these differences did not have statistical
significance (Table 1)
The same results appeared in the analysis of babies Mental Development at 12 months old, where
babies born to women who scored as having a low MFA during pregnancy had lower mean for Global
Mental Development compared with babies born to women with a high MFA during pregnancy, without
statistical significance. We found a statistical significance in the Locomotor subscale, babies born to
women who have a high MFA during pregnancy have a hight mean value than babies born to women who
have show a low MFA during pregnancy (Table 2).
When we correlated data from Maternal Adjustment and Maternal Attitudes (MAMA) and infant
Mental Development, it was found that babies at 3.5 months, born to women who scored as having a low
MAMA had lower Global Mental Development values, when compared with babies born to women who
scored as having a high. However, these values were not statistically significant (Table 3).
At 12 months of age, we found that babies born to women with low MAMA had a higher mean
value of Global Mental Development (M=107.1; SD=11.3), and in the Locomotion subscale showed a
statistically significant higher mean value (Table 4).
With regards to the association between Mother-Infant relationship during pregnancy (MFAS and
MAMA) and babies Social-Emotional State, we analyze the boys and grils separately.
When we analyzed MFA and Social-Emotional state at 12 months, we found a total of 23 (31.5%)
infants with a positive screen for BITSEA, being 4 (5.5%) infants born to women who scored has having

339

low MFA and 19 (26%) infants born to women who scored as having high MFA. These values showed no
statistical significance.
Specially when we explored if the BITSEA positive screens in babies born to mothers with a low
MFA was due to higher scores in the Problem or Competencies domains, we found a total of 3 (4.1%)
infants born to women who scored has having low MFA scored positive for the Problem domain and 2
(2.7%) infants born to women who scored has having low Maternal-Fetal Attachment who presented a
positive screen for the Competencies domain. These values showed no statistical significance.
When we analyzed Maternal Adjustment and Attitudes during pregnancy and Social-Emotional
sate at 12 months we found a total of 30 (39.5%) infants with a positive screen for BITSEA, being 16
(21%) infants born to women who scored has having low MAMA during pregnancy and 14 (18.4%)
infants born to women who scored has having high MAMA.
These differences had statistically significant values for the group of the boys group (Table 5).
When we analyzed if the positive screen for BITSEA in the babies born to women with a low
score for MFA was due to higher scores in the Problem or Competencies domains we found a total of 15
(19.8%) infants born to women who scored has having low MAMA during pregnancy who presented a
positive screen for the BITSEA Problems domain. Once again these differences were statistically
significant for the boys (Table 6).
In what concerns BITSEA Competencies domain, it was possible to observe a positive screen for
7 (9.2%) infants, born to women who scored has having low MAMA during pregnancy. Therefore,
infants born to women who scored has having low MAMA during pregnancy, presented a BITSEA
positive screen, apparently because they had more problems and not because their lacked the
competencies to solve them.

340

Discussion
The purpose of this investigation was to study how the Maternal-Fetal Attachment and Maternal
Adjustment and Maternal Attitudes during pregnancy influenced babiess Mental and Socio-Emotional
Development at 3.5 and 12 months old.
Studies show that mothers who provided more affection during pregnancy and that, in general,
fantasized about their unborn babies, showed a greater global involvement in the interaction by being
more active, especially in stimulating their babies (Siddiqui & Hagglof, 2000). The mother does play a
critical role in the interaction and development of the infant (Thomas, Lima, Tavares, & Oliveira, 2005;
Lopes, Oliveira, Vivian, Bohmgahren, Piccinini, & Tudge, 2007; Frizzo & Piccinini, 2007; Piccinini, R.,
Gomes, & De Nardi, 2008; Seild-De-Moura, Ribas, Seabra, Rocha, & Vicente, 2008).
Our study findings revealed that babies at 3.5 months and one year of age, born of mothers
classified with a good MFA during pregnancy had a higher Global Mental Development than infants
whose mothers did not. In the same line babies who were born to mothers with a good MAMA during
pregnancy had better levels of Social-Personal, Eye-Hand Coordination, Realization as well as a better
Global Mental Development. In addiction, studies have showed that MFA can be positively correlated to
the mother-infant attachment and to the social, emotional and mental development in the postnatal period
(Condon & Corkindale, 1997).
We know from research that in the first months of age, a baby has already built up the primary
structures of social interactions (Costa, 2009), the expansion of these interactions will not be noticeable if
the mother does acknowledge the babys signs (Lier, 1988). If there is not basic social interaction the
baby will be at lost interpreting the social contact. In more extreme cases of a mother total failure in
responding to the babys needs it will cause an emotional recession where the baby will withdraw and be
easily disturbed by social contact to the point of even avoiding eye contact (Lier, 1988). Interestingly, in
our study babies born to mothers with a low MFA presented higher values in the Language and
Performance subscales. We think that one of the hypotheses for this to have happened is that these babies
made more sounds and gestures to get their mothers attention, as an expression of their need for
341

emotional survival. This being true, their capacity to awaken their mothers attention seemed to have
faded out at 12 months as if the babies had just given up. The infants who employ their coping strategies
unsuccessfully and repeatedly fail to repair mismatches will begin to feel helpless. These infants
eventually give up attempting to mend the misalignments and increasingly focus their coping behaviors
on self-regulation in order to control the negative emotion generated (Costa, 2009).
When babies reach 10-12 months of age they are capable of crawling around trying to explore and
get familiar with their surroundings. At this stage well adjusted babies are able to grasp that there other
forces and powers besides their own. The mothers can boost or halt the children by oral and corporal
signals. The children may challenge, agree or rebut and this will reflect and show their personality (Lier,
1988).
In our study we found that one year old infants born to women with low MAMA during
pregnancy had a higher Locomotor development when compared with infants born to mothers with a
good maternal adjustment during pregnancy. Siddiqui & Hagglof (2000) argue that children actively seek
information from the beginning and use, to the effect, the mother as an instrument during the interaction.
In line with this, in our study, it seems that babies born to mothers with low MAMA, needed to make a
bigger effort to compensate this gap by using locomotion, such as movements of arms and legs, to try to
interact with their mothers and to seek information, than the ones born to mothers with a higher MAMA
value.
The literature indicates that the socio-demographic variables that influence the MFA would be the
advancement of gestational age, fetal movements and social support from family members and peers
(Doan & Zimerman, 2003). These findings were confirmed in this study because, in general, the level of
MFA was medium to high reducing the comparable differences between the two groups, since the
pregnant in this study did not have statistically significant differences concerning socio-economics factors
like gestational age social support or the marital status. This is probably the reason why in our study we
found more babies with a positive screen for BITSEA who were born to women who scored has having
high Maternal-Fetal Attachment.
342

The fact that the level of MFA, in the whole sample was medium to high, can also be attributed to
the fact that the women interviewed were already in their last trimester of pregnancy during which fetal
movements are already instituted, which may have influenced the results in positive attachment, since
MFA increases over the course of the pregnancy (Grace, 1989).
According to the attachment theory stressful contextual factors activate the internalized
attachment system leading to behavioral and emotional responses. In the case of pregnant women, the
transition to motherhood becomes a stress factor that activates the internal working model of attachment,
therefore, the manifestation of psychological distress may occur, among other factors, because of the
internalized type of attachment (Mohler, Parzer, Brunner, Wiebel, & Resch, 2006).
Leifer in 1977 concluded that while pregnancy was a time of emotional upheaval and rapid role
change, it was also a time of maturation development.
The mother's ability to accommodate in her own mind the notion that her baby has feelings,
desires and intentions, as her primary maternal concern (Winnicott, 1988) creates a state in which the
mother is able to emphasize with the primary needs of the baby, gives the baby a secure base to discover
his/hers own feelings and thoughts, and it takes us back to the mother's inner qualities that allow her to be
sensitive to her babys needs which is crucial for the babys development (Fonagy, 1996).
It was possible to verify that infants born to mothers with low maternal adjustment presented
difficulties at the social and emotional levels. Temperament influences behavior and experience, and
provides the essential biological basis for the development of personality (Costa, 2009). This definition
highlights the importance of temperament as a framing that allows the association of psychological and
neurophysiological research (Goldsmith, Buss, Plomin, Rothbart, Thomas, Chess, Hinde, McCall, 1987).
The temperamental characteristics are relatively stable over time, with periods of instability and
stability according to the transitions of maturation (Rothbart, 1989). It may be that while some
characteristics change, others remain stable. The expression of temperament is influenced by the degree
of stimulation and regulation provided by the environment and vice versa, in a model of interaction
(Rothbart, 1989).
343

The quality of the first relationships and of those that are closer to them will make the babies to
have a more organized behavior even at an early stage of their lives and having thus an active role in their
own development (Zamberlan, 2002).
This study showed that maternal experiences of affections are associated with the mother-infant
interaction providing a better or worse Mental, Emotional and Social Development, and as such, can be
an important diagnostic aid to identify women for whom the mother-baby relationship is sub-optimal.
In this study we only evaluated the Maternal-Fetal Attachment and the Maternal Adjustment at the
beginning of the research, for future investigations we would suggest that the relationship is studied all
through pregnancy in order to be able to verify the variance of the relationship throughout this period. It is
also suggested for future investigations to study the types of attachment present in the babies.
Another limitation in this study was the failure to study the mental health or maternal social
support as these factors may have influenced the MFA and MAMA.
Even though, our findings might have been affected by some limitations, like the sample size
which resulted in a design that may have underpowered the findings, it would be important to conduct
more research in this field in order to better understand the MFAS and MAMA, during pregnancy.

344

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Table 1. MFAs and Griffiths Mental Scale 0-2 at 3.5 months.

Low HFA

High MFA
p

(DP)

(DP)
M

Locomotion

104,4

(16,9)

106,7

(18,2)

0,523

Personal-Social

93,5

(18,5)

97,4

(22,1)

0,366

Language

102,3

(13,5)

99,9

(16,4)

0,445

Eye-hand coordination

95,4

(18,3)

101,2

(17,0)

0,099

High
97,7MFA (18,2)

0,797

Performance
Global

Low 98,6
HFA

(12,9)

99,2

(12,7)
(DP)

100,3

(14,7) p 0,705
(DP)

M
Locomotion

104,4

(16,9)

106,7

(18,2)

0,523

Personal-Social

93,5

(18,5)

97,4

(22,1)

0,366

Language

102,3

(13,5)

99,9

(16,4)

0,445

Eye-hand coordination

95,4

(18,3)

101,2

(17,0)

0,099

Performance

98,6

(12,9)

97,7

(18,2)

0,797

Global

99,2

(12,7)

100,3

(14,7)

0,705

348

Table 2. MFAS and Griffiths Mental Scale 0-2 at 12 months

Low MFA

Hight MFA
p

(DP)

(DP)

Locomotion

94,5

(16,9)

100,7

(12,7)

0,038

Personal-Social

102,1

(18,1)

105,8

(15,7)

0,305

Language

111,6

(11,3)

114,4

(11,8)

0,276

Eye-hand coordination

109,8

(16,8)

112,5

(13,9)

0,401

Performance

104,1

(13,0)

103,3

(12,9)

0,785

Global

104,7

(14,0)

107,2

(10,6)

0,314

Table 3. MAMA and Griffiths Mental Scale 0-2 at 3.5 moths

Hight

Low

MAMA

MAMA

(DP)

(DP)

Locomotion

106,9

(17,2)

104,6

(19,2)

0,523

Personal-Social

97,4

(18,9)

94,9

(23,9)

0,366

Language

99,8

(16,6)

99,8

(16,0)

0,445

Eye-hand coordination

99,8

(15,1)

98,3

(21,3)

0,099

Performance

98,3

(15,7)

96,0

(19,7)

0,797

Global

100,4

(13,0)

98,8

(16,5)

0,705

Table 4. MAMA and Griffiths Mental Scale 0-2 ate 12 moths

349

Higth

Low

MAMA

MAMA

Valor-p*

(DP)

(DP)

Locomotion

98,4

(13,7)

100,4

(13,3)

0,038

Personal-Social

105,5

(17,3)

104,5

(14,6)

0,305

Language

113,4

(11,7)

114,3

(11,9)

0,276

Eye-hand coordination

111,4

(14,1)

112,6

(15,1)

0,401

Performance

102,2

(11,5)

105,0

(14,2)

0,785

Global

106,3

(11,3)

107,1

(11,3)

0,314

Table 5. BITSEA (boys) and MAMA

Negativo
N
Abaixo da mdia

(%)

12 (80,0)

Positivo
N

(%)

7 (41,2)

(30,8)

Valor-p*

0,036

Table 6. BITSEA (Problems domain - Boys) and MAMA

Negativo
N

(%)

Positivo
N

(%)

Abaixo da mdia

14 (82,4)

5 (33,3)

Acima da mdia

3 (17,6)

10 (66,7)

350

Valor-p*

0,010

ANEXO 8
PAPER 5

351

Violence during pregnancy and its effects on motherbaby relationship during pregnancy

Abstract
Background: Human beings have an innate need to form close emotional bonds with significant
others (Schmidt & Argimon, 2009).
Objective: The purpose of this research was to study the effect of domestic violence during
pregnancy in the mother-infant relationship. Method: 204 pregnant outpatients (of the Obstetrics
and Gynecology Department of the Hospital Pedro Hispano, Portugal) with a mean age of
twenty-nine and in their last three months of pregnancy were the participants of this study. To
assess the violence level during pregnancy, we used the Conflict Tactic Scale 2 (CTS2). The
mother-baby relationship was determined using the Maternal Fetal Attachment Scale (MFAS)
and the Maternal Adjustment and Maternal Attitudes questionnaire (MAMA). Results: In our
work, we encountered one hundred and seven pregnant victims (52.4% of all outpatients) of
domestic violence. The results showed that victims of domestic violence had a poor relationship
with the foetus (M = 97.4, SD = 8.1), but not to the point of statistical significance. In these same
patients, we also detected minor adjustments and attitude shifts towards pregnancy (M = 117, SD
= 14.2) and this result was statistically significant when compared with women who did not
experience domestic violence. Conclusion: Our results suggest that women who are victims of
domestic violence are more likely to have a lower attachment with the foetus when compared
with women who dont suffer domestic violence. Additionally, the victims showed more
negative attitudes towards pregnancy and the foetus when compared to non abused women.

Keywords: Violence; Pregnancy; Mother-Fetal Attachment; Maternal Adjustment and

Maternal Attitudes.

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353

Violence during pregnancy and its effects on motherbaby relationship during pregnancy

During pregnancy, women undergo many psychological changes. It is a complicated

process that requires many adjustments to everyday routine and it can also impact on personal
relationships (Canavarro, 2001). When these changes are associated with domestic crises and
marital abuse, the picture becomes particularly severe, further enhancing the negative
consequences of abuse alone.
Many international studies have shown a prevalence of intimate partner violence during
pregnancy anywhere from 1% to 32% of reported cases (Rachana, Suraiya, Hisham, Abdulaziz
& Hai, 2002; Reichenheim, Moraes & Hasselmann, 2000; Menezes, Amorim, Santos & Fandes,
2003; Janssen, Holt, Sugg, Emanuel, Critchlow & Henderson, 2003; Bacchaus, Mezey &
Bewley, 2003; Castro & Ruiz, 2004). Such a wide range of results suggests that domestic
violence is interpreted differently across cultures and as in most studies, these findings are
dependent on population sample and the method of data collection.
According to known research studies conducted in Portugal, the prevalence and incidence
of intimate partner violence during pregnancy reported in a 24 hour postpartum period is 8.4%
and 9.7%, respectively (Rocha, 2006).
Contrary to common belief, pregnancy does not seem to protect women from domestic
violence. Indeed, many of them even report increased frequency and abuse patterns change
during this period (Glander, Moore, Michiellutte & Parson, 1998). Previous research studies
suggest that pregnancy and the months following birth are periods of increased risk for abuse
(Moraes & Reichenheim, 2002; Gazmararian, Lazorick, Ballad, Saltzman & Marks, 1996;
Stewart, 1994).

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354

In abused women, it is likely that the internal models of self and others are affected by
domestic violence, especially during pregnancy when they are forming and rearranging
representations of themselves as caregivers and of their babies (Leifer, 1977; Lumley, 1982;
Zeanah, Carr, & Wolk, 1990). In women, foetus movements can be perceived as a threat and/or
may re-evoke aspects of the trauma associated with having been raped by their partner (HutchBoks, Levendosky, Theran & Bogota, 2004; Fraiber, 1980).
It is important to note that pregnancy invokes internal representational models in a
woman where she has to assess the relationship she had with her own mother. Similarly, she is
developing attitudes and representations about her own development as a child, in three forms: of
her own mother and respective attachment relationship; of her baby; and of the new role as a
mother herself (Bibring, Dwyer, Huntington & Valenstein, 1961; Hutch-Boks, Levendosky,
Theran & Bogat, 2004).
Some qualitative studies on maternal behaviour adjustment to pregnancy suggest that the
Maternal Fetal Attachment (MFA) is greatly influenced by a womans own representations of
her foetus/baby. These representations are built upon the image she has of the fetal physical and
emotional characteristics and even by creating scenarios of her interactions with the baby (Rubin,
1975). Additionally, the current research views are being expanded to also include the fetal
period as an important attachment stage (Chamberlain, 1994; Piontelli, 1995; Caron, 2002),
demonstrating that the MFA is a predictor of postnatal attachment between mother and baby
(Rubin, 1965).
MFA is a term used to describe the relationship between a pregnant woman and her
foetus. Cranley (1981, p. 282) defined the MFA as "the degree to which the mother manifests
behaviors that represent the membership and integration with her child intra-womb".
The MFA can be accessed by a womans caring attitudes towards her foetus (Salisbury,
Law, LaGasse & Lester, 2003). Women who experienced domestic violence are significantly
more likely to be classified as insecurely attached mothers (Hutch-Boks, Levendosky, Theran &
Bogat, 2004) and to show reduced MFA scores (Quinlivan & Evans, 2005).
In addition to the attachment process during pregnancy, we should consider the formation
of maternal identity, maternal sensitivity and the womans representations of her baby and her
role as a mother as important developmental aspects (Rubin, 1975; Hart & McHahon, 2006;
Relvas, 1996; Bibring, Dwyer, Huntington & Valenstein, 1961; Leifer, 1977).

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355

Domestic violence is considered a risk factor for maternal and infant well-being since
women who experience domestic violence have significantly more negative representations of
their infants and of themselves as mothers (Hutch-Boks, Levendosky, Theran& Bogota, 2004).
Women abused during pregnancy report higher levels of anxiety, depression and
emotional stress (Campbell, Poland, Waller & Ager, 1992; Resnick, Kilpatrick, Dansky,
Saunders & Best, 1993). These women tend to be physically aggressive towards their children
and have a greater inconsistency in parenting (Holden, Ritchie, Harris & Jouriles, 1998).
Studies show that infants born to abused mothers are more likely to remain in the hospital
after their mothers discharge (Dye, Tollivert, Lee & Kenny, 1995). Additionally, these children
are more likely to have insecure, or disorganized attachments (Zeanah, Danis, Hirshberg, Benoit,
Miller & Heller, 1999) and greater chance of presenting symptoms of posttraumatic stress
disorder, hyperactivity, increased fear/aggression/irritability/disturbances (Scheering & Zeanah,
1995) and regressive behaviors (Osofsky, 1999).
In our work, we investigated the effects of domestic violence on the adjustment and
attitudes towards pregnancy, as well as maternal fetal attachment in abused pregnant women.
METHOD
Participants
A convenience sample was drawn from participants attending outpatient appointments in
their routine prenatal clinic at the Obstetrics and Gynecological Department of Pedro Hispano
Hospital, Matosinhos/Oporto, Portugal. All women required to be in the third trimester of their
pregnancy, aged between 16-25 and to be of Portuguese nationality.
Two groups were created: Group 1 consisted of non-abused pregnant women (n=77,
41.8%) and Group 2 consisted of (n=107, 58.2%) pregnant victims of domestic violence.

Materials
Three psychometric scales were used to assess participants.
The forms were composed of a brief Socio-demographic questionnaire designed for the
study, the Conflict Tactics Scale 2 (Figueiredo & Alexandra, 2006), the MFAS (Mendes, 2002)
and the MAMA (Figueiredo, Mendona & Sousa, 2004), and it were performed on P1, when
women were in there third trimester of pregnancy.

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In addition to the three psychometric scales demographic details were noted. The
following data were gathered from participants: age; marital status; profession; schooling and
health habits.
Conflict Tactic Scale 2 (CTS2, Straus, Hamby, Boney-McCoy, & Sugarman, 1996
Portuguese version Figueiredo & Alexandra, 2006)
The Conflict Tactic Scale 2 (CTS2, Straus, 1996) measures the extent to which partners
in a dating, cohabiting, or marital relationship engage in psychological and physical attacks on
each other and also their use of reasoning or negotiation to deal with conflicts. The scale
measured a total of 39 behaviours, for a total of 78 questions. Each of these behaviours can be
divided into five categories: Physical Assault; Injury; Psychological Aggression; Sexual
Coercion, and Negotiation. The response format includes eight categories, (from 0 (never) to 6
(more than 20 times), and an additional 7th category (not during these time periods, but it
happened before), with the first six determining the prevalence and chronicity in the last year.
Higher scores indicate greater severity of abuse. To determine the severity of the acts, the
psychological, physical, and sexual subscales include items that can be classified as minor or
severe.
CTS2 shows a high coefficient of internal consistency ( =. 86) (Cortina, 1993) in Portuguese
version.
Maternal Fetal Attachment Scale (MFAS: Cranley, 1981 - Portuguese version,
Mendes, 2002)
Maternal-Fetal attachment was measured using the Maternal-Fetal Attachment Scale
(MFAS). This scale measures the mothers engagement in the behaviour of expressing a sense of
belonging and an interaction with the unborn baby (Cranley, 1981).
This scale contains 24 items intended to measure maternal fetal attachment. These items
are grouped into of five subscales: differentiation of self from the foetus (3 items); interaction
with the foetus (4 items); attributing characteristics and intentions to the foetus (6 items), giving
of self (6 items) and role-taking (4 items). The MFAS is a 4-point Likert scale and scores are
ranged from 23 to 92, with high scores indicating a high level of maternal-fetal attachment.
In this study only the Global Scale was used and the subscales were disregarded. The
MFAS showed adequate internal consistency in this study (Cronbachs .76) (Cortina, 1993).

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357

Maternal Adjustment and Maternal Attitudes (MAMA: Kumar, Robson & Smith,
1984 Portuguese version Figueiredo, Mendona & Sousa, 2004).
The MAMA measures the adjustment and maternal attitudes and thus helps to detect
situations in where there is misalignment, as well as less favourable maternal attitudes by
pregnant woman. This is a self-report, with 60 items that are distributed equally across five subscales of 12items each with the following dimensions: body image, somatic symptoms and
attitudes towards the partner, sex, pregnancy and the baby. The answering format is in likert
type, fluctuating between 1 (never / not at all) and 4 (very often/very much during the last
month). Higher scores reflect lower levels of adjustment or more negative attitudes. The MAMA
had adequate internal consistency in this study (Cronbachs .82) (Cortina, 1993).
Procedure
We conducted a cross-sectional study with data collection that took place between 2008
and 2009. The patients were approached by the nurse or the obstetrician, who informed them that
a study was on-going and asked if they were willing to participate. All participants were
provided with a full explanation of the study and invited to participate by two psychologists who
were previously trained to conduct the questionnaires, which they handed out to all participants.
The psychologists were available to answer any questions that arose during the process.
Confidentiality and anonymity were strictly enforced at all times.
The approval for this study was obtained from the Pedro Hispano Hospitals Ethical
Commission prior to implementation.
We obtained informed, written consent (Helsinki, form) (World Medical Association,
2000) from all participants and they were told of their right to withdraw at anytime throughout
the study and that their nonparticipation would not have any negative in their care and treatment.
Data analysis
Descriptive statistics, comprising percentage and mean (Standard Deviation (SD)), were
calculated. An independent Student's t test was used to test the difference in the demographicobstetric variables and MFAS scores between two groups.
Summary statistics were applied when appropriate. Categorical variables were described using
absolute frequencies (n) and relative (%).

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358

All data was analysed with the Statistical Package for Social Sciences (SPSS version 19)
(Arbuckle, 2010).
Results
A total of 184 pregnant in their third trimester, outpatients in their routine prenatal
appointments at the Obstetrics and Gynaecologic Department of Pedro Hispano Hospital,
Matosinhos/Oporto, Portugal were signed up to this study from a larger study (N=204) to
examine several consequences of domestic violence on pregnant and their babies.
As previously mentioned, two groups were created: Group 1 consisted of non-abused
pregnant (n=77, 41.8%) of women and Group 2 consisted of (n=107, 58.2%) pregnant victims of
domestic violence.
The group of pregnant victims of domestic violence have a mean age of 29 SD years.
We have done the Chi square test to find out if any of these factors such as marital status,
schooling, professional and a age stood out as being associated with the presence of violence, but
no statistically differences regarding socio- were found.
In the group of pregnant women abused, it was found most were married (51.1%),
worked in the area of trade and services (43.2%) and completed ninth grade (30.7%) (Table 1).
In the Maternal Fetal Attachment analysis, we found that 84 (79.2%) of women who
suffered violence from their partners during pregnancy had a poor relationship with their foetus
compared with 64 (83.1%) women who were not victims. These values were not statistically
significant (p=0.511). When comparing the score mean value it was noted that abused women
scored lower, although not statistical significant (p=0.711). Abused women showed a mean value
of 97.4 (SD = 8.1) and non-abused women a mean value of 97.8 (SD = 8.2).
We found that abused womens showed lower levels of adjustment or more negative
attitudes regarding pregnancy and the foetus, when analysing global MAMA scale. To a
significance level of 0.01, abused pregnant scored significantly higher (p=0.003). Studying the
MAMAs subscales we noticed that abused pregnant had more somatic complains (p=0.003), a
more unsatisfactory Marital Relationship (p=0.006) and more negative and concerned attitudes
concerning pregnancy/baby (p=0.002). Standard deviation in this group was also superior in the

VIOLENCE DURING PREGNANCY AND MOTHER-BABY RELATION

359

Body Image, Somatic Symptoms and Marital Relationship subscales, which showed a bigger
dispersion (Table 2).
Abused women also had higher mean value levels at Global scale with 124 (SD = 15.5),
and in the same subscales: Somatic Symptoms with 26 (SD = 4.4), marital relationship with 20
(SD = 5.5) and Attitudes towards pregnancy/babies with 25 (SD = 3.8). We encountered this
same trend in the remaining scales of the maternal adjustment and attitudes to pregnancy, but
with no statistically significance.
Discussion
This study investigated the MFA, Maternal Adjustment and Attitudes of pregnant victims
of domestic violence by their partners.
In the course of this investigation we encountered one hundred and seven (58.2%)
pregnant victims of domestic violence, an unexpectedly high number, which might be due to
cultural issues where some abusive behaviours are still seen as a normal pattern in marital
relationships. Prenatal attachment gradually develops throughout pregnancy (Laxton-Kane,
2002; Hart & McHahon, 2006), which is crucial to the mother-baby relationship after birth, as
well to her role as caregiver and to the childs well-being (Hutch-Boks, Levendosky, Theran, &
Bogat, 2004).
Abuse during pregnancy is increasingly being identified as an important issue with
significant consequences for maternal and infant health (Campbell, Garcia-Moreno, & Sharp,
2004).Initial attachment patterns between mother and baby is key for an infants healthy
development, particularly for the brain (Bowlby 1982; Main et al. 2005; McCain & Mustard
1999; Prior & Glaser 2006). Initial attachment also forms the basis to a womans psychological,
social and emotional growth, cements her sense of confidence and security and her ability to
create healthy relationships throughout the life (Egeland & Erickson 1999; Main et al. 2005;
Prior & Glaser 2006).
The presence of prenatal domestic violence has an important influence during the time
when mothers are forming these relationships with their infants in uterus. When affected by
domestic violence a mother tends to have difficulty empathizing with her infant, and present
themselves with greater insecurity thus being unable to provide her infant with a secure base,
(Huth-Bocks, Theron, Levendosky, & Bogat, 2011) which has been shown to increase the risk of

VIOLENCE DURING PREGNANCY AND MOTHER-BABY RELATION

360

neglect, emotional and physical abuse (English et al. 2003).

The results of this study showed a higher prevalence in battered women of low maternalfetal attachment, and negative attitudes towards pregnancy and foetus. These findings are in line
with previous studies that found that experience of domestic violence during pregnancy were
related with a non-harmonic representations of their children and of themselves as parents
(Hutch-Boks, Levendosky, Theran, & Bogat, 2004) and with a significantly more insecure
attachment (especially disorganized) with their babies (Zeanah, Danis, Hirshberg, Benoit,
Miller, & Heller, 1999). Even before the infant is born many women can deliver the message that
only the partners needs count therefor not allowing the development of a close relationship with
their baby, transmitting that both the baby and herself are vulnerable beings, which translates
into a detrimental start of the attachment relationship (Ranford& Hester 2006, Quinlivan &
Evans, 2005). This is consistent with our abused pregnant score in Marital Relationship as more
unsatisfactory (more hopelessness and less confidence in the partner) than that of non abused
pregnant. Abused women also presented more Somatic Symptoms complains due to the course
of pregnancy.
Abused women frequently describe fear for theirs and their children safety, as well as for
their mental health (Herman 1992, Radford & Hester 2006). This fear may be unconsciously
passed on to their infants, resulting in a disorganized attachment patterns.
We know from literature that victims of violence during pregnancy develop a set of
representations of attachment that reactivate negative thoughts and emotions, which may affect
the representation of self and child and contribute to an insecure attachment pattern.
Since the moment babies are born, they are totally dependent on adults to survive and the
role of mother-infant relationship is extremely important to the regulation of babies internal
states and external stressors. There fore a mothers distress levels affect attachment relationship
even more than the poor parenting (Levendosky et al. (2006).
Maternal identifications have an essential role in the parental behaviour of the mother
which, in turn, will have a major impact on hers representations of the child, as well as in the
development of its identity nuclei (Zeanah, Danis, Hirshberg, Benoit, Miller, & Heller, 1999)
impairing the development of positive internal working models of self and others because these
babies are less likely to have their basic need full fuelled from an available and responsive
caregiver (Ainsworth, Blehar, Waters, & Wall, 1978).

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361

The results of this study may have been affected by several constraints. One of the
limitations was the failure to collect data on the maternal social support, as well as the socioeconomic characteristics. Also we did not investigate the mental health of pregnant women,
which might act as a protective factor for pregnancy adjustment and to their relationship with the
foetus (Gazmararian, Lazorick, Ballad, Saltzman, & Marks, 1996).
The results of this study are not necessarily generalized to other groups of women. Since
this study was based on a sample of convenience, it reinforces the need for further research.
If these findings are confirmed by future research, the identification of patterns of
violence in women during pregnancy may provide an important opportunity to begin a program
of support to these women in order to optimize the mother-baby relationship. By helping the
mothers awareness and understanding of how her feelings, responses and behaviours may affect
her baby (Levendosky, Huth-Bocks, Shapiro, & Semel, 2002) it might ultimately improve the
development of her children.
It is of great importance that social workers and health professional are adequately
trained to recognize and assess the cases of domestic violence (Radford & Hester 2006). By
understanding how domestic violence can impact the mother/infant relationship and attachment
(Mckinnon 2008, Bunston 2006; Jenney & Sura-Liddell 2007), healthcare workers could act
preventively and making informed recommendations to women who use their services. Research
has clearly shown that intervention can have positive effects on attachment patterns (Sternberg et
al. 2005).

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366

Table 1: Socio-demographic Specifications

Total
Population
N

NonVictim
N

Missing
Values
N

Victim

Marital
Status
Single
Married
Living with a partner
Divorced or separated

38
100
31
14

26
51
16
6

10
38
12
7

2
11
3
1

Student
Housewives
Health
Area of trade and services
Education
Banking
Another area

4
40
12
84
12
5
24

3
22
8
41
6
2
13

1
15
3
35
6
2
8

0
3
1
8
0
1
3

First cycle
Second cycle
Secondary education
Undergraduate degree

39
60
46
46

24
31
20
25

12
27
19
16

3
2
7
5

36

13

21

46

30

12

33

20

11

14

67

33

25

151

84

54

13

Profession

Schooling

Health
Habits
Currently practicing physical
exercise
Smoked in the months prior to
pregnancy?
And now you smoked?
Drank alcohol in the months
prior to pregnancy?
And now consumes alcohol?
Consumed drugs in the months
prior to pregnancy?
And now consumes drugs?
Took folic acid (vitamin B6) in
the months prior to
pregnancy?
And now consumes folic acid?

367

Table 2: MAMA's different subscales quotation Abused/ non-abused

Abused

Non-Abused

(SD)

(SD)

P* Value

Body image

25

(6,1)

24

(4,9)

0.119

Somatic symptoms

26

(4,4)

24

(3,8)

0.003

Marital relationship

20

(5,5)

18

(4,3)

0.006

Attitude to sex

28

(3,5)

28

(4,1)

0.783

Attitudes to pregnancy/babies

25

(3,8)

23

(3,9)

0.002

Global

124

(15,5)

117

(14,2)

0.003

368

ANEXO 9
PAPER 6

369

370

Common Mental Disorders in Pregnancy in the context of Interpartner Violence

Abstract
Pregnancy is generally described as a period with a high incidence of common mental
disorders (CMD) in the life cycle of many women who incur the risk of developing mental
problems including depression, post traumatic stress and drug abuse.
Our objective with this study was to gauge how the presence of violence in Portuguese
pregnant women affected their psychopathology.
One hundred and eighty-four pregnant outpatients of the Obstetrics and Gynecology
Department of the Hospital Pedro Hispano in Matosinhos, Oporto, Portugal with an average
age of twenty-nine and in their last three months of pregnancy were the subjects of this study.
These participants were divided into two groups. One of abused women (N = 107) and
another of non-abused women (N = 77). In order to be able to compare them, both groups
were assessed with the Conflict Tactic Scale 2 (CTS2), the Brief Symptom Inventory (BSI)
and the Inventory of Clinical Depression Evaluation (IACLIDE).
It was observed that pregnant women who had suffered violence during pregnancy exhibited
some form of CMD during pregnancy. Another important finding was the evidence of the
negative impacts that domestic violence had on the mental health of women.
Keywords: Common mental disorders; domestic violence; depression; pregnancy;
psychopathology;

252

Common Mental Disorders in Pregnancy in the context of Interpartner Violence

Violence against women by their partners has become a growing public health
problem (Malcoes, Duran, & Montgomery, 2004). Domestic violence is considered to be any
act that has the intention or is perceived as having the intention to cause physical and/or
emotional injury, not accidental (American College of Obstetricians and Gynecologists,
1995) Such violence represents a pattern of coercive conduct towards women (Nuez-Rivas,
Monge-Rojas, Gros-Dvila, Elizondo-Urea, & Rojas-Chavarra, 2003) that may express
itself through greater frequency of active behavior (physical, psychological, emotional or
sexual) or passive behavior (omission or negligence in care and affection) (Magalhes, 2004;
Bogat, Levendosky, & Eye, 2005).
In abusive relationships the violence is, generally, not an isolated event but occurs
repeatedly (McFarlane, Parker, & Soeken, 1996). Predominantly in serious cases of abuse,
the violence typically does not cease when the women become pregnant but can instead even
escalate (Helto & Snodgrass, 1987; Campbell, Poland, Waller, & Ager, 1992).
Pregnancy is considered to be a time of great changes in women, not only physical but
also mental and social, altering their psyche and their roles in the household (Falcone, Mader,
Nascimento, Santos, & Nbrega, 2005; Baptista, Baptista, & Torres, 2006; Pereira & Lovisi,
2008).
Several studies corroborate that during a womans life cycle, pregnancy is the period
with the highest incidence of common mental disorders (CMD) (Evans, Heron, Francomb, &
Golding, 2001; Andersson, Sundstrom-Poromaa, Wulff, Bondestam, & Astrom, 2003;
Bennett, Einarson, Koren, & Einarson, 2004), defined as depressive and anxiety disorders
classified in CID-10 as neurotic, stress-related and somatoform disorders and mood
disturbances (Patel & Kleinman, 2003), are observed (Falcone et al., 2005; Pereira & Lovisi,
2008), with an increasing prevalence as shown by recent studies which found 41.4% of the
pregnant women with CMD as compared to 17 to 27% verified in prior studies (Cooper,
Murray, Hooper, & West, 1996; Silva, Ores, Mondin, Rizzo, Moares, Jasen, & Pinheiro,
2010).
Another factor to be taken into account is that many of the CMD that appear during
pregnancy are not presented in a pure form, comorbidity being the rule (Bateman & Fonagy,
2008).

253

There also seems to be a positive association between CMD during pregnancy and the
presence of domestic violence during pregnancy, especially emotional violence (Crempien,
Rojas, Cumsille, & Oda, 2010).
Existing documentation suggests that those profound physical and psychological
effects are endemic following intimate partner violence.
Even though this is an important public health issue, only in 2003 has domestic
violence been included in the public crimes category. This delay certainly contributed to the
fact that most people feel that whatever happens in the privacy of their homes is normal and
should stay there, which makes it very hard to be detected or even screened for during routine
antenatal appointments. Pregnant women are commonly screened for gestational diabetes or
pre-eclampsia but not for domestic violence during pregnancy which we know is much more
frequent yet it is seldom done (Cokkinides & Coker, 1998).
CMD during pregnancy are associated with poor maternal health (Barr et al., 2006;
Stowe, et al., 2005) and inadequate prenatal care (Kelly, Danielsen, Golding, Anders, Gilbert,
& Zatzick, 1999; Kim, Mandell, Crandall, Kuskowski, Dieperink, & Buchberger, 2006).
Maternal psychiatric disorders during pregnancy and the postpartum period are also
associated with numerous adverse outcomes for the offspring, including maladaptive fetal
growth and development (Kim et al., 2006; Punamaki, Repokari, Vilska, Poikkeus,
Sinkkonem, & Tulppala, 2006; Repokari, et al., 2006; Weinber & Tronick, 1998) poor
cognitive development and behavior during childhood and adolescence, and negative
nutritional and health effects (Barr, Bookstein, O'Malley, Connor, Huggins, & Streissgyth,
2006; Rahman, Bunn, Lovel, & Creed, 2007; Monuteaux, Blacker, Biederman, Fitmaurice, &
Buka, 2006).
Chronic maternal distress compromises the normal regulation of hormonal activity
during pregnancy; it may slow down the growth rate during the prenatal period and cause
premature delivery and low birth weight (Weinstock, 2005). The harmful consequences of a
mothers CMD on her capacity to properly attend to her baby have been evidenced in
connection to older children (Patel & Kleinman, 2003) and consequently may hamper the
expected nurturing and affection for her new baby in the period right after birth.
The objective of this study was to grasp the influence of violence during pregnancy in
the presence of psychopathology during this period.

254

Method
Participants
Two hundred and four pregnant women, of which only one hundred and eighty four pregnant
were considered, with an average age of twenty-nine years old and in their third trimester of
pregnancy participated in this study. Twenty subjects were lost to follow-up during the trial.
With regards to marital status, thirty-eight (18.8%) reported being unmarried, one
hundred (49.5%) married, thirty-one (15.3%) lived with a partner and fourteen (6.9%) were
separated or divorced.
Materials
Conflict Tactic Scale 2 (CTS2, Straus, 1996 Portuguese version Figueiredo, 2006)
In this study we used the Conflict Tactic Scale 2 (CTS2, Straus, 1996). The scale
comprises 39 items grouped together for a total of 78 questions.
The scale assesses the number of occurrences of violence during the past year by the
participant and her partner. The response format includes eight categories with the first six
determining the prevalence and chronicity in the last year. Women can be classified in more
than one subscale and can be considered as suffering from severe violence and minor
violence at the same time. CTS2 shows a high coefficient of internal consistency ( =.86).
Brief Symptom Inventory (BSI: Derogatis & Leonard, 1993 Portuguese version,
Canavarro, 1999)
The BSI consists of 53 symptoms drawn from the Symptom Checklist-90-R and
assesses current psychological symptomatology.
It is composed of nine primary symptom dimensions and three global indices, which
refer to a summary assessment of emotional distress. BSIs Likert type responses range from
0 (never happened) to 4 (always happened).
The dimensions are: Somatization; Obsession-Compulsion; Interpersonal Sensitivity;
Depression; Anxiety; Hostility; Phobic Anxiety; Paranoid Ideation and Psychoticism.
The BSI scale has a high coefficient of internal consistency for all scales:
Somatization ( =.78), Obsession Compulsion ( =.77), Interpersonal Sensitivity ( =.82),
Depression ( =.84), Anxiety ( =.82), Hostility ( =.82), Phobic Anxiety ( =.77), Paranoid
Ideation ( =.79); Psychoticism (=.79).
The three indices are: General Symptom Index, Total of the Positive Symptoms and
the Indices of Positive Symptoms.
Inventory of the Clinical Evaluation of Depression (IACLIDE: Vaz Serra, 1994)
255

The IACLIDE is a Portuguese Inventory of the Clinical Evaluation of Depression,

consisting of 23 questions with Likert type responses covering four types of disturbances:
Work changes; Cognitive changes; Interpersonal Relationships changes and Biological
changes. These four types of disturbances reflect the correlation that a person has with the
body, with oneself as a person, with others and with work.
This scale has four severity levels of the depressive symptoms states, which are: No
Depression, Mild Depression, Moderate Depression and Severe Depression.
IACLIDE scales show good internal consistency coefficients: Work ( =.66),
Cognitive ( =.83), Interpersonal Relationships ( =.51), Biological ( =.77), Total ( =.76).
Procedure
A cross-sectional design was employed using convenience sampling, which was
randomly collected in the obstetrics service of the Obstetrics and Gynecology Department, at
Hospital Pedro Hispano, Matosinhos, Portugal during routine appointments. Participants
were approached by the nurse or the obstetrician, who briefed them about the study and asked
if they wanted to participate. The women who responded affirmatively were then presented to
the psychologist/investigator who explained the details of the study. To be part of the sample,
the following inclusion criteria had to be met: over 16 years old, at a minimum of 25 weeks
of gestation and to be of Portuguese nationality.
Participants were given a set of instructions by two psychologists, previously trained
to administer the questionnaires, who assisted the participants while they were self
completing the forms. All participants signed a consent form (Helsinki form) (World Medical
Association , 2000) and were told that the questionnaire would be treated anonymously and
that they could withdraw at any time during the study if they so wished. The ethical
commission of the Hospital Pedro Hispano approved this study. Data collection took place
between 2008 and 2010.
The forms handed out to the participants were composed of the Conflict Tactics Scale
2 (Figueiredo, 2006), the BSI (Canavarro, 1999) and the IACLIDE (Vaz Serra, 1994).
All data was analyzed with the Statistical Package for Social Sciences (SPSS version 19),
through descriptive analysis, categorical variables were described by absolute frequency (n)
and relative (%). In all the tests of the hypothesis, a level of significance of 0.05 was
considered. The analysis was performed using the Student t test for independent samples.
Results
256

Two groups were created, one of non-abused women and the another of women
victims of violence by their partners. The abused pregnant group included all women who
reported having suffered any act of abuse during pregnancy in CTS2.The two final groups
were composed of one hundred and seven (58.2%) abused women and seventy-seven (41.8%)
non-abused women. In the abused group, one hundred and eleven (59.3%) women had
suffered from Psychological Aggression, fifty-four (15.8%) Physical Abuse, forty-six
(24.6%) Sexual Coercion and four (2.1%) were Injured (Table I), suggesting that some
abused women suffered from several types of aggression at the same time.
Statistically significant differences were found between the abused and the nonabused group. The abused group showed higher rates than average in all of the subscales of
the BSI including the GSI with the exception of the Phobic Anxiety subscale.
The abused group showed mean scores of .85 (SD= .69) on the Somatization subscale, at an Obsessive-Compulsive level .84 (SD= .62), .63 (SD= .70) Interpersonal
Sensitivity, .74 (SD= .75) on Depression sub-scale, .73 (SD=.67) on Anxiety sub-scale, .97
(SD= .74) on Hostility sub-scale, .90 (SD= .79) on Paranoid Ideation sub-scale, .53, (SD=
.66) on Psychoticism sub-scale.
Regarding the Global Severity Index (GSI), the battered group showed .76 mean value (SD=
.59). We also found a large dispersion among the whole sample, reinforcing the results
obtained that abused pregnant women show psychopathological symptoms (Table II).
Comparing the severity of depression state on the two groups, we found that seventy-seven
(72.6%) of the abused women were not depressed against sixty eight (90.7%) of the nonabused women. It was found that twenty (18.9%) abused women and seven (9.2%) nonabused women were suffering from mild depression. Moderate and severe depression
occurred only in abused women, of which seven (6.6%) had moderate depression and two
(1.9%) had severe depression.
Concerning the four dimensions (Work, Cognitive, Interpersonal and Biological)
statistically significant differences were found between the abused group and the non-abused
group. The abused group showed higher average scores in all four dimensions including the
total.
The abused group presented higher scores in changes at Work (M = 2.2, SD= 2.0), Cognitive
(M = 2.1, SD= 2.7), Interpersonal (M = 1.3, SD= 1.3) and Biological (M = 3.9, SD= 3.2)
levels. Total results also showed that the abused group had higher average values (M=9.5;
SD=7.4). There was a wide dispersion of results among the sample, further supporting the
idea that pregnant women victims of violence suffer from depression (Table III).
257

Discussion
The scientific literature indicates that the pregnancy-puerperal period has the highest
prevalence of CMD in women, especially in the first and third trimester of pregnancy and the
first 30 days postpartum (Botega & Dias, 2006). The intensity of the psychological changes
depends on factors such as physical, family, marital, social, cultural and personality of the
expectant mother (Falcone et al., 2005). About one fifth of women during pregnancy and
puerperium have depression (Limlommwongse & Liabsuetrakul, 2006).
Several investigations have shown that women victims of violence by their partners
are at risk of developing psychological problems including depression, postpartum
depression, post traumatic stress and alcohol and drugs consumption, suggesting the
existence of a correlation between domestic violence and the psychological functioning of
women (Hazen, Connelly, Kelleher, R., & Landsverk, 2006; Ludmir, Lewis, Valongueiro,
Arajo, & Araya, 2010; Beydoun, Al-Sahab, Beydoun, & Tamim, 2010; Bogat, Leahy, Eye,
Maxwell, Levendosky, & Davidson II, 2005).
As to the prevalence of violence during pregnancy, and according to our results, we
observed that 58.2% of the women in our study suffered from moderate to severe abuse, both
physically and psychologically, these values higher were than expected. Particularly
noteworthy was the fact that violence (including physical, psychological and sexual) is much
more widespread than anticipated, as studies available on this phenomenon concerning the
Portuguese population suggest a prevalence of 9.7% and an incidence of 8.4% in relation to
physical violence during the postpartum year (Rocha, 2006) which might be due to the fact
that other forms of violence, besides the physical one, were excluded.
The reasons for the discrepancies detected when comparing the CTS2 and the AAS
results and comments of the participants are not totally clear. Culturally, in Portugal, pregnant
women that are, by all definitions, abused by their partners, do not report it and more
seriously still, do not perceive themselves as being victims of domestic violence (Pais, 1998).
For them, violence only happens if they are threatened with a weapon and/or suffer serious
consequences, like being hospitalized, all the verbal, pushing and psychological abuse is
considered normal within an intimate relationship and should remain private.
In Portugal, domestic violence is now considered a public crime, which undoubtedly
will make this kind of behaviour more visible, but this fact alone will not be able to
immediately change the mindset. A lot more time and awareness are needed for people to
really internalize that violent behaviours are neither normal nor should they be tolerated.

258

During pregnancy, psychological aggression was more closely tied to women's

depression levels, regardless of its frequency. In addition, women who experienced any level
of physical assault or sexual coercion by their intimate partners (before or during pregnancy)
had higher levels of depressive symptoms compared to non victims (Martin, Li, Casanueva,
Harris-Britt, kupper, & Cloutier, 2006).
Our results are compatible with the existence of an association between domestic
violence and the psychological performance of women (high levels of depression, anxiety,
post traumatic stress and suicidal behavior) (Bogat, Levendosky, & Eye, 2005). They also
show that pregnant victims of domestic violence have more repeated CMD in comparison to
non-abused pregnant.
We can also confirm that pregnant victims of violence by their partners are more
depressed in relation to work, in their interpersonal relationships, at both cognitive and
biological levels, than the non-abused pregnant. Out of all these, depression is the most
prevalent mental disorder during pregnancy in abused women, compared with other
psychiatric problems (Stewart, 1994). The literature suggests that increased psychological
and social stress during pregnancy are significant risk factors, which exacerbate the
emotional consequences of the abuse (Wadhwa, Culhane, Rauh, & Barve, 2001) (Bogat et al.,
2005).
This study shows the existence of a positive correlation between CMD and pregnant
women who are victims of violence. The values described here show much higher average
values for the group of abused women when compared with the group of non-abused women.
This, therefore, confirms that abused women are more likely to suffer some kind of
psychopathology, namely depression.
It is of great importance to identify pregnant victims of domestic violence in order for
them to externalize what they feel and to ensure that there is an escape from their emotional
and social isolation (Crempien, Rojas, Cumsille, & Oda, 2010).
Most women with this problem are not being diagnosed or treated. Frequently they
go unrecognized by the health care professionals (Sleath, Thomas, Jackson, West, & Gaynes,
2007), often due to difficulty in recognising the pathological condition or ignorance of the
assessment tools but also because quite a few underestimate the incidence of CMD during
pregnancy.
There is a need to screen psychopathology in pregnant women to identify the ones at
risk of depression or post-traumatic stress disorder, and to take pre-natal care of the baby, so
that optimal fetal growth and fetal development can be achieved throughout the gestation
259

period. This screening could be done during normal and routine appointments with the health
professionals (nurses, obstetricians, midwives or even general practitioners) where on top of
the normal procedures specific to the womens pregnancy, a probing of their emotional state
and experiences of emotional distress should also be undertaken.
Early identification of maternal psychopathology risk helps prevent the worsening of
symptoms and assists in early intervention (Dennis, 2005), which can reduce the impact of
maternal depression on mothers and their children (Buist, Barnett, Milgrom, Pope, Condon,
Ellwood, Boyce, Austin, Hayes, 2002).
However, deficient knowledge and consciousness of the health care players may
account for the low visibility given to the significant risk factors for mental disorders (Lewis,
2007). Other suggestions are that it may reside in the way the health providers interact with
their patients, which does not allow these professionals to have a psychosocial or emotional
dialogue (Roter, Geller, & Bernhardt, 1999).
Evidence suggests that there are some protective factors that potentially provide a
buffer for abused women from becoming mentally ill. (Carlson, McNutt, Choi & Rose,
2002). Resources like, Social and emotional support (as well as the perception of these
support), optimism, positive role models, the struggling for a normal life and the role as a
mother, are being used by abused women to increased their resilience (Arias, Lyons & Street,
1997; 91,92; Trotter, Bogat, & Levendosky, 2004;).
Conversely, we know that women are reluctant to seek this kind of help. The
admission of mental health problems is parallel for women to thinking they are not fit
mothers and that it is their obligation to guard themselves from being morally or otherwise
judged by the health professionals (Montgmery, Tompkins, Forchuk, & French, 2006; Davies
& Allen, 2007) and considered as not being prepared or capable of caring for their babies
(Heneghan, Mercer, & Deleone, 2004).
Increased trust by women in their health care professionals will undoubtedly not only
improve attendance but also foster a more open and honest communication (Jess, Dolbier, &
Blanchard, 2008).
When we talk about screening for violence in pregnancy, several reasons for failure
have been proposed including general reluctance. However, the most common barrier to
screening domestic violence in health care seems to be time (Wiebe & Janssen, 2001;
Mezey, Bacchus, A., & Bewley, 2003) with up to 46% of the health care providers citing
time constraints as the main reason for not screening all female patients for domestic violence
(D'Avolio & Mahoney, 1998).
260

professionals need to be trained to enable women to disclose abuse and to get support.
Other reasons for this failure include lack of confidence, personal discomfort, the
belief that women will not disclose the abuse or seek help and not knowing what to do if the
violence is revealed (Feder, Ramsay, & Dunne, 2009).
Several reasons hinder the disclosure of domestic violence. Women are afraid of
being retaliated against, being responsible, not being understood by others and losing their
children (Kershner & Anders, 2002).
It is therefore very important and fundamental to create and develop training programs
and intervention protocols involving different health professionals in Portugal in the pre and
postnatal periods where the screening of family violence and common mental disorders will
become a routine procedure.
We know that the reality in Portugal, unlike many other countries, is that there is not
an institutionalized practice of screening either for violence or for mental health in pregnant
women who use the national public health system. Despite all the difficulties that other
countries have faced when screening for violence and CMD, we do think it would be very
valuable to learn from their experience and adapt it to a Portuguese context. A first step was
taken when, in a departmental meeting at the Hospital, we presented these results to all the
physicians. They were made aware of the seriousness of the conclusions and of the need to
screen for violence signals/symptoms during pregnancy.
Given the potential impact of antenatal mental disturbances on maternal and infant
outcomes, additional investigations into the psychiatric evaluation and treatment of pregnant
women in the obstetrical sector are required.
This study corroborates the need to understand mental illness and violence by ones
partner during pregnancy as an issue of social nature and public health.

261

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267

Table 1
CTS2 Prevalence

Psychological
Aggression
Minor
Severe
Phisical Assault
Minor
Severe
Sexual Coercion
Minor
Severe
Injury
Minor
Severe

Victim (%)

87
24

46.6
12.7

45
9

11.1
4.7

42
4

22.4
2.2

3
1

1.6
.5

Table 2
BSI Results
Non-Victim
M
SD
.48
.42

M
.85

SD
.69

.001**

.50

.84

.62

.001**

.54

.63

.70

.004**

.50
.50
.51
.47

.74
.73
.97
.47

.75
.67
.74
.70

.001**
.005**
.001**
.453

.62

.90

.79

.001**

.33
.41

.53
.76

.66
.59

.001**
.001**

Somatization
Obsession .49
Compulsion
Interpersonal
.34
Sensitivity
Depression
.38
Anxiety
.48
Hostility
.53
Phobic Anxiety
.34
Paranoid .55
Ideation
Psychoticism
.21
GSI
.45
*p< .05 **p< .01 ***p< .001

Victim

268

Table 3
IACLIDEe Dimensions
Victim
Work
Cognitive
Interpersonal
relations
Biological
Total
*p<.05 **p< .01

269

M
2.2
2.1

SD
2.0
2.7

Non Victim
M
SD
3.3
2.9
4.8
5.9

1.3

1.3

2.1

1.9

.002**

3.9
9.5

3.2
7.4

5.7
16.0

4.4
13.3

.009**
.711

.008**
.001**

ANEXO 10
PAPER 7

270

Violence during pregnancy and babies development: the role of maternal

psychopathology and mother baby relationship.

Abstract
The primary objective of this study was to evaluate maternal mental health, maternal
attitudes and adjustment and mother-baby relationship during pregnancy as moderator factors
between domestic violence during that period and babies development in the first year of
life. One hundred and seven pregnant abused outpatients of the Obstetrics and Gynecology
Department of the Hospital Pedro Hispano in Matosinhos (Oporto, Portugal) and in their last
trimester of pregnancy, with a mean of age of twenty-nine, were assessed.
Participants were assessed with the Conflict Tactic Scale 2 (CTS2), the Brief
Symptom Inventory (BSI), the Inventory of Clinical Depression Evaluation (IACLIDE), the
Maternal Fetal Attachment Scale (MFAS), the Maternal Adjustment and Maternal Attitudes
questionnaire (MAMA), Griffiths Mental Scale (0-2) and Brief Infant Social Emotional
Assessment (BITSEA).
It was concluded that being victim while depressed during pregnancy were a
protective factor to Locomotor, Earing-Speech, Performance and Global development on
babies. Curiously, it was verified that having psychopathology while being victim during
pregnancy were protective to Eye-Hand Coordination and Global development on babies.

Keywords: domestic violence; mother-baby relationship; maternal attitudes; mental

development.

271

Violence during pregnancy and babies development: the role of maternal

psychopathology and mother baby relationship.
Domestic violence is defined as violence perpetrated by persons who have or had a
kinship or affection relationship with the women, most frequently their intimate patners
(World Health Organization, 2002, p. 5). This type of violence can involve direct violent or
passive behaviors (Magalhes, 2004): physical acts (slapping, pushing, kicking,
strangulation), psychological abuse (insults, humiliation, coercion, intimidation and/or
threats) and sexual behaviors (forced sexual intercourse or humiliating sexual practices)
(Bogat, Levendosky & Eye, 2005; Simpsa, Isabel, Cerrato & Everaed, 2000). The prevalence
of domestic violence during pregnancy is estimated between 4, 8 and 8.1 % (Gazmararian,
Lazorick, Spitz, Ballard, Saltzman & Marks, 1996). In women can occur physical
(tachycardia, high blood pressure, abortions and much dependence) and psychological
consequences (stress, depression, anxiety) (Taylor & Nabors, 2009).
Some researchers concluded that domestic violence during pregnancy has several
consequences for women and their babies, demonstrated that both maternal physical and
emotional victimization were to have a negative impact on childrens overall health
(McMahon, Huang, Boxer & Postmus, 2011). Almeida (2011) studied the impact of domestic
violence on babies development during first year of life and concluded that violence during
pregnancy has a direct effect on babies' mental skills: babies at three and a half and at twelve
months old, of mothers victims of domestic violence, had lower results to mental global
functioning.
Another aspect reported in the literature is the association between domestic violence
and the presence of Common Mental Disorders (CMD) during pregnancy (Crempien, Rojas,
Cumsille & Oda, 2010). Maternal psychiatric disorders during pregnancy and postpartum
period are also associated with numerous adverse outcomes for children, including: poor
cognitive development and behavior during childhood and adolescence and negative
nutritional and health effects (Barr, Bookstein, O'Malley., Connor, Huggins & Streissguth,
2006; Rahman, Bunn, Lovel & Creed, 2007).
Particularly, maternal depression during pregnancy was identified as a risk factor for
babies, with impact on: mental and neurological development, (Field, 1992), babies
behaviour as avoidance of gaze and less vocalization, and less positive affects at three

272

months, suggesting presence of depressive behaviour (Field, 1998; Pickens & Field, 1993;
Brouwers, van Baar & Pop, 2001).
Regarding to the maternal adjustment and attitudes during pregnancy (MAMA), these
are influenced by two factors: the situation lived by the women before she was a pregnant and
the way she projected herself in that role and the babys dynamics; and how they interact with
the environment (Teixeira & Leal, 1995).
Although related with maternal adjustment, Brown (1994) concluded that marital
problems predict maternal adjustment in birth and after, and compromises maternal
satisfaction on being a mother as well as the needed adaptation to this new role (cit. in
Pereira, Santos & Ramalho, 1999).
Other essential factor on babies development is the Maternal-Fetal Attachment
(MFA). This process is defined as the extent to which women engage in behaviors that
represents an affiliation and interaction with their unborn child (Cranley, 1981, p. 282).
MFA is based in the quality of the mother-infant relation carries implications for the babies
social, cognitive, neurobiological and emotional development (Muller & Ferketich, 1993;
Verssimo, Moteiro, Verssimo, Monteiro, Vaughn & Santos, 2003; Piontelli, 1995; LaxtonKane & Slade, 2002). In adition, an early disruption of this relationship has consequences on
brain plasticity and implications for psychopathology of baby (Cirulli, Berry & Alleva,
2003). Literature suggested that mothers who suffered domestic violence during pregnancy
deteorize MFA (Zeitlin, Dhanjal & Colmsee, 1999) and that has negative effects in fetus and
newborn health and socio-emotional development of the child (Rachana, Suraiya, Hishman,
Abdulaziz & Hai, 2002). Babies socio-emotional state is weaker in one year babies of (at
one year of age was found a greater number of positive screens among babies born to)
battered women, when compared to babies born to non-abused women (Almeida, 2011). This
same author found that babies at 3.5 and 12 months born to women who have a poor scored
in MFA had lower Global mental development comparing with babies born to women who
showed a good MFA (Almeida, 2011). A study with 38 women victims of abuse during
pregnancy found that these women had lower mother-fetal and mother-infant attachment
(Zeitlin, Dhanjal & Colmsee,1999), reported less secure attachments to their infants,
perceived their infants in a more negative way and viewed themselves as less competent
caregivers (Huth-Bocks, Levendosky, Theran & Bogat, 2004).
This research as the objective of study the presence of maternal psychopathology,
MAMA and MFA during pregnancy of battered womens on as moderator factors of
domestic violence consequences on their babies development at 3 and 12 months of age.
273

Method
Participants
The participants in this study were one hundred and seven pregnant outpatients abused
women in their third trimester of pregnancy, in their routine prenatal appointments at the
Obstetrics and Gynecologic Department of Pedro Hispano Hospital, Matosinhos/Oporto,
Portugal.
In the sample of pregnant victims of domestic violence, the mean age was twenty nine
years (SD= 29). Fifty-one women were married (51.5%), twenty-six were single (26.3%),
sixteen (16.2%) were unmarried but living with a partner and six were separated or divorced
(6.1%). As for their occupation fourty-one percent reported working in the area of trade and
services (43.2%), twenty-two were housewives (23.2%), eight worked in health care (8.4%),
six in education (6.3%), three were students (3.2%), two worked in the area of banking
(2.1%), and thirteen worked in another area other than those mentioned above (13.7%).
Regarding education, thirty-one percent finished second cycle (30.7%), twenty-five finish a
bachelors degree (24.8%), twenty-four of the participants finished the first cycle (23.8%),
twenty completed high school education (19.8%) and one had a post-graduation (1%). During
pregnancy twenty percent of women smoked (25%), seventeen engaged in some sort of
physical exercise (16.5%), and three drank alcohol (2.8%).

Materials and Procedure

The present study, participants were assessed by the following instruments:
Socio-demographic questionnaire
The socio-demographic questionnaire was specially constructed for the present study
and this aim is to characterize the participants in terms of age, profession, education level,
marital status, whether or not they do some physical exercise, and history of consumption of
smoking, alcohol and drugs and folic acid consumption during pregnancy.
Conflict Tactic Scale 2 (CTS2, Straus, Hamby, Boney- McCoy & Sugarman, 1996
Portuguese version, Alexandra & Figueiredo, 2006).
The scale has 78 questions that measured 39 behaviors each one divided in 5
categories: physical assault, injury, psychological aggression, sexual coercion and
negotiation. The response includes eight categories: 0 (never), 1 (once), 2 (twice), 3 (3-5
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times), 4 (6-10 times), 5 (11-20 times), 6 (more than 20 times), and 7 (not during these time
periods, but it happened before), with the first six determining the prevalence and chronicity
in the last year. Higher scores indicate greater severity of partner violence and abuse. CTS2
revealed a high coefficient of internal consistency ( =.86).
Brief Symptom Inventory (BSI: Derogatis, 1993 Portuguese version, Canavarro, 1999)
The Brief Symptom Inventory (BSI) is constituted by 53 symptoms drawn from the
Symptom Checklist-90-R and evaluates current psychological symptomatology
(Somatization; Obsession-Compulsion; Interpersonal Sensitivity; Depression; Anxiety;
Hostility; Phobic Anxiety; Paranoid Ideation and Psychoticism). The answers are Likert type
range from 0 (never happened) to 4 (always happened). There were high coefficients of
internal consistency for all scales: Somatization ( =.78), Obsession Compulsion ( =.77),
Interpersonal Sensitivity ( =.82), Depression ( =.84), Anxiety ( =.82), Hostility ( =.82),
Phobic Anxiety ( =.77), Paranoid Ideation ( =.79); Psychoticism (=.79).
Inventory of the Clinical Evaluation of Depression (IACLIDE: Vaz Serra, 1994)
The Inventory of the Clinical Evaluation of Depression (IACLIDE: Vaz Serra, 1994)
is a Portuguese Inventory of the Clinical Evaluation of Depression, consisting on 23
questions with Likert type responses covering four types of disturbances (work changes,
cognitive changes, interpersonal relationships changes and biological changes) which reflect
the correlation that a person has with their body, himself as a person, with others and with
work. This scale has four severity levels of the depressive symptoms states, which are: No
Depression, Mild Depression, Moderate Depression and Severe Depression.This scale
showed a good internal consistency coefficients ( =.76).
Maternal Fetal Attachment Scale (MFAS: Cranley, 1981 - Portuguese version, Mendes,
1998)
Maternal Fetal Attachment Scale (MFAS) assesses Maternal-Fetal Attachment (MFA)
and it is composed for 24 items divided into five subscales (differentiation of self from the
fetus, interaction with the fetus, attributing characteristics and intentions to the fetus, giving
of self and role-taking). The responses are Likert scale range from Definitely Yes to
Definitely No and are scored from 1-5, with 5 being the most positive statement. In
present study was only used the Global Scale. This scale presented an adequate internal
consistency in this study (Cronbachs .76).
The Maternal Adjustment and Maternal Atitudes (MAMA: Kumar, Robson & Smith,
1984 Portuguese version Figueiredo, Mendona & Sousa, 2004)

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The Maternal Adjustment and Maternal Atitudes (MAMA) is a 60-item self report
which objective is to evaluate maternal adjustments and attitudes during the pregnancy
and baby. This questionnaire has five subscales: Body Image; Somatic Symptoms;
Marital Relationships; Attitudes to Sex and Attitudes to Pregnancy/Baby. The answers are
likert type in which 1 is never / not at all and 4 very often / very much during the last
month and the score is a 4-point scale, being the higher scores the lower desirable
atitudes.
MAMA had adequate internal consistency in this study (Cronbachs .82).
Griffiths Mental Scale (0-2) (Griffiths 0-2: Griffiths, 1996 Portuguese version
Castro & Gomes, 1996)
Griffiths Mental Scale (0-2) has the aim to observe babies and young
infants mental development since birth until age of two years. It is composed to five
subscales each one with 35 items: A - Locomotion; B - Personal-Social; C - Language; D
- Eye and Hand Coordination; E Performance. The score is obtained by adding up the
number of items that the baby successfully performed in each of the sub-scales and then
raw scores of each subscale is converted on standard scores. This instrument had adequate
internal consistency (= .89).
The Brief Infant Toddler Social Emotional Assessment (BITSEA: Briggs-Gowan &
Carter, 2004)
The Brief Infant Toddler Social Emotional Assessment (BITSEA) consists of a
screening of the development of socio-emotional behavior and competencies of babies
from 12 to 35 months 30 days with possible socio-emotional behavior problems and/or
possible delays or deficits in socio-emotional competencies. It is composed by 42 items
lickert type which responses varies between 0 (false/rarely) and 2 (true/often), in which
lower scores indicate fewer problems and lower competence. BITSEA showed an
adequate internal consistency ( = .79) in this study.
Procedure
A convenience sample was collected in the service of the Obstetrics and Gynecology
Department, at Hospital Pedro Hispano, Matosinhos (Oporto, Portugal) during routine
appointments. The ethical commission of the Hospital Pedro Hispano approved this study.
Participants were approached by the nurse or the obstetrician, who briefed them about
the study and asked if they wanted to participate. To be part of the sample, the pregnant had

276

to have the following characteristics: Portuguese nationality, more than 16 years of age and to
have at least 25 weeks of gestation. All participants signed a consent form (Helsinki form)
(World Medical Association , 2000), and questions as the anonymity and the possibility to
withdraw at any time during the study were clarified. Data collection took place between
2008 and 2010.
A cohort study was conducted in three distinct periods. Data collection began during
the third trimester of pregnancy (T1) and two groups were created through the use of CTS2:
one of non abused pregnant and other with pregnant victims of domestic violence. The
abused pregnant group included all women who reported having suffered any act of abuse
during pregnancy. In this period we examined the maternal-fetal attachment (MFA), the
maternal attitudes and adjustments during pregnancy (MAMA) and the presence of
psychopathology (BSI and IACLIDE). At that time, it was also applied a small sociodemographic questionnaire.
After the babies birth, it was done one assessment of their overall mental
development at 3.5 months was performed (Griffiths) (T2) and at 12 months (T3) and also of
their socio-emotional state (BITSEA). Data that could not be directly observed was asked to
the mothers, as contemplated in the scale.
To verify the first objective it was calculated the risk measure through odds ratio and
this 95% interval confiance. To study the moderator factors of relationship between domestic
violence during pregnancy and babies development it was used multivariated linear
regression. The significance level used was .05 for all tests. All tests were rated according to
their standards. All data was analysed with the Statistical Package for Social Sciences (SPSS
version 19).
Results
By analyzing the Maternal Mental Health in Pregnancy ( BSI ) as protective or risk
factor , we found that Infants born to mothers victims of violence and without
psychopathology during pregnancy are less likely to obtain ratings below average level of
competence eye - hand coordination to 3.5 months (OR = 0.303 , IC 95% = 0,09; 0.756 ) (
table 1 ) .
We can thus say that being a victim and suffer from psychopathology is a protective
factor for the development of competence Eye - hand coordination for Babies to 3.5 months.
By analyzing the Maternal Mental Health in Pregnancy ( BSI ) as protective or risk factor ,
we found that Infants born to mothers victims of violence and without psychopathology

277

during pregnancy are less likely to obtain ratings below average at Global at 12 months
(OR=0.222; IC95%=0.066; 0.745 ) ( table 2 ) .
We can say that being a victim and suffer from psychopathology is a protective factor
for the Mental Global Development at 12 months.
When comparing the Development of Infants at 3.5 months , children of pregnant
victims of violence in pregnancy appears that the children of mothers with no pathology has a
better mental development , and in the performance subscale these same infants have
significant values ( p = 0.037 )(table 3 ) .
For the BSI uses the PTSI which is used by Canavarro that was the one who tested the
discriminative power in Portugal this " test" and found that PSTI > = 1.7 or < 1.7 is the best
discrimination between women in pathological and non-pathological .
Infants whose mothers suffer from domestic violence and have no pathology in
relation to depression during pregnancy reveal less chance of getting ratings below average in
locomotion subscale, compared with infants whose mothers suffer domestic violence but had
depression , odds ratio is 0.283 (IC 95% = [ 0.103 , 0.775 ] ) at 3, 5 months old (table 4).
Thus, the fact that the mother is a victim of violence and do not have depression
during pregnancy appears to be a protective factor for ratings below average in locomotor
subscale in infants.
The fact that the mother is a victim of violence and do not have depression during
pregnancy appears to be a protective factor in getting rated below average in language
subscale in infants, at 3.5 months of age, because the odds ratio , 0.367 indicates that the
chance of a baby whose mother suffered from domestic violence and did not suffer from
depression have ratings below average in language subscale , compared with infants whose
mothers suffered from domestic violence and depression , is smaller (table 5).
The Babies of mothers victims of violence who have depression during pregnancy
reveal less chance , odds ratio 0.36 , get rated below average in the realization subscale ,
compared with infants born to mothers victims of violence but no depression at 3.5 months
old (table 6)
There is therefore an indication of this being a protective factor for obtaining ratings
below average to realization subscale however this association was not significant (p > 0, 05).
Regarding the relationship between depression of mothers during pregnancy and baby
Global Mental Development, no exist significant association , however , there seems to be an
indication that children of mothers who are victims of violence and who have not suffered

278

depression during pregnancy have less chance (OR = 0.321 ) to obtain ratings below the
average level of the Global Mental Development ( table 7 ) .
When comparing the Mental Development of Infants children of victims of domestic
violence in pregnancy , with and without depression in pregnancy , the results we get are that
babies are born to mothers without depression , present values of hand - eye coordination ,
performance and global significantly higher than those babies whose mothers suffered from
depression in pregnancy . In the remaining subscale, although differences are true, they are
not significant (table 8).
The presence of maternal depression symptoms at 3.5 months old of baby (T2) in
victims of violence may represent a protective factor for the development of language
competence of infants at 3.5 months of age.
This is because the baby, children of mother victims of violence and without
depression in T2 are less likely (odds ratio 0.341) to obtain ratings below average level of
language competence compared to babies whose mothers are victims of violence but who
have depression T2 (OR = 0.341 , IC 95% = [ 0.130 , 0.894 ] ) ( table 9 ).
The same seems to happen with the competence eye - hand coordination of the infants
at 12 months of age, since the infants of mothers victims of violence and without depression
at T2 , are less likely (OR = 0.289 ) of having below average ratings level at eye-han
coordination at 12 months of age ( T3 ) , ie not having depression in T2 , appears to be a
protective factor for lower development of eye - hand coordination in infants whose mothers
suffered violence. This association is however not significant (IC 95% = [ 0.091 , 0.920 ] )
(table 10).
In comparison to the other subscales of the Griffiths were not statistically significant
to be able to tell what is being assessed or not a protective factor for the development of the
baby.
When compared to each other the development of infants born to mothers who are
victims of violence during pregnancy , with better or worse maternal - fetal attachment, we
found better results to locomotion s , personal- social and hand - eye coordination subscale in
infants born to mothers with a better relationship with the fetus . However none of these
results was statistically significant (table11).
Regarding the Maternal Adjustment and Maternal Attitudes in pregnancy in pregnant
victims of domestic violence, there were no statistically significant differences.

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Specifically , infants whose mothers are abussed and have a good marital relationship in
pregnancy have 0,357 times less likely to obtain ratings below average in personal- social
subscale compared to babies whose mothers are abussed but have a worse marital
relationship ( IC 95 % ( ODDS ) = [ 0.137 , 0.929 ] ) ( table 12).
Besides the fact of being a victim of violence during pregnancy and have a better
marital relationship makes their infants presenting 0.383 times less likely to obtain ratings
below average to hand - eye coordination subscale , at 3.5 months, compared with babies
whose mother is abused and have a poor marital relationship during pregnancy (IC 95 % (
ODDS ) = [ 0.156 , 0.938 ] ) ( table 13) .
Likewise , the infants whose mothers are victims of violence during pregnancy and
show a good marital relationship have less chance , odds ratio (IC 95 %) of 0.359 ( [ 0.144 ,
0.893 ] ) to obtain ratings below average for performance subscale , at 3.5 months , compared
with infants whose mothers were victims of violence but admitted to have a worse marital
relationship ( table 14) .
In conclusion, it seems that the fact that pregnant women victims of domestic
violence, rate your marital relationship as good, is a protective factor for the development
skills : personal- social , hand - eye coordination and performance of babies at 3.5 months.
As regards , on attitudes towards pregnancy and baby ( MAMA ) , it was found that a
better attitude towards pregnancy and the baby 's mother abussed seems to be a protective
factor for language competence (OR = 0.392 , IC 95% (OR ) = [ 0.162,0.949 ] ) ( Table 15 )
protector for global mental development of infants (OR = 0.414 , IC95% (OR ) = [
0.176,0.975 ] ) at 3.5 months of age (table 15) .
That is, infants whose mothers are victims of domestic violence and who were
classified as having best attitudes against pregnancy and baby, have less chance , odds ratio
0.392 , to obtain ratings below average for the competence of language compared to babies
whose mother are raped but consider having worse MAMA.
And Infants whose mothers are victims of violence and presented a better attitude
against pregnancy and baby reveal less chance, odds ratio of 0.414 times to obtain ratings
below average in terms of overall mental development. Thus, the presence of a better MAMA
seems to indicate to be a protective factor for child development in babies whose mother is
abused, however, this association was not significant (table 16).
Given the already relatively attitude against sex during pregnancy (MAMA), it was
concluded that a best attitude against sex during pregnancy for pregnant victims of violence

280

during pregnancy appears to be a protective factor for hand-eye coordination competence of

the babies at 3.5 months of age (OR = 0.399, CI 95% = [0.169, 0.941]) (table 17).
Interestingly, babies at 12 months, children of abused mothers with best attitude
against sex during pregnancy are more likely to be classified with values below average in
competence locomotion at 12 months (OR = 3.936, CI 95% (OR) = [1.453, 10.662].
Accordingly, the presence of a better attitude against sex during pregnancy, is likely to be a
risk factor for the development of locomotion babies born of abused mothers at 12 months
(table 18).
Discussion
Literature demonstrates that the domestic violence, prior and during pregnancy, brings
negative consequences to the health and well-being of mothers and their babies (McMahon,
Huang, Boxer & Postmus, 2011; Audi, Segall-Corra, Santiago, Andrade & Perz-Escamilla,
2008).
According to Maldonado-Durn, Lartigue e Feintuch (2000), problems like domestic
violence, maternal anxiety, depression and psychological problems (i.e. fear of becoming a
mother and denial of pregnancy) during pregnancy can have consequences on babies
emotional and mental aspects and the mother-baby relationship.
Thereby, the main goal of this investigation was to study the maternal mental health,
maternal attitudes and adjustment and mother-infant relationship during pregnancy as
moderator factors of the relation between domestic violence during pregnancy and the babies
development.
Relatively to impact of maternal mental health on babies development it was found
that the mothers without psychopathology during pregnancy are a protector factor for eyehand coordination, performance and global development to the baby ate 3.5 moths. At 12
moths of age of babies is was found the same results to the global development, in other
words, be a victim and not have psychopathology during pregnancy is a protector factor de
the global development of the babies at one year of age.
Regarding to the presence of depression, the babies of mothers who dont suffering
depression during pregnancy are a lower change to obtain ratings below average to de
locomotion and language development, that is, be a mother who suffered violence during
pregnancy but dont depression is a protector factor to de locomotion and language
development of the baby at 3.5 moths.

281

Is was observed that babies at 3.5 moths have a lower chance obtain ratings below
average to language and ratings below average to hand-eye coordination at 12 moths of age
when the mothers dont suffered depression at T2, ie, dont suffered depression at T2 is a
protective factor for the language development at 3,5 moths and a protective factor for de
hand-eye coordination at 12 moths of the baby.
Several studies revealed that maternal psychopathology has adverse effects on fetal
growth and development (Punamaki et al., 2006; Repokari, et al., 2006; Brunette & Jacobsen,
2006) as cognitive and behavior problems during childhood and adolescence as well negative
nutritional and health effects (Barr et al., 2006; Monuteaux, Blacker, Biederman, Fitmaurice
& Buka, 2006; Rahman et al., 2007; Flach, Leese, Heron, Evans, Feder, Sharp & Howard,
2011), in this study we found that the mother dont suffering psychopathology can have a
positive impact in some babies development aspects.
Results also demonstrated that maternal attitudes and adjustment during pregnancy
namely a good marital relationship had important effects on babies development. So, a good
marital relationship during pregnancy is a likely protector factor of personal-social, eye-hand
coordination and performance development in babies (3.5 months). It is known that the
quality of the mother-infant attachment is directly related to positive outcomes in the child
development (Mller & Ferketich, 1993; Piontelli, 1995; Verssimo, Monteiro, Vaughn &
Santos, 2003).
A previous study revealed that maternal indifference and care problems toward babies
have impact in several aspects of babies development (Fleming et al., 1988). Present study
verified this question and concluded that a good attitude towards pregnancy and baby (during
pregnancy) had also presumable protector effects on language and global development in
babies with 3.5 months old. The results contradicts a previous study that showed that babies
whose mothers had a worst attitude towards pregnancy and baby presented lower scores in
global and language development (Almeida, 2011). However, these results may emerge due
to the fact of mothers begin to see their child as a victim of the same domestic violence as she
(Huth-Bocks, Levendosky, Theran & Bogat, 2004; Lyons-Ruth & Jacobvitz, 1999; Zeanah,
Danis, Hirshberg, et. al, 1999; Theran, Levendosky & Huth-Bocks, 1999).
Finally, it was verified that a good attitude towards sex (during pregnancy) had a
protective factor to the eye-hand coordination ate 3,5 moths and had a supposable risk effect
on locomotor development in one year babies. According to several authors marital
problems can influence maternal adjustment to the baby (Mller & Ferketich, 1993) and
therefore have impact on maternal representations of their child (Piontelli, 1995) what lead to
282

a deterioration of the mother-baby attachment (Zeitilin, Dhanjal & Colmsea, 1990; LyonsRuth & Jacobvitz, 1999). These results can also be explained by the theory that affirms that
the baby can reactivate the negative feelings and emotions that are associated with the
perpetrator of the violence, seeing the child as part of the abuser (Huth-Bocks, Levendosky,
Theran & Bogat, 2004; Lyons-Ruth & Jacobvitz, 1999; Zeanah, Danis, Hirshberg, et. al,
1999; Theran, Levendosky & Huth-Bocks, 1999).
Limitations and future research
The present study has several limitations. The small size of the sample and the fact
that this is a convenience sample and therefore cannot be applicable to other groups of
women is a disadvantage. Maybe these sample limitations can explain the borderline results
of this study. So, future researches may integrate more subjects.
The maternal psychopathology wasnt assessed before pregnancy, which is a
limitation of study because it could be important for the findings of study and could help to
better understand them. Posterior studies may be aware of this variable trying to control it.
Another limitation is the way of assessement of babies development and behavior:
the Griffiths 0-2 was applied by direct observation in two moments (3,5 and 12 months after
birth); and assessment of BITSEA was done orally through reports of mothers and
consequently their perception about appropriate behavior and welfare. Thus, these assessment
problems can be impact on investigation results. An extra care on the assessement of these
instruments should take into account in future investigations.
As this theme is so relavant, is important that future researches focus on it to better
understand this fenomenon and its impact on babies development and health. It is interesting
that in the future, the attention is centered on possible mediators and moderators of
relationship between domestic violence and babies development and health as attachment,
emotional regulation strategies used by mothers, quality of social support and other. Is also
relevant that longitudinal studies similar to the present study are made namealy to evaluate
the impact of domestic violence on babies development and health after one year after birth
and during infancy.

283

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287

Table 1 Presence of Maternal Pathology during Pregnancy (BSI) and Development of eyehand coordination (GRIFFITHS) of baby at 3.5 months.
BSI T1
Without pathology
With pathology

below average
N
(%)
23
(50.0)
23
(50.0)

above the average

N
(%)
33
(64.5)
10
(35.5)

p
0.015

OR
0.303

OR IC 95%
0.090
0.756

(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 2 Presence of Maternal Pathology during Pregnancy (BSI) and Global Mental
Development (GRIFFITHS) of babies at 12months.
Below average
Above average
BSI T1
N
(%)
N
(%)
P*
OR
OR IC 95%
Without pathology
5
(27.8)
26
(63.4)
0.022
0.222
0.066 0.745
With pathology
17
(72.2)
15
(36.6)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 3 - Characterization of the values in the range of Griffiths Mental Development using
PSTI (considering only women victims of violence of some kind).
Without
With
pathology
pathology
p
M
(DP)
M
(DP)
LI
Locomotion
108
(17,5)
105
(17,4)
0,538
-5,628
Personal-Social
98
(20,3)
96
(21,7)
0,751
-8,141
Language
101
(14,5)
99
(14,5)
0,624
-5,090
Hand-eye coordination
102
(15,4)
95
(21,5)
0,086
-1,011
Performance
100
(15,3)
92
(16,8)
0,037
,500
Global
101
(13,4)
97
(12,5)
0,218
-2,311
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

288

IC95% **
LS
10,704
11,248
8,444
15,147
15,223
9,978

Table 4 - Association Between Maternal Depression in Pregnancy (IACLIDE) and

development of Locomotion (GRIFFITHS) of Infants at 3.5 months.
Below average
Aboveaverage
IACLIDE
N
(%)
N
(%)
p
OR
OR IC 95%
Without pathology
12 (52,2)
54 (79,4) 0,016
0,283
0,103
0,775
With pathology
11 (47,8)
14 (20,6)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 5 Association between Maternal Depression in Pregnancy (IACLIDE) and Language

Development (GRIFFITHS) at 3.5 months.
below average
aboveaverage
IACLIDE
N
(%)
N
(%)
P*
OR
OR IC 95%
Negative
21 (60,0)
45 (80,4)
.034
.367
.143
.943
Positive
14 (40,0)
11 (19,6)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 6 Association between Maternal Depression in Pregnancy (IACLIDE) and

Performance development (GRIFFITHS) of Infants at 3.5 months.
IACLIDE
Negative
Positive

Below average
N
(%)
32 (64,0)
18 (36,0)

Above average
N
(%)
34 (82,9)
7 (17,1)

P*
.044

OR
.366

OR IC 95%
.135
.993

(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

289

Table 7 Association between Maternal Depression in Pregnancy (IACLIDE) and Global

Development (GRIFFITHS) of Infants at 3.5 months.
Below average Above average
IACLIDE
N
(%)
N
(%)
P*
OR
OR IC 95%
Negative
16 (88,9)
14 (93,3)
.018
.321
.123
.838
Positive
2 (11,1)
1 (6,7)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 8 - Characterization of the values in the range of Griffiths Mental Development in

Infants with 3.5 months using the IACLIDE T1 (considering only women victims of violence
of some kind).
Nor Depressed
Depressed
IC95%
p
M
(DP)
M
(DP)
LI
LS
Locomotion
109
(15,3)
101
(22,0)
0,199
-16,203
-0,071
Personal - Social
98
(17,7)
93
(28,0)
0,187
-15,181
4,332
Language
102
(14,0)
96
(15,5)
0,089
-12,541
0,908
Eye-hand coordination
102
(14,5)
93
(23,6)
0,040
-17,643
-1,467
Performance
100
(13,1)
89
(21,5)
0,015
-18,436
-3,743
Global
102
(11,4)
94
(17,5)
0,036
-14,234
-1,837
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 9 Presence of Maternal Depression at T2 (IACLIDE) and Language Development

(GRIFFITHS) at 3.5 months
Below average Above average
IACLIDE T2
N
(%)
N
(%)
p
OR
OR IC 95%
Without pathology
21
(60,0)
44
(81,5) 0,026
0,341
0,130
0,894
With pathology
14
(40,0)
10
(18,5)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

290

Table 10 Association between Depression in T2 (IACLIDE) and Eye-hand coordination

(GRIFFITHS) of Infants at 12 months.
Below average Above average
IACLIDE T2
N
(%)
N
(%)
P*
OR
OR IC 95%
Negative
8 (50,0)
45 (77,6)
.030
.289
.091
.920
Positive
8 (50,0)
13 (22,4)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%
Table 11- Characterization of the values in the range of Griffiths Mental Development using
MFAS (considering only women victims of violence of some kind).
Below
Above
IC95% **
p
M
(DP)
M
(DP)
LI
LS
Locomotion
106 (16,4)
107
(17,8)
0,745
-7,519
10,472
Personal - Social
96 (17,9)
97
(21,9)
0,845
-9,747
11,886
Language
103 (11,4)
100
(14,2)
0,464
-9,632
4,430
Hand-eye coordination
96 (19,2)
101
(16,5)
0,233
-3,464
14,030
Performance
98 (11,5)
97
(17,7)
0,818
-9,516
7,532
Global
100 (11,4)
100
(14,0)
0,930
-7,242
6,627
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 12 - Association between marital relationship (MAMA) and Personal -Social

Development (GRIFFITHS) of Infants at 3.5 months.
Below average Above average
MAMA
N
(%)
N
(%)
P*
OR
OR IC 95%
Below 19.7
29 (52,7)
25 (75,8) 0,032
0,357
0,137
0,929
Above 19.7
26 (47,3)
8 (24,2)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

291

Tabele 13 Association between marital relationship (MAMA) and eye-hand coordination

(GRIFFITHS) at 3.5 months of Babies
Below average
MAMA

(%)

Above average
N

(%)

OR

OR IC 95%

Below 19.7
24 (51,1)
30 (73,2)
.034
.383
.156
Above 19.7
23 (48,9)
11 (26,8)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 14 Association between Marital relationship (MAMA) and Performance

Development (GRIFFITHS) of Infants at 3.5 months.
Below average Above average
MAMA
N
(%)
N
(%)
P*
OR

.938

OR IC 95%

Below 19.7
25 (51.0)
29 (74.4)
0026
.359
.144
Above 19.7
24 (49.0)
10 (25.6)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

.893

Table 15 - Association between attitudes towards pregnancy and baby (MAMA) and
Language Development (GRIFFITHS) of Infants at 3.5 months.

MAMA
Below 24
Above 24

Below average
N
(%)
12 (35.3)
22 (64.7)

Above average
N
(%)
32 (58.2)
23 (41.8)

p
.036

OR
.392

OR IC 95%
.162
.949

(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

292

Tabele 16 - Attitude towards pregnancy and baby (MAMA) and Global Development
(GRIFFITHS) at 3.5 months
Below average
Above average
MAMA
N
(%)
N
(%)
p
OR
OR IC 95%
Below 24
15
(37.5) 29
(59.2) 0.042
0.414
0.176
0.975
Above24
25
(62.5) 20
(40.8)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

Table 17 Association between attitude towards sex (MAMA) and the development of eyehand coordination (GRIFFITHS) of babies at 3.5 months.

below average
above average
MAMA
N
(%)
N
(%)
p
OR
OR IC 95%
Below 23
17 (37.0)
25 (59,5)
.034
.399
.169
.941
Above 23
29 (63.0)
17 (40,5)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test of
Fisher; OR Odds Ratio; OR IC 95%

Table 18 - Attitude towards sex in pregnancy (MAMA) and Development of Locomotion

(GRIFFITHS) of Baby at 12 months.
below average
Above average
MAMA at. sex
N
(%)
N
(%)
p
OR
OR IC 95%
Below 23
19
(65,5) 14
(32,6) 0,006
3,936
1,453
10,662
Above de 23
10
(34,5) 29
(67,4)
(SD) Standard Deviation; Min Minimum; Max Maximum; * Qui-square; ** exact test
of Fisher; OR Odds Ratio; OR IC 95%

293