Background
Childhood abuse is a major global and public health problem associated with a myriad of adverse outcomes across the life course. Suicide is one of the leading causes of mortality during the perinatal period. However, few studies have assessed the relationship between experiences of childhood abuse and suicidal ideation in pregnancy.
Objective
We sought to examine the association between exposure to childhood abuse and suicidal ideation among pregnant women.
Study Design
A cross-sectional study was conducted among 2964 pregnant women attending prenatal clinics in Lima, Peru. Childhood abuse was assessed using the Childhood Physical and Sexual Abuse Questionnaire. Depression and suicidal ideation were assessed using the Patient Health Questionnaire-9 scale. Logistic regression procedures were performed to estimate adjusted odds ratios and 95% confidence intervals adjusted for potential confounders.
Results
Overall, the prevalence of childhood abuse in this cohort was 71.8% and antepartum suicidal ideation was 15.8%. The prevalence of antepartum suicidal ideation was higher among women who reported experiencing any childhood abuse compared to those reporting none (89.3% vs 10.7%, P < .0001). After adjusting for potential confounders, including antepartum depression and lifetime intimate partner violence, those with history of any childhood abuse had a 2.9-fold (2.90, adjusted odds ratio; 95% confidence interval, 2.12–3.97) increased odds of reporting suicidal ideation. Women who experienced both physical and sexual childhood abuse had much higher odds of suicidal ideation (adjusted odds ratio, 4.04; 95% confidence interval, 2.88–5.68). Women who experienced any childhood abuse and reported depression had 3.44-fold (3.44, adjusted odds ratio; 95% confidence interval, 1.84–6.43) increased odds of suicidal ideation compared with depressed women with no history of childhood abuse. Finally, the odds of suicidal ideation increased with increased number of childhood abuse events experienced ( P value for linear trend < .001).
Conclusion
Maternal history of childhood abuse was associated with increased odds of antepartum suicidal ideation. It is important for clinicians to be aware of the potential increased risk of suicidal behaviors among pregnant women with a history of childhood physical and sexual abuse.
Introduction
Approximately 275 million children per year suffer acts of violence in their own home. As many as 40 million children <15 years of age in Latin America and the Caribbean countries have experienced violence, abuse, and neglect. Childhood abuse includes all forms of physical and psychological maltreatment that pose harm to a child’s health, development, or dignity, and include physical abuse and sexual abuse. Notably, childhood abuse is rarely a solitary incident; rather, it appears to co-occur with ≥1 type of childhood maltreatment (ie, physical neglect, emotional neglect, and emotional abuse). Childhood abuse has been reported to be associated with adverse psychiatric and physical health conditions in adulthood. In pregnant women, exposure to childhood abuse has been associated with psychiatric disorders, sleep disturbances, health risk behaviors, and unfavorable pregnancy outcomes. However, few studies have assessed the relationship between experiences of childhood abuse and suicidal ideation in pregnancy. Suicidal ideation and suicide attempt during pregnancy are associated with a myriad of adverse maternal and infant outcomes including psychiatric disorders such as depression, fetal growth restriction, premature labor, and cesarean delivery. Notably, an emerging body of evidence now implicates suicidal ideation as a precursor and important predictor of later suicide attempts and completions. Given that suicide is one of the leading causes of mortality during the perinatal period and given the gap in the existing literature, we conducted the current analysis, in a large pregnancy cohort, to assess the extent to which, if at all, women’s history of physical and/or sexual abuse in childhood is associated with antepartum suicidal ideation. Documentation of associations of childhood abuse with suicidal ideation in this population may have important clinical implications, to the extent that health care providers are alerted to the need for evaluating and screening women for past abuse.
Materials and Methods
Participants in this cross-sectional study were women who received prenatal care at the Instituto Nacional Materno Perinatal (INMP) from February 2012 through March 2014 and who enrolled in the ongoing Pregnancy Outcomes, Maternal and Infant cohort study. The INMP is the main reference establishment for maternal and perinatal care operated by the Ministry of Health of the Peruvian Government. Eligible participants were pregnant women who were 18-49 years of age and were <16 weeks of gestational age during the prenatal care visit. Details of the study setting and data collection procedures have been described previously. Briefly, each participant was interviewed, in a private setting, by trained research personnel using a structured questionnaire. The questionnaire was used to elicit information regarding maternal sociodemographic, and lifestyle characteristics; medical and reproductive histories; symptoms of depression; and childhood abuse experiences. All participants provided written informed consent prior to interview. The institutional review boards of the INMP, Lima, Peru, and the Harvard T. H. Chan School of Public Health, Office of Human Research Administration, Boston, MA, approved all procedures used in this study.
Analytical population
Our study population is derived from information collected from participants who enrolled in the Pregnancy Outcomes, Maternal and Infant study. During the study period, a total of 3045 participants completed the structured interview. For the analysis described here, we excluded participants with missing information on suicidal ideation (N = 37), history of childhood abuse (N = 69), and symptoms of depression (N = 21). The final analysis included 2964 participants. Excluded participants did not differ from the rest of the cohort with regard to sociodemographic or lifestyle characteristics.
Childhood abuse assessment
The Childhood Physical and Sexual Abuse Questionnaire was used to collect information concerning participants’ experiences with physical and sexual abuse in childhood. Participants were categorized as having experienced childhood physical abuse if, before the age of 18 years, they reported that an older person hit, kicked, pushed, or beat them and/or their life was seriously threatened. Participants were categorized as having experienced childhood sexual abuse if, before the age of 18 years, they reported that an older person touched them in a sexual way, they were made to touch someone else in a sexual way, or someone attempted or completed intercourse with them. Participants who responded “no” to all questions regarding childhood sexual and physical abuse were categorized as having experienced no abuse.
Participants who experienced any childhood physical or sexual abuse were further classified into 3 groups: “childhood physical abuse only” if they only endorsed physical abuse questions, “childhood sexual abuse only” if they only endorsed sexual abuse questions, or “both childhood physical and sexual abuse” if they endorsed both physical abuse and sexual abuse questions. Furthermore, the number of childhood abuse events was assessed by summing responses to individual abuse questions and creating the following response categories: 0, 1, 2, 3, 4, 5, or 6–8.
Lifetime intimate partner violence assessment
Questions pertaining to intimate partner violence (IPV) were adapted from the protocol of Demographic Health Survey Questionnaires and Modules: Domestic Violence Module and the World Health Organization Multi-Country Study on Violence Against Women. Participants were assessed for several physical and/or sexual coercive acts used against them by a current or former spouse or intimate partner during their lifetime. A participant was classified as having experienced physical violence if she endorsed any of the following acts: being slapped or having something thrown at her; being pushed, shoved, or having her hair pulled; being hit; kicked, dragged, or beaten up; being choked or burnt on purpose; and being threatened or hurt with a weapon (eg, a gun or knife). A participant was classified as having experienced sexual violence if she endorsed any of the following acts: being physically forced to have sexual intercourse; having had unwanted sexual intercourse because of fear of what the partner might do; or being forced to perform other sexual acts that she found degrading or humiliating. In this analysis, we categorized participants as having experienced either no physical and sexual violence or any physical or sexual violence during their lifetime.
Depression and suicidal ideation assessments
The Patient Health Questionnaire (PHQ)-9 is a 9-item depression screening scale based on the criteria from the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition . The questionnaire assesses 9 depressive symptoms in the 14 days prior to evaluation. The PHQ-9 score is calculated by assigning a score of 0-3 to the response categories “not at all,” “several days,” “more than half the days,” and “nearly every day.” Suicidal ideation was assessed based on the PHQ-9 question inquiring as to patient having “thoughts that you would be better off dead or of hurting yourself in some way.” Participants responding to this question with “several days,” “more than half the days,” and “nearly every day” were categorized as affirmative for suicidal ideation. The question asking about suicidal ideation was not considered in the total score for depression. The first 8 questions (PHQ-8) were used to calculate a depression score. Participants were categorized as “yes” for depression with a PHQ-8 score ≥10, similar to the cutoff for the PHQ-9. The use of PHQ-8 depression questionnaire has been demonstrated to minimally influence overall scale performance, mean scores, or diagnostic cut points as compared with use of PHQ-9. The utility and validity of PHQ-9 depression screening and item-9 suicidal ideation assessments have been established in the current study population.
Other covariates
Maternal age was categorized as 18–19, 20–29, 30–34, and ≥35 years. Educational attainment was categorized as ≤6, 7–12, and ≥12 completed years of schooling. Other sociodemographic variables were categorized as: marital status (married/living with partner vs other), employment status (employed vs not employed), race/ethnicity (Mestizo vs other), difficulty accessing basic foods (hard vs not very hard), parity (nulliparous vs multiparous), and planned pregnancy (yes vs no). Gestational age (in weeks) was based on the date of the last menstrual period and ultrasound assessment. Maternal early pregnancy body mass index (kg/m 2 ) was categorized as <18.5, 18.5–24.9, 25–29.9, and ≥30 using directly measured weight and height taken at the first study visit by trained research personnel.
Statistical analysis
Frequency distributions of maternal sociodemographic characteristics according to types of childhood abuse events were examined. Analysis of variance (ANOVA) was used to assess differences in means of continuous variables, while the χ 2 test was used to compare percentages of categorical variables according to history of childhood abuse. Multivariate logistic regression procedures were used to calculate maximum likelihood estimates of odds ratios (ORs) at 95% confidence intervals (CIs) for the presence of suicidal ideation in relation to childhood abuse (none, physical abuse only, sexual abuse only, physical and sexual abuse) and number of childhood abuse events, respectively. Potential confounders were selected a priori based on their hypothesized relationship with childhood abuse and suicidal ideation during early pregnancy. These included maternal age, maternal race/ethnicity, IPV exposure, and depression status. Because depression might modify the association between childhood abuse and suicidal ideation, analyses were repeated after stratifying the cohort according to depression status (yes vs no). Participants with no abuse served as the reference group across all analyses. All reported P values are 2-sided with a statistical significance set at .05. Statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC). All figures were plotted using R 3.1.0 (R Development Core Team, Vienna, Austria) (package ggplot2).
Materials and Methods
Participants in this cross-sectional study were women who received prenatal care at the Instituto Nacional Materno Perinatal (INMP) from February 2012 through March 2014 and who enrolled in the ongoing Pregnancy Outcomes, Maternal and Infant cohort study. The INMP is the main reference establishment for maternal and perinatal care operated by the Ministry of Health of the Peruvian Government. Eligible participants were pregnant women who were 18-49 years of age and were <16 weeks of gestational age during the prenatal care visit. Details of the study setting and data collection procedures have been described previously. Briefly, each participant was interviewed, in a private setting, by trained research personnel using a structured questionnaire. The questionnaire was used to elicit information regarding maternal sociodemographic, and lifestyle characteristics; medical and reproductive histories; symptoms of depression; and childhood abuse experiences. All participants provided written informed consent prior to interview. The institutional review boards of the INMP, Lima, Peru, and the Harvard T. H. Chan School of Public Health, Office of Human Research Administration, Boston, MA, approved all procedures used in this study.
Analytical population
Our study population is derived from information collected from participants who enrolled in the Pregnancy Outcomes, Maternal and Infant study. During the study period, a total of 3045 participants completed the structured interview. For the analysis described here, we excluded participants with missing information on suicidal ideation (N = 37), history of childhood abuse (N = 69), and symptoms of depression (N = 21). The final analysis included 2964 participants. Excluded participants did not differ from the rest of the cohort with regard to sociodemographic or lifestyle characteristics.
Childhood abuse assessment
The Childhood Physical and Sexual Abuse Questionnaire was used to collect information concerning participants’ experiences with physical and sexual abuse in childhood. Participants were categorized as having experienced childhood physical abuse if, before the age of 18 years, they reported that an older person hit, kicked, pushed, or beat them and/or their life was seriously threatened. Participants were categorized as having experienced childhood sexual abuse if, before the age of 18 years, they reported that an older person touched them in a sexual way, they were made to touch someone else in a sexual way, or someone attempted or completed intercourse with them. Participants who responded “no” to all questions regarding childhood sexual and physical abuse were categorized as having experienced no abuse.
Participants who experienced any childhood physical or sexual abuse were further classified into 3 groups: “childhood physical abuse only” if they only endorsed physical abuse questions, “childhood sexual abuse only” if they only endorsed sexual abuse questions, or “both childhood physical and sexual abuse” if they endorsed both physical abuse and sexual abuse questions. Furthermore, the number of childhood abuse events was assessed by summing responses to individual abuse questions and creating the following response categories: 0, 1, 2, 3, 4, 5, or 6–8.
Lifetime intimate partner violence assessment
Questions pertaining to intimate partner violence (IPV) were adapted from the protocol of Demographic Health Survey Questionnaires and Modules: Domestic Violence Module and the World Health Organization Multi-Country Study on Violence Against Women. Participants were assessed for several physical and/or sexual coercive acts used against them by a current or former spouse or intimate partner during their lifetime. A participant was classified as having experienced physical violence if she endorsed any of the following acts: being slapped or having something thrown at her; being pushed, shoved, or having her hair pulled; being hit; kicked, dragged, or beaten up; being choked or burnt on purpose; and being threatened or hurt with a weapon (eg, a gun or knife). A participant was classified as having experienced sexual violence if she endorsed any of the following acts: being physically forced to have sexual intercourse; having had unwanted sexual intercourse because of fear of what the partner might do; or being forced to perform other sexual acts that she found degrading or humiliating. In this analysis, we categorized participants as having experienced either no physical and sexual violence or any physical or sexual violence during their lifetime.
Depression and suicidal ideation assessments
The Patient Health Questionnaire (PHQ)-9 is a 9-item depression screening scale based on the criteria from the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition . The questionnaire assesses 9 depressive symptoms in the 14 days prior to evaluation. The PHQ-9 score is calculated by assigning a score of 0-3 to the response categories “not at all,” “several days,” “more than half the days,” and “nearly every day.” Suicidal ideation was assessed based on the PHQ-9 question inquiring as to patient having “thoughts that you would be better off dead or of hurting yourself in some way.” Participants responding to this question with “several days,” “more than half the days,” and “nearly every day” were categorized as affirmative for suicidal ideation. The question asking about suicidal ideation was not considered in the total score for depression. The first 8 questions (PHQ-8) were used to calculate a depression score. Participants were categorized as “yes” for depression with a PHQ-8 score ≥10, similar to the cutoff for the PHQ-9. The use of PHQ-8 depression questionnaire has been demonstrated to minimally influence overall scale performance, mean scores, or diagnostic cut points as compared with use of PHQ-9. The utility and validity of PHQ-9 depression screening and item-9 suicidal ideation assessments have been established in the current study population.
Other covariates
Maternal age was categorized as 18–19, 20–29, 30–34, and ≥35 years. Educational attainment was categorized as ≤6, 7–12, and ≥12 completed years of schooling. Other sociodemographic variables were categorized as: marital status (married/living with partner vs other), employment status (employed vs not employed), race/ethnicity (Mestizo vs other), difficulty accessing basic foods (hard vs not very hard), parity (nulliparous vs multiparous), and planned pregnancy (yes vs no). Gestational age (in weeks) was based on the date of the last menstrual period and ultrasound assessment. Maternal early pregnancy body mass index (kg/m 2 ) was categorized as <18.5, 18.5–24.9, 25–29.9, and ≥30 using directly measured weight and height taken at the first study visit by trained research personnel.
Statistical analysis
Frequency distributions of maternal sociodemographic characteristics according to types of childhood abuse events were examined. Analysis of variance (ANOVA) was used to assess differences in means of continuous variables, while the χ 2 test was used to compare percentages of categorical variables according to history of childhood abuse. Multivariate logistic regression procedures were used to calculate maximum likelihood estimates of odds ratios (ORs) at 95% confidence intervals (CIs) for the presence of suicidal ideation in relation to childhood abuse (none, physical abuse only, sexual abuse only, physical and sexual abuse) and number of childhood abuse events, respectively. Potential confounders were selected a priori based on their hypothesized relationship with childhood abuse and suicidal ideation during early pregnancy. These included maternal age, maternal race/ethnicity, IPV exposure, and depression status. Because depression might modify the association between childhood abuse and suicidal ideation, analyses were repeated after stratifying the cohort according to depression status (yes vs no). Participants with no abuse served as the reference group across all analyses. All reported P values are 2-sided with a statistical significance set at .05. Statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC). All figures were plotted using R 3.1.0 (R Development Core Team, Vienna, Austria) (package ggplot2).
Results
Selected sociodemographic data and reproductive characteristics of participants are presented in Table 1 . Of the 2964 study participants, 71.8% reported experiencing any type of childhood physical or abuse. Approximately 36.7% of participants reported experiencing intimate partner abuse in their lifetime. Further, 26.3% of participants were found to have depression (PHQ-8 score ≥10) and 15.8% reported suicidal ideation during early pregnancy. The mean age of participants was 28.1 years (SD 6.3 years) and the mean gestational age at interview was 9.2 weeks (SD 3.5 weeks). The majority of participants (75.1%) identified themselves as Mestizo (mixed European and indigenous ancestry) and 95.6% had at least 7 years of education. Characteristics of the study cohort according to childhood abuse groups are also presented in Table 1 . Age, access to basics, being nulliparous, experiencing IPV, and depression were statistically significantly associated with any type childhood abuse experienced ( P value < .05). The groups were otherwise similar for other covariates.
| Characteristics | All participants, N = 2964 | No abuse, N = 836 | Physical abuse only, N = 1146 | Sexual abuse only, N = 231 | Physical and sexual abuse, N = 751 | P value | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | ||
| Age, y a | 28.1 ± 6.3 | 27.7 ± 6.1 | 28.0 ± 6.4 | 28.2 ± 6.5 | 28.7 ± 6.3 | .02 | |||||
| Age, y | .02 | ||||||||||
| 18–19 | 162 | 5.5 | 39 | 4.7 | 67 | 5.8 | 15 | 6.5 | 41 | 5.5 | |
| 20–29 | 1658 | 55.9 | 512 | 61.2 | 633 | 55.2 | 128 | 55.4 | 385 | 51.3 | |
| 30–34 | 609 | 20.5 | 154 | 18.4 | 236 | 20.6 | 40 | 17.3 | 179 | 23.8 | |
| ≥35 | 535 | 18.0 | 131 | 15.7 | 40 | 18.3 | 48 | 20.8 | 146 | 18.0 | |
| Education, y | .68 | ||||||||||
| ≤6 | 125 | 4.2 | 37 | 4.4 | 48 | 4.2 | 5 | 2.2 | 35 | 4.7 | |
| 7–12 | 1621 | 54.7 | 467 | 55.9 | 623 | 54.4 | 123 | 53.2 | 408 | 54.3 | |
| >12 | 1211 | 40.9 | 330 | 39.5 | 473 | 41.3 | 101 | 43.7 | 307 | 40.9 | |
| Mestizo ethnicity | 2226 | 75.1 | 640 | 76.6 | 853 | 74.4 | 180 | 77.9 | 553 | 73.6 | .34 |
| Married/living with partner | 2390 | 80.6 | 688 | 82.3 | 928 | 81.0 | 177 | 76.6 | 597 | 79.5 | .20 |
| Employed | 1367 | 46.1 | 382 | 45.7 | 516 | 45.1 | 111 | 48.1 | 358 | 47.7 | .65 |
| Access to basic foods | <.0001 | ||||||||||
| Hard | 1474 | 49.7 | 350 | 41.9 | 559 | 48.8 | 126 | 54.5 | 439 | 58.5 | |
| Not very hard | 1488 | 50.2 | 486 | 58.1 | 585 | 51.0 | 105 | 45.5 | 312 | 41.5 | |
| Nulliparous | 1448 | 48.9 | 452 | 54.1 | 548 | 48.0 | 115 | 49.8 | 333 | 44.3 | .001 |
| Planned pregnancy | 1222 | 41.2 | 367 | 43.9 | 480 | 41.9 | 90 | 39.0 | 285 | 37.9 | .10 |
| Gestational age interview, wk a | 9.2 ± 3.5 | 9.3 ± 3.4 | 9.3 ± 3.5 | 9.3 ± 3.3 | 9.2 ± 3.6 | .91 | |||||
| Early pregnancy body mass index, kg/m 2 | .52 | ||||||||||
| <18.5 | 59 | 2.0 | 21 | 2.5 | 23 | 2.0 | 4 | 1.7 | 11 | 1.5 | |
| 18.5–24.9 | 1423 | 48.0 | 383 | 45.8 | 563 | 49.1 | 120 | 51.9 | 357 | 47.5 | |
| 25–29.9 | 1088 | 36.7 | 323 | 38.6 | 414 | 36.1 | 76 | 32.9 | 275 | 36.6 | |
| ≥30 | 362 | 12.2 | 93 | 11.1 | 141 | 12.3 | 26 | 11.3 | 102 | 13.6 | |
| Lifetime intimate partner violence | 1087 | 36.7 | 203 | 24.3 | 382 | 33.3 | 99 | 42.9 | 403 | 53.7 | <.0001 |
| Depression, PHQ-8 score ≥10 | 781 | 26.3 | 125 | 15.0 | 338 | 29.5 | 48 | 20.8 | 270 | 36.0 | <.0001 |
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