Thanks for the opportunity to be here.
As introduced, I'm Jocelynn Cook. I am the scientific director for the Society of Obstetricians and Gynaecologists of Canada, which is a member-based organization of about 3,000 members, including family physicians, nurses, midwives, obstetricians, and gynecologists.
Today I'm going to talk a little bit about pregnancy and violence, and touch on postpartum mental health. I will then talk a little bit about our guidelines for intimate partner violence, which you will receive a copy of, if you haven't already, and then the role of physicians in terms of best practices for preventing violence against women.
Everybody knows that violence against pregnant women is a threat to both maternal and fetal health as well as to newborn health. It's a unique stage in women's lives where they're particularly vulnerable because of their pregnancy.
The incidence of physical abuse during pregnancy has been reported to be between 4% and 17%. The data show there can be increases or decreases in abuse during pregnancy, or it can stay the same. There are different types of abuse that can occur.
We know that the acts of violence during pregnancy tend to be recurring and tend to escalate over time.
Violence against pregnant women can cause physical and psychological harm. It can lead to pregnancy complications, morbidity, and mortality for both the mother and the baby. It can also contribute towards poor outcomes for babies.
Some of the data show that because of violence, women may have delayed or no prenatal care. We know there are negative consequences associated with that. There's an increased risk for women who experience violence to use tobacco, alcohol, and illicit drugs, which also have negative impacts both on pregnancy and on fetal outcome. We can have maternal death. We can have low birth weight when babies are born, and pregnancy complications such as hemorrhaging, infection, poor weight gain, miscarriage, pre-term birth, and small babies. There can also be antenatal violence, which also has implications.
There are a number of studies, not a lot, but there are a few studies, that show a relationship between violence and postpartum mental health, which I think is really important to touch on.
We know that violence increases the risk of postpartum depression, generalized anxiety disorder, obsessive-compulsive disorder, PTSD, and other forms of psychosis. These data have been established.
The data also show that women who experienced violence before or during pregnancy reported higher levels of postpartum mental health problems. As the number of types of violence increased, so did the negative effects on postpartum mental health. Psychological violence, physical violence, and emotional violence increased the negative effects.
Mental health problems have also been shown to be associated with early breastfeeding discontinuation, bonding impairment between mother and babe, fewer positive parenting behaviours, substance abuse, self-harm, and some of the other indications of which you are probably all aware that are specific to women and which we touched on earlier.
With regard to physicians and violence against women, what is their role, and what can they do in terms of improving outcomes for women and their babies?
We know that approximately only 3% of incidents of violence against pregnant women are identified by primary care physicians. That's not a high proportion. We also know that even fewer cases are identified by obstetricians and gynecologists.
It's probably very important, and even essential, for physicians to become adept at identifying women who might be at risk of experiencing violence or abuse during their lives, as well as during pregnancy and the postpartum period. It's important for them to create an environment where it's safe for women to talk about their situations, so that the physicians can really start to understand the complexity of the environment in which they are living, and so that they can refer them for effective treatment and intervention.
Something that's really important is that routine perinatal care visits really offer excellent opportunities for health care providers to screen, to talk to women, to build those relationships, and to start to refer them to effective interventions and put into place and implement best practices for talking to women about complex issues related to lifestyle and behaviour, but also related to pregnancy.
What can we do in terms of better understanding the impacts of violence and abuse during pregnancy in the postnatal period, in this unique period? How can we better improve outcomes for women and their children?
The SOGC guidelines suggest that it's very important, as you might imagine, for health providers to create that safe environment, to really understand the context in which women are living, understand the linkages to the social determinants of health and the implications, and how those very specific contexts and situations that women are in with their children or during their pregnancy.... What are some of the best options for interventions, for referral, to keep women and their babies safe?
We know that knowledge of whether women have actually experienced abuse will help to target as well those very important postpartum mental health interventions, which are really critical. There is research that examines the long-term impact of violence and abuse on maternal and child health, but we really need to bolster that research, have nice longitudinal studies where we can look at the specifics of situations of violence and then look at best effective practices that come out of that that improve outcomes.
There is some really exciting emerging data—and I'm a scientist, so forgive me for getting excited about this—that show that environmental factors, including stress and nutrition, can affect a woman's brain. Those brain changes can be passed on to future generations and could possibly cause children later in life to become more susceptible to insults—toxicological insults, physiological insults—potentially to an increased mental health risk. That's called epigenetics, when things in the environment can change the actual genes that can be passed on to future generations. We need to better understand that. We need to better understand what's happening during the perinatal period that can affect child development later in life as well.
We need to develop, implement, and evaluate strategies to reduce violence during the perinatal period. Right now, with the information and best practices in the evaluation of those practices, it's difficult to determine during the post-pregnancy and the postpartum period which interventions should really be pinpointed. Again, as you can imagine, it really depends on the situation that the woman is living in. It depends on the resources that are available. It depends on that whole complex context.
We really need more information from well-conducted studies that determine the optimal interventions. It's also very important for our organization to recognize the impact that violence and abuse have on pregnant women and their babies, their fetuses, and all the outcomes, and to work together to help to create knowledge opportunities for health care providers, to help them understand what resources are out there, where they can refer women, and really help facilitate and advocate through that health system. I think that's really important. We as an organization are thinking about helping to create some of those learning opportunities for our members that cross the health sectors that deal with perinatal health.
Thank you.