
==== Front
Eur J Psychotraumatol
Eur J Psychotraumatol
European Journal of Psychotraumatology
2000-8066
Taylor & Francis

39267605
2398961
10.1080/20008066.2024.2398961
Version of Record
Basic Research Article
Research Article
Wellbeing and illbeing in women exposed to physical and sexual violence during peripregnancy: a population-based longitudinal study
Bienestar y malestar en mujeres expuestas a violencia física y sexual durante el periparto: un estudio longitudinal basado en la poblaciónEUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY
L. MAYERHOFER ET AL.
https://orcid.org/0009-0000-8253-8530
Mayerhofer Lilian a
Bang Nes Ragnhild abc
Lan Xiaoyu a
Czajkowski Nikolai ab
Ystrøm Eivind ab
Røysamb Espen ab
a PROMENTA Research Center, Department of Psychology, University of Oslo, Oslo, Norway
b Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
c Department of Philosophy, Classics, and History of Arts and Ideas, University of Oslo, Oslo, Norway
CONTACT Lilian Mayerhofer lilianjk@uio.no PROMENTA Research Center, Department of Psychology, University of Oslo, Forskningsveien 3A Harald Schjelderup’s House, Oslo 0373, Norway
Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2024.2398961.

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ABSTRACT

Background: Physical and sexual violence against pregnant women have been associated with detrimental mental health outcomes for victims. Few studies have examined both positive (wellbeing) and negative (illbeing) mental health indicators in the same sample. Additionally, the literature assessing mental health based on different forms of violence is limited.

Objective: To compare both wellbeing (life satisfaction) and illbeing (anxiety and depression) trajectories between non-victimized and victims of physical, sexual and both forms of violence that occurred during or shortly before pregnancy. Further, we analyse whether social support moderates these trajectories.

Method: This longitudinal study is based on the Norwegian Mother, Father and Child Cohort, including the period from early pregnancy to toddlerhood (3 years). We compared wellbeing and illbeing trajectories of non-victims (n = 73,081), victims of physical abuse (n = 1076), sexual abuse (n = 683), and both forms of abuse (n = 107) using Growth Curve Modelling. Finally, social support was included as a moderator of wellbeing and illbeing trajectories.

Results: Results indicated that victims scored systematically lower in wellbeing and higher in illbeing. Exposure to violence did not significantly change the wellbeing trajectory, pointing to similar developments in wellbeing among victims and non-victims for the considered period. On the other hand, different trajectories in illbeing occurred between victims and non-victims, as well as between victimized groups. Victims experienced greater change in illbeing scores, with a steeper decrease in illbeing compared to non-victims. Both victims and non-victims returned to respective baseline scores 3 years after birth. All women benefited from social support, but victims of physical abuse were particularly protected by social support.

Conclusions: There is an alarming persistence of mental health problems in women exposed to violence during peripregnancy. Different forms of violence differentially impact women’s mental health. Social support is beneficial among all pregnant women.

Highlights

Victims of peripregnancy violence score systematic lower in wellbeing over time than non-victims. However, the wellbeing trajectories among victims and non-victims are similar.

On the other hand, illbeing (anxiety and depression) trajectories differ for non-victims and victims of physical, sexual and both forms of violence. All women decreased their levels of illbeing from pregnancy to the first 6 months postpartum, but victims had a steeper decrease during this period compared to non-victims.

All women benefited from social support, but victims of physical abuse were particularly protected by social support.

Antecedentes: La violencia física y sexual contra mujeres embarazadas se ha asociado con resultados perjudiciales en la salud mental de las víctimas. Pocos estudios han examinado simultáneamente los indicadores positivos (bienestar) y negativos (malestar) de la salud mental en una misma muestra. Además, la literatura que evalúa la salud mental en función de diferentes formas de violencia es limitada.

Objetivos: Comparar las trayectorias de bienestar (satisfacción con la vida) y malestar (ansiedad y depresión) entre mujeres no victimizadas y víctimas de violencia física, sexual o ambas, que ocurrieron durante o poco antes del embarazo. Asimismo, analizamos si el apoyo social modera estas trayectorias.

Método: Este estudio longitudinal se basa en la Cohorte de Madres, Padres y Niños de Noruega, que incluye el período desde el inicio del embarazo hasta la primera infancia (3 años). Comparamos las trayectorias de bienestar y malestar de las mujeres no victimas (n = 73.081), víctimas de abuso físico (n = 1.076), abuso sexual (n = 683) y de ambas formas de abuso (n = 107) utilizando el Modelo de Curva de Crecimiento. Finalmente, se incluyó el apoyo social como moderador de las trayectorias de bienestar y malestar.

Resultados: Los resultados indicaron que las víctimas obtuvieron puntuaciones sistemáticamente más bajas en bienestar y más altas en malestar. La exposición a la violencia no cambió significativamente la trayectoria del bienestar, lo que sugiere desarrollos similares en el bienestar entre víctimas y no víctimas durante el período considerado. Por otro lado, se observaron trayectorias diferentes en el malestar entre víctimas y no víctimas, así como entre los diferentes grupos de víctimas. Las víctimas experimentaron un mayor cambio en los puntajes de malestar, con una disminución más pronunciada en el malestar en comparación con las no víctimas. Tanto las víctimas como las no víctimas volvieron a sus puntuaciones iniciales tres años después del nacimiento. Todas las mujeres se beneficiaron del apoyo social, pero las víctimas de abuso físico fueron particularmente protegidas por este.

Conclusiones: Existe una alarmante persistencia de problemas de salud mental en mujeres expuestas a violencia durante el periparto. Las distintas formas de violencia impactan de manera diferente la salud mental de las mujeres. El apoyo social es beneficioso para todas las mujeres embarazadas.

KEYWORDS

Life satisfaction
illbeing
social support
physical violence
sexual violence
Norwegian Mother, Father and Child Cohort
Medical Birth Registry of Norway
PALABRAS CLAVES

Satisfacción con la vida
malestar
apoyo social
violencia sexual
violencia física
embarazo
Cohorte de Madres
Padres e Hijos de Noruega
Registro Médico de Nacimientos de Noruega
Research Council of Norway 10.13039/501100005416 grant numbers 288083, 320709 The study was supported by grants from the Research Council of Norway [grant numbers 288083, 320709].
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pmc1. Introduction

Violence against women is highly prevalent globally. It is estimated that one in three women are subjected to physical or sexual violence in their lifetime (World Health Organization, 2021). The experience of violence can be particularly harmful during pregnancy due to significant changes in women’s socioemotional and biological needs, and the potential adverse effects on the offspring. The prevalence of violence against pregnant women differs across populations. Several studies have attempted to establish a global prevalence with the estimates for sexual violence ranging from 8% (James et al., 2013) to 17% (Bazyar et al., 2018). The divergences are likely to reflect methodological and cultural differences. A significant number of cases remain unreported, leading to a substantial underestimation of the problem (Gracia, 2004).

The pregnancy and postpartum periods are considered risk factors for experiencing domestic violence (Finnbogadóttir & Dykes, 2016). It is well documented that prenatal violence may be detrimental to the later wellbeing of mothers, children, and the whole family system (Chisholm et al., 2017). These deleterious consequences, along with the limited number of robust population-based prospective studies, emphasize the need for an investigation regarding the mental health impact of violence exposure in pregnancy. These insights could ultimately contribute to evidence-based strategies to prevent or reduce negative health outcomes in different areas of women’s lives. Pregnant women subject to violence experience worse pregnancy-related physical discomfort compared to those not exposed (Gürkan et al., 2020). The problems are aggravated by the avoidance of seeking professional health care. A history of sexual violence has been found to be independently and significantly associated with avoidance of gynecological care (Razi et al., 2021). These findings, combined with the experience of abuse itself, were associated with harmful offspring outcomes. Infants of women victims of prenatal physical violence showed excess risk of low birth weight (Harron et al., 2021), pre-term birth (Finnbogadóttir et al., 2020), admission to neonatal intensive care and developmental difficulties during their first years of life (Chan et al., 2021; Do et al., 2021; Toso et al., 2020). Violence exposure during the prenatal period is also detrimental to the mental health of pregnant women (Do et al., 2021). A recent study by Do et al. (2021) showed victimized women to be approximately twice as likely to experience poor mental health in comparison to non-victims. Violence has repeatedly been described as a risk factor for depression during pregnancy, increasing the risk of depressive symptoms up to five-fold (Ghoneim et al., 2021; Mahapatro et al., 2022; Tesfaye & Agenagnew, 2021).

Prior research on violence against pregnant women has reported critical findings, but several conceptual and methodological limitations still merit further investigation. The majority of previous studies focus on physical violence, neglecting the impact of sexual violence and the potential synergistic effect of co-occurring physical and sexual violence on women’s mental health (Trevillion et al., 2012). Conceptually, most studies have focused on mental ‘illbeing’, commonly measured as anxiety and depressive symptoms (Cummins et al., 2004), providing limited understanding of victims’ wellbeing (Da Costa et al., 2006; Lagadec et al., 2018). As documented by e.g. the dual factor model, wellbeing and illbeing are not merely opposite sides of the same spectrum, but are constructs with both distinct and overlapping features (Keyes, 2002, 2005; Suldo & Shaffer, 2008; Westerhof & Keyes, 2010). A key indicator of wellbeing is the overall satisfaction with life (SWL) (Diener, 2000). How physical and sexual violence impact both wellbeing and illbeing trajectories from pregnancy to the years following birth remains unclear.

Furthermore, less research has been devoted to protective factors, such as social support, in the association between violence and maternal mental health. Support is a central aspect of most close relationships, and people who have supportive relationships report higher levels of wellbeing and lower levels of mental illness (Warren et al., 2018). According to the multidimensional model of support (Barry et al., 2009), different types of social support can be identified. The ‘advice’ support is defined as the provision of information and guidance (Barry et al., 2009). Social support may impact wellbeing and illbeing directly and indirectly by moderating the association between violence exposure and wellbeing and illbeing. Low social support has been associated with increased risk of depression and anxiety among pregnant women, regardless of violence exposure (Bedaso et al., 2021). Considering the moderation effect, social support can be especially important for victims of violence (Sylaska & Edwards, 2014) and has been linked with reduced risk of anxiety and depression (Coker et al., 2002). Pregnant women exposed to violence have lower frequency of social support in comparison to non-victims (Kita et al., 2020; Nguyen et al., 2018). The role of social support in the trajectories of wellbeing and illbeing from pregnancy to toddlerhood among victims and non-victims remains unclear.

Methodologically, most of the prior research on violence against women has regarded wellbeing and illbeing as static conditions during pregnancy, restricting our knowledge about the development of maternal wellbeing and illbeing. Another knowledge gap is how this change occurs among non-victims and the different victimized groups.

Attempting to fill these conceptual and methodological gaps, the current study aimed to compare the longitudinal developments of wellbeing (life satisfaction) and illbeing (anxiety and depressive symptoms) for non-victims, victims of physical, sexual, and both forms of violence, from pregnancy to 3 years after birth. We also investigated the role of social support for changes in both wellbeing and illbeing in this period, for the four groups, controlling for covariates. We aim to investigate a) whether there are differences between non-victims and victims of physical, sexual and both forms of violence in their early pregnancy levels of wellbeing and illbeing following a recent (up to 6 months before pregnancy) episode of violence, b) if the change (development) in wellbeing and illbeing differs across these four groups, c) the moderating role of social support in the change observed in wellbeing and illbeing across these four groups.

2. Methods

2.1. Participants and procedures

The present study relied on data from the Norwegian Mother, Father and Child Cohort Study (MoBa) (Magnus et al., 2016), where pregnant women were recruited during their first ultrasound appointment (18th week of pregnancy). The current study is based on version 12 of the quality-assured data files released for research in 2020. The establishment of MoBa and initial data collection was based on a license from the Norwegian Data Protection Agency and approval from The Regional Committees for Medical and Health Research Ethics. The MoBa cohort is currently regulated by the Norwegian Health Registry Act. The current study was approved by The Regional Committees for Medical and Health Research Ethics (reference number 318756). The study also included information from the Medical Birth Registry of Norway (MBRN), which is a national health registry containing information about all births in Norway (Irgens, 2000).

Initially, 95,136 women were included in the cohort, from which 74,947 were included in this study. A complete description of the sampling process is described in Figure 1. For women taking part in MoBa multiple times (multiple pregnancies), only the first pregnancy was included, as we investigate between-person differences. From the women included in the study, 73,081 were non-victims, 1,076 were victims of physical abuse only, 683 victims of sexual abuse only and 107 victims of both physical and sexual abuse. The prevalence of any form of violence in the sample was 2.49%. Figure 1. Subsampling procedure.

Notes: Flow chart of included and excluded study participants. MoBa, the Norwegian Mother, Father and Child cohort study.

 Data were collected at four time points. Prenatal data collection occurred at 18 weeks (T1) and 30 weeks (T2) of pregnancy. After birth, data were collected at 6 months (T3) and 36 months (T4). Participation varied across the different timepoints, with 74,947 (100%) women responding at T1; 69,342 (92.52%) at T2; 65,386 (87.24%) at T3 and 43,979 (58.68%) at T4, respectively. We analysed the attrition based on the core variables of interest (i.e. wellbeing, illbeing, and violence exposure) through Little’s test (Little & Rubin, 2019) and Welch t-statistic test. Our analyses pointed to selective attrition for these three variables. However, this bias is likely to mainly affect means and prevalences, but not estimates of associations between variables (Gustavson et al., 2012; Nilsen et al., 2009). Additionally, the magnitude of attrition bias was small. Subsequent drop-out explained less than 0.5% of the variance in wellbeing, illbeing and violence exposure. The significant correlations between subsequent drop-out and other key variables (at T1) were: age (r = –0.04), education (r = –0.12), income (r = –0.07), physical violence (r = 0.02), physical and sexual violence (r = 0.01) and pre-term birth (r = 0.03), all with a significance level p < .001. Sexual violence was not significantly associated with drop-out status.

2.2. Measures

Birth-related measures were obtained from the Medical Birth Registry of Norway (MBRN) (Irgens, 2000). Sociodemographic information was obtained at T1 through self-report. A complete description of the sample’s characteristics is provided in Table 1. Table 1. Sociodemographic characteristics of the sample.

Baseline characteristics	Non-victims
(n = 73,081)	Physical violence
(n = 1076)	Sexual violence
(n = 683)	Both forms
(n = 107)	Full sample
(n = 74,947)	
n	%	n	%	n	%	n	%	n	%	
Age (M ± SD years)	30.1 ± 4.5	–	28.1 ± 5.2	–	29.4 ± 5.7	–	26.7 ± 5.6	–	30 ± 4.6	–	
Marital Status	 	 	 	 	 	 	 	 	 	 	
 Married /co-habiting	70,543	96.5	955	88.8	558	81.7	74	69.2	72,130	96.2	
 Divorced / widow / single	1,467	2	94	8.7	90	13.2	30	28	1,681	2.2	
 Other	740	1	17	1.6	25	3.7	2	1.9	784	1	
 Missing values	331	.4	10	.9	10	1.5	1	.9	352	.5	
Education	 	 	 	 	 	 	 	 	 	 	
 ≤ Secondary school	1,651	2.3	69	6.4	45	6.6	16	15	1,781	2.4	
 High school	19,217	26.3	349	32.4	206	30.2	37	34.6	19,809	26.4	
 ≥ Undergraduate	45,064	61.7	520	48.3	347	50.8	29	27.1	45,960	61.3	
 Missing values	7149	9.8	138	12.8	85	12.4	25	23.4	7397	9.9	
Employment	 	 	 	 	 	 	 	 	 	 	
 Employed	59,142	80.9	759	70.5	451	66	43	40.2	60,395	80.6	
 Unemployed	4457	6.1	105	9.8	72	10.5	28	26.2	4662	6.2	
 Student	7673	10.5	170	15.8	121	17.7	33	30.8	7997	10.7	
 Rehabilitation/disability	594	.8	22	2	14	2	2	1.9	632	.8	
 Other	918	1.3	17	1.6	22	3.2	1	.9	958	1.3	
 Missing values	297	.4	3	.3	3	.4	0	0	303	.4	
Income	 	 	 	 	 	 	 	 	 	 	
 No income	1620	2.2	54	5	38	5.6	19	17.8	1731	2.3	
 < 150,000	10,938	15	235	21.8	177	25.9	39	36.4	11,389	15.2	
 151,000 to 199,999	7686	10.5	146	13.6	95	13.9	14	13.1	7941	10.6	
 200,000 to 299,999	24,365	33.3	345	31.8	186	27.2	19	17.8	24,912	33.2	
 300,000 to 399,999	17,763	24.3	185	17.2	97	14.2	5	4.7	18,050	24.1	
 400,000 to 499,999	5140	7	50	4.6	39	5.7	4	3.7	5233	7	
 > 500,000	3210	4.4	28	2.6	22	3.2	0	0	3260	4.3	
 Missing values	2359	3.2	36	3.3	29	4.2	7	6.5	2431	3.2	
Parity	 	 	 	 	 	 	 	 	 	 	
 Primiparous	39,203	53.6	653	60.7	303	44.4	59	55.1	40,218	53.7	
 1 previous child	21,369	29.2	260	24.2	212	31	23	21.5	21,864	29.2	
 > 2 previous children	12,251	16.8	162	15.1	167	24.5	25	23.4	12,605	16.8	
 Missing values	258	.3	1	0	1	0	0	0	260	.3	
Notes: Frequencies of age, marital status, education, employment, income and parity for each of the exposure groups. n = participants in the groups, M = mean, SD = standard deviation. Income was based on Norwegian Krone. For the percentages, the first decimal was rounded.

Exposure to violence was assessed through self-report at T1. Physical violence was investigated with the question ‘Have you ever in your adult life been slapped, hit, kicked, or bothered in any way physically? (you may mark several options)’. Response options included ‘yes’, ‘no’, and ‘don’t remember' for the periods ‘during this pregnancy’ and ‘last 6 months before pregnancy’. Answers marked as ‘don’t remember’ were recoded into ‘missing’. History of sexual violence was also evaluated through the question ‘Have you ever been pressured or forced to have sexual intercourse?’, discriminating the periods ‘during this pregnancy’ and ‘last 6 months before pregnancy’. Answer options were ‘no, never’, ‘yes, pressured’, ‘yes, forced with violence’, and ‘yes, raped’. Four groups were created based on violence exposure from 6 months prior to pregnancy till completing the questionnaire: (a) physical violence only, (b) sexual violence only (containing those who answered affirmatively to either ‘pressured’, ‘forced’ or ‘raped’), (c) both physical and sexual violence and (d) non-victims.

Social support was measured at T1 with the question ‘Do you have anyone other than your husband/partner you can ask for advice in a difficult situation?’. Possible answers were ‘no’, ‘yes, 1 or 2 people’, and ‘yes, more than 2 people’. Participants who answered ‘no’ were categorized as ‘without social support’, whereas those responding they had at least one person to ask for advice were categorized as ‘with social support’.

Wellbeing was assessed through the Satisfaction with Life Scale (SWLS) (Diener et al., 1985; Pavot & Diener, 1993). The SWLS is composed of 5 items and all answers are scored on a 7-point scale from ‘strongly disagree’ to ‘strongly agree’. In this study, a composite score was calculated based on all 5 items. The scale had good internal consistency, with Cronbach’s alphas of .88 at T1, .89 at T2, .88 at T3, and .90 at T4, respectively. Additionally, we constructed a dichotomous measure using the cutoff of < 3 to compare those who were dissatisfied/extremely dissatisfied with the remaining responders (Pavot & Diener, 1993).

Illbeing (anxiety and depression symptoms) was assessed through the Hopkins Symptoms Checklist (SCL) (Tambs & Moum, 1993; Tambs & Røysamb, 2014). The SCL-5 and SCL-8 scales are a selection of five and eight items, respectively, from the SCL-25 (Hesbacher et al., 1980). SCL-5 was used in T1, whereas SCL-8 was used in T2, T3 and T4. The 4 response categories range from ‘not bothered’ to ‘very bothered’, and a composite score was calculated. SCL had suitable internal consistency, with Cronbach’s alphas of .79 at T1, .80 at T2, .81 at T3, and .84 at T4, respectively. We adopted the cutoff value of > 1.85 as a predictor of mental stress (Strand et al., 2003).

2.3. Data analysis

Analyses were modelled through Growth Curve Models (GCM) (Duncan & Duncan, 2009; Meredith & Tisak, 1990) using R version 4.0.3 and RStudio version 1.4.1717, with the package ‘lme4’ (Bates et al., 2015).

GCM based on Mixed-Effect (ME) account for the general mean growth for all observations (fixed effects), and individuals’ trajectories over time (random effects) (Curran & Bauer, 2011). This is important as there is variability between individuals in their initial scores and in their trajectories over time. Trajectories can be linear or non-linear. Considering the number of timepoints in this study, it was possible to test both linear and quadratic trajectories (Bollen & Curran, 2006).

We used full information maximum likelihood for both wellbeing and illbeing curves and started by establishing the unconstrained model (‘null model’, with no predictors). Then we followed a progressive increase in model complexity, including different predictors (maternal age, parity, marital status, education, income, social support and violence exposure status as fixed effects; and time as both fixed and random effects), ) (Monsalves et al., 2020). In comparison to the unconstrained model, the model with these predictors fitted the data significantly better (p < .001). Therefore, we have established the basic model as the one where all predictors are already included in the fixed component of the model, and time is included in both fixed and random components.

This basic linear model includes time in both fixed and random component as a linear term. To test for a quadratic trajectory, we established a basic quadratic model, adding a quadratic time term to the fixed component. We have tested including the quadratic time term also as a random component. However, the model failed to converge due to the number of participants who did not respond to at least 3 timepoints in either SWLS or SCL (16% of the sample). Still, we have subsampled the data to include complete cases in both SWLS and SCL and compared models with and without the quadratic time term in the random component. We found virtually no change in fixed coefficients and no change in significance levels among predictors.

Comparing the basic linear model to the basic quadratic model, we found that the basic quadratic model had a better fit (Table 2). Therefore, we extended the fixed component of the basic quadratic models in two directions to: a) include the interaction between time and violence exposure (extension 1) and b) include the interaction between time and social support (extension 2). In other words, we tested whether violence exposure (extension 1) or social support (extension 2) influence wellbeing and illbeing trajectories over time. Further, extensions 1 and 2 were combined in a single model (extension 3). Finally, extension 4 expanded extension 3 to include a triple interaction between time, violence exposure and social support. We then compared the fit among these models. Model fit was assessed by comparing the competing growth trajectories through a two-way ANOVA to choose the most parsimonious one (McNeish & Matta, 2018). Model comparison was also based on the Akaike Information Criteria (AIC), the Bayesian Information Criteria (BIC), and conditional log-likelihood (Müller et al., 2013). The R script for the models is available in the supplementary material. For a tutorial in GCM, we recommend McNeish and Matta (2018), Duncan and Duncan (2009) and Meredith and Tisak (1990). Table 2. Model fit comparison among the different models tested.

Model	AIC	BIC	LogLik	
Wellbeing	 	 	 	
 Basic linear model	567,636	567,915	–283,791	
 Basic quadratic model	564,004	564,293	–281,974	
 Extension 1	564,012	564,363	–281,972	
 Extension 2	563,989	564,299	–281,964	
 Extension 3	563,997	564,369	–281,962	
 Extension 4	563,986	564,451	–281,948	
Illbeing	 	 	 	
 Basic linear model	146,722	147,001	–73,334	
 Basic quadratic model	146,566	146,856	–73,225	
 Extension 1	146,468	146,819	–73,200	
 Extension 2	146,546	146,856	–73,243	
 Extension 3	146,449	146,821	–73,188	
 Extension 4	146,412	146,877	–73,161	
Notes: Extension 1 = quadratic model with interaction between time and violence exposure; Extension 2: quadratic model with triple interaction between social support, time and violence exposure. AIC = Akaike Information Criteria, BIC = Bayesian Information Criteria, LogLik = conditional log-likelihood.

Finally, of clinical importance, we have estimated the odds ratio of dissatisfaction (SWLS < 3) and mental distress (SCL-5 > 1.85) among non-victims and the different victimized groups at all timepoints.

3. Results

3.1. Descriptive statistics

An overview of the unadjusted average through different timepoints for both wellbeing and illbeing is shown in Figure 2. Among all women, the correlation between wellbeing and illbeing varied between –0.50 and –0.35 at all timepoints. The means for each timepoint for the different groups are shown in Table 3. Figure 2. Wellbeing and illbeing averages over time.

Notes: Unadjusted averages for both wellbeing (a) and illbeing (b). Time (x axis) is counted in weeks, where time = 0 represents the first timepoint (T1, 18 weeks of pregnancy) for data collection. Bars indicated the 95% confidence interval at each timepoint.

Table 3. Means of wellbeing and illbeing and prevalence of dissatisfaction and mental distress.

Measures	Non-victims	Physical violence	Sexual violence	Both forms	
 	M	CI	M	CI	M	CI	M	CI	
T1	 	 	 	 	 	 	 	 	
 Wellbeing	5.68	5.68,5.69	5.10	5.03,5.18	4.76	4.66,4.86	4.21	3.95,4.47	
 Illbeing	1.25	1.25,1.25	1.53	1.50,1.57	1.63	1.58,1.67	2.09	1.95,2.23	
 Prevalence of dissatisfaction	2.55%	2.44,2.67	7.52%	5.93,9.10	11.40%	8.98,13.80	22.90%	14.80,30.9	
 Prevalence of mental distress	6.18%	6.0,6.3	19.80%	17.4,22.0	26.40%	23.1,29.7	54.30%	44.80,63.8	
T2	 	 	 	 	 	 	 	 	
 Wellbeing	5.76	5.75,5.77	5.24	5.16,5.31	4.89	4.8,4.99	4.47	4.16,4.79	
 Illbeing	1.25	1.24,1.25	1.45	1.42,1.49	1.53	1.48,1.57	1.87	1.7,2.04	
 Prevalence of dissatisfaction	1.69%	1.59,1.79	5.39%	3.95,6.83	8.48%	6.28,10.70	17.40%	9.42,25.50	
 Prevalence of mental distress	5.93%	5.75,6.11	15.8%	13.4,18.1	20.20%	17.00,23.30	39.1%	28.80,49.30	
T3	 	 	 	 	 	 	 	 	
 Wellbeing	5.79	5.79,5.8	5.24	5.16,5.32	4.88	4.77,4.99	4.38	4.06,4.7	
 Illbeing	1.22	1.22,1.23	1.42	1.38,1.45	1.49	1.45,1.53	1.83	1.68,1.98	
 Prevalence of dissatisfaction	1.61%	1.51,1.71	5.44%	3.91,6.97	8.95%	6.60,11.3	14.3%	6.47,22.1	
 Prevalence of mental distress	5.52%	5.42,5.70	14.40%	12.00,16.70	17.40%	14.30,20.5	42.50%	31.70,53.30	
T4	 	 	 	 	 	 	 	 	
 Wellbeing	5.53	5.52,5.54	5.03	4.91,5.14	4.67	4.53,4.8	4	3.51,4.48	
 Illbeing	1.25	1.24,1.25	1.4	1.36,1.45	1.51	1.45,1.57	2.07	1.81,2.33	
 Prevalence of dissatisfaction	2.84%	2.68,3.00	10.40%	7.71,13.00	12.50%	9.05,16.00	22.00%	9.28,34.6	
 Prevalence of mental distress	6.18%	6.00,6.35	19.80%	17.40,22.20	26.40%	23.10,29.70	54.30%	44.8,63.8	
Notes: Mean scores (unadjusted) for wellbeing and illbeing across the four exposure groups over all timepoints. M = mean, CI = 95% confidence interval, T1 = timepoint 1, T2 = timepoint 2, T3 = timepoint 3, T4 = timepoint 4.

Victims had four times the odds of being either dissatisfied or extremely dissatisfied (Pavot & Diener, 1993) in comparison to non-victims at all timepoints (OR = 4.05, 4.46, 4.87 and 4.61 for T1, T2, T3 and T4, respectively). Likewise, victims had higher odds of mental distress at all timepoints (OR = 4.85, 3.63, 3.51 and 3.28 for T1, T2, T3 and T4, respectively) compared to non-victims.

The prevalence of lack of social support was 3.47% among non-victims and 7.38% for victims in general. Across the different violence groups, lack of social support was reported by 6.43% of the victims of physical abuse, 7.89% of victims of sexual abuse and 14% of victims of both forms of abuse. The unadjusted average for both wellbeing and illbeing among victims and non-victims, stratified by social support, is shown in Figure 3. Figure S1 in the supplementary material expands Figure 3, discriminating the different violence exposure groups. Figure 3. Wellbeing and illbeing averages over time stratified by social support.

Notes: Unadjusted averages for both wellbeing (a) and illbeing (b). Time (x axis) is counted in weeks, where time = 0 represents the first timepoint (T1, 18 weeks of pregnancy) for data collection. Bars indicated the 95% confidence interval at each timepoint.

3.2. Modelling trajectories of growth

Following the fit comparison among the different models (Table 2), a quadratic GCM is preferred over a linear for both wellbeing and illbeing. When assessing measures of model fit, despite discordant AIC and BIC values, the comparison through ANOVA points to extension 4 as fitting the data significantly better (p < .001) in both SWLS and SCL trajectories.

3.2.1. Wellbeing

The intercept for the GCM across the four groups was fixed at T1 and adjusted for covariates. Victims of any form of abuse scored, on average, 0.57 (p < .001) lower than non-victims. Differences in the intercepts between all four groups were significant. Intercept values were lower for victims of both forms of abuse, followed by sexual only, physical only and non-victims. Regarding trajectories of growth (interaction between time and violence exposure), there was no significant difference between victims and non-victims. Between-group differences in the intercept, linear and quadratic slopes are shown in Table 4. Table 4. Growth curve coefficients.

Coefficients	Non-victims	Non-victims – physical violence	Non-victims – sexual violence	Non-victims – both forms	Physical – sexual violence	Physical – both forms	Sexual – both forms	
 	M	CI	M	CI	M	CI	M	CI	M	CI	M	CI	M	CI	
Wellbeing	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
 Intercept	5.82**	5.78,5.88	.41**	.34,.47	.78**	.69,.85	1.1**	.87,1.3	.36**	.26,.46	.68**	.46,.9	.31**	.09,.54	
 Linear slope	.20**	.19,.21	.01	–.05,.09	–.04	–.40,.11	–.14	–.40,.11	–.05	–.17,.06	–.15	–.42,.11	–.10	–.37,.17	
 Quadratic slope	–.08**	–.08,–.09	00	–.03,.02	.01	–.04,.14	.05	–.04,.14	.02	–.02,.06	.05	–.04,.14	.03	–.06,.13	
Illbeing	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
 Intercept	1.25**	1.24,1.28	–.22**	–.24,–.19	–.33**	–.36,–.30	–.65**	–.73,–.56	–.11**	–.15,–.07	–.43**	–.51,–.34	–.31**	–.40,–.23	
 Linear slope	–.02**	–.02,–.01	.05**	.02,.08	.12**	.08,.16	.24**	.13,.34	.07**	.02,.12	.19**	.08,.30	.12*	.01,.23	
 Quadratic slope	.006**	.005,.007	–.008	–.02,.002	–.03**	–.04,–.02	–.07**	–.10,–.03	–.02**	–.04,–.007	–.06**	–.1,–.02	–.04*	–.08,–.00	
Notes: Intercept and slopes adjusted for covariates for non-victims (reference group), for both wellbeing and illbeing. Difference in intercepts and slopes (adjusted) between the different exposure groups and the reference. M = mean, CI = 95% Confidence Interval. *p < .05. **p < .001.

Women in the whole sample without social support scored 0.34 (p < .001) lower at T1 in comparison to those with social support. Social support was especially important for victimized women. The difference in wellbeing between victims and non-victims was larger for women without social support than for women with social support (0.38, p < .001) at the intercept. Considering growth for the whole sample, women without social support had a lower quadratic slope (difference of 0.02, p < .01), although the difference in the linear was marginally not significant (p = .06). Among victimized groups, the triple interaction between time, violence exposure and social support was significant only in the difference between victims of physical abuse and non-victims (difference of 0.40, p < .01 for the linear slope and 0.12, p = .02 for the quadratic slope). Differences in the triple interaction between other victimized groups and non-victims, as well as between victimized groups, were non-significant.

3.2.2. Illbeing

The intercept for illbeing was fixed at T1 and adjusted for covariates. Victims in general scored 0.28 higher (p < .001) than non-victims. The difference between non-victims and the three victimized groups was higher for victims of both forms, followed by victims of sexual and physical abuse, respectively. Significant differences in trajectories were found between victims and non-victims (–0.08, p < .001, for the linear slope and 0.02, p < .001, for the quadratic slope). Differences in the slopes between all four groups were significant. Between-group differences in the intercept, linear and quadratic slopes are shown in Table 4.

Among women without social support, the difference in illbeing between victims and non-victims was larger than the respective difference among those with social support (0.19, p < .001) at the intercept. For women without social support, non-victims and victims of physical abuse had a significant difference in the trajectory (–0.13, p = .03, for the linear slope. Quadratic slope not significant). Lack of social support did not significantly change the trajectory for other victimized groups in comparison to non-victims without social support.

4. Discussion

In this study, we analysed wellbeing and illbeing growth curves from pregnancy to toddlerhood for women exposed and not exposed to physical and/or sexual violence. We further analysed the moderator effect of social support for the different groups. Several findings warrant further discussion.

First, in accordance with previous studies, the findings point to the detrimental effect of any form of abuse exposure to women’s mental health (Do et al., 2021; Ghoneim et al., 2021; Mahapatro et al., 2022; Tesfaye & Agenagnew, 2021). Victims in general had higher odds of both being dissatisfied with their lives and score above the cut-point for mental distress in comparison to non-victims across all timepoints. The magnitude of life dissatisfaction and mental distress also varied between the different forms of violence. On average, the prevalences of life dissatisfaction and mental distress among victims of both forms of abuse were twice as high as for those exposed to either sexual or physical abuse. This points to the detrimental effect in both wellbeing and illbeing of violence exposure, with this effect substantially more severe in cases exposed to both physical and sexual violence, pointing to a synergistic effect (Trevillion et al., 2012).

Second, there was no significant difference in wellbeing trajectories among victims and non-victims. Women, regardless of violence exposure, experienced an increase in wellbeing from early pregnancy, peaking between late pregnancy and the first 6 months after birth, and then declining between 6 and 36 months after birth, as showed in previous studies (Dyrdal et al., 2011). However, abuse exposure was associated with an initial lower level of wellbeing. Considering the lack of significant difference in growth trajectories, an initial lower score led to a vertical shift in the growth curve, where victims scored lower in all timepoints in comparison to non-victims. The lowest wellbeing curve was shown for victims of both forms of abuse, followed by victims of sexual and then physical abuse. The lack of difference in wellbeing trajectories between victims and non-victims could point to resilience among victims. In other words, victims may still respond positively, experiencing increasing wellbeing from pregnancy to after birth despite the violence exposure.

Third, illbeing growth curves were different for victims and non-victims and varied across violence groups. Previous findings have pointed to change in the intercept of the illbeing curve for women exposed to violence, but not in the slope (Lindhorst & Oxford, 2008). In this study, however, we found changes in both intercept and slopes. Victimized women scored higher in illbeing at all timepoints in comparison to non-victims. Among the different violence groups, the highest scores were observed for victims of both forms of violence (i.e. likely more severe), followed by sexual and physical violence, respectively. Regarding the growth trajectories, we observed a decrease in the linear term (non-victims > physical violence > sexual violence > both forms of violence) and an increase in the quadratic term (non-victims ≈ physical violence < sexual violence < both forms of violence) across the different groups. The decrease in the linear term will shift the vertex or the curve right and down (Cappiello, 2013), whereas an increase in the quadratic term will narrow the parabola (Blanchard & Porretta, 2001). In other words, non-victims tend to remain relatively stable in their illbeing levels throughout the period of evaluation. There is a small decrease in illbeing levels between late pregnancy and the first 6 months after birth, followed by a small increase and a subsequent return to the baseline levels. By contrast, victimized groups experienced a greater negative change in their illbeing levels. Victims had a greater decrease in illbeing scores between late pregnancy and the first 6 months after birth, returning to levels similar to the baseline (early pregnancy) by 3 years after birth.

Fourth, victims scored lower in wellbeing and higher in illbeing in comparison to non-victims at all timepoints, suggesting a long-term effect of abuse exposure. This contrasts previous literature, which poses an adaptation to traumatic events, where the scores of victims approach those of non-victims after some time (Bonanno et al., 2002; Bonanno et al., 2004; Brickman et al., 1978; Diener et al., 2009; Lucas et al., 2003; Suh et al., 1996). Still, the violence that occurred up to six months before pregnancy could potentially impact women’s mental health up to 3 years after birth. The likely long-lasting effects of abuse exposure highlight the need for violence reduction, mental health promotion, and interventions in victims even after a considerable period has passed since their exposure to violence.

Fifth, social support is a modifiable environmental factor influencing both wellbeing and illbeing growth curves. Following previous studies, lack of social support was more prevalent among victims than non-victims (Kita et al., 2020; Nguyen et al., 2018). Those exposed to both forms of abuse were especially vulnerable to experiencing lack of social support, with a prevalence twice as high as the other victimized groups. Also in accordance with previous literature, women without social support scored lower in wellbeing and higher in illbeing compared to those with support (Warren et al., 2018). Victims of physical abuse especially benefit from social support (Coker et al., 2003; Gielen et al., 2001). The difference in both wellbeing and illbeing between women with and without social support was larger among victims of physical abuse than non-victims. This points to the protective effect of having someone to seek advice from if exposed to physical abuse. Surprisingly, the advice component of social support was equally important for non-victims, victims of sexual abuse, and both forms of abuse. One possible explanation is that victimized groups may need a wider range of social support, such as instrumental or emotional support (Coker et al., 2003). These other forms of social support, however, were not included in this study. Considering how women overall benefit from social support and its persistent beneficial effect, it becomes imperative to promote measures that strengthen meaningful social support in pregnant women.

Lastly, our findings support the idea of wellbeing and illbeing as partly distinct entities (Keyes, 2002; Suldo & Shaffer, 2008; Westerhof & Keyes, 2010). Interestingly, wellbeing and illbeing growth curves behaved differently in the presence of the same exposure (violence). This corroborates a potential difference in response to stressors between these two concepts, as showed previously in the literature (Hofgaard et al., 2021; Nes et al., 2014).

5. Limitations and direction for future studies

The current study relies on a substantial number of participants and a significant follow-up period, allowing for a better understanding of the phenomenon under consideration. The extensive number of participants also enabled comparison between different kinds of violence exposure, as well as the synergic effect of multiple types of violence in women’s mental health. Still, several limitations exist and are addressed, as well as potential directions for future studies.

From the 277,702 pregnancies invited to take part in the cohort, the participation rate was 41% (Magnus et al., 2016), which might not cover the full range of experiences among pregnant women in Norway. As almost 95% of the cohort was composed by Norwegian and other northern European women, the sample could be considered western, educated, industrialized, rich and democratic (WEIRD), limiting the diversity and generalizability of the findings. Considering that MoBa questionnaires were also in Norwegian language, the inclusion of a more diverse ethnic background was limited. Previous studies point to the importance of nationality as a risk factor for the experience of violence (Antoniou & Iatrakis, 2019), and further studies in this direction are recommended.

Additionally, regarding the study design and information collected, there was no information about the perpetrator of the violence. Therefore, we could not establish this form of violence as intimate partner violence (IPV). This study focused on recent violence exposure, where earlier exposure is beyond the scope of the current analyses. We acknowledge psychological violence as an important form of violence, however, the data used in this study did not include information regarding this type of violence. Therefore, we strongly encourage future studies to expand work in this direction. Regarding the long-term effects of both social support and violence exposure, we cannot differentiate whether these reflect the sustained impact of previous exposure to violence or reflect persistent and ongoing violence exposure/social support after the first assessment.

Other limitations that may hinder the generalization of the present findings unequivocally include the use of retrospective self-reported data, which made the study subject to reporting or recall bias (Sedgwick, 2012). Information regarding social support was also limited and did not cover the whole spectrum of social support diversity. More extensive measurement of social support, including different dimensions of the phenomenon are strongly encouraged in future studies.

6. Conclusion

Recent violence exposure can affect in the long term both wellbeing and illbeing among women. Even though the trajectory of wellbeing / illbeing development is similar among different violence exposure groups, victims score chronically lower in wellbeing and higher in illbeing in comparison to non-victims. This potentially persistent effect of violence on women’s wellbeing and illbeing supports targeting these women in actions that promote wellbeing and reduce illbeing, even when years have passed since their violence exposure. Experiencing both physical and sexual violence seems to be particularly harmful to women’s mental health. All women benefit from social support, but victims of physical violence can be especially susceptible to this beneficial effect. Considering the benefit of social support shared by all groups, measures that foster social contact and support should be encouraged, especially among victimized women, for whom lack of social support was particularly salient. Wellbeing and illbeing growth curves behave differently in the presence of violence exposure, pointing these concepts as partially independent, although correlated.

Supplementary Material

Supplementary Material.docx

Acknowledgements

We thank the families taking part in this research, as well as MoBa cohort funders. The Norwegian Mother, Father and Child Cohort Study is supported by the Norwegian Ministry of Health and Care Services and the Ministry of Education and Research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data from the Norwegian Mother, Father and Child Cohort Study and the Medical Birth Registry of Norway used in this study are managed by the national health register holders in Norway (Norwegian Institute of Public Health). Researchers who want access to data sets for replication should apply through helsedata.no.
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