Abstracts

INTRODUCTION

Many studies on violence committed against women have identified the victim’s intimate partner as the most common aggressor.⁵5 .DOliveira AFPL, Schraiber LB, França-Júnior I, Ludermir AB, Portella AP, Diniz CS, et al. Fatores associados à violência por parceiro íntimo em mulheres brasileiras. Rev Saude Publica. 2009;43(2):299-310. DOI:10.1590/S0034-89102009005000013^,99 .Gielen AC, O’Campo PJ, Faden RR, Kass NE, Xue X. Interpersonal conflict and physical violence during the childbearing year. Soc Sci Med. 1994;39(6):781-7. DOI:10.1016/0277-9536(94)90039-6^,1919 .Saltzman LE, Christopher HJ, Gilbert BC, Goodwin MM. Physical abuse around the time of pregnancy: an examination of prevalence and risk factors in 16 states. Matern Child Health J. 2003;7(1):31-43. DOI:10.1023/A:1022589501039 These studies have also estimated its magnitude⁷7 .Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet.2006; 368(9543):1260-69. DOI:10.1016/S0140-6736(06)69523-8 and the factors associated with intimate partner violence (IPV) before and during pregnancy¹⁹19 .Saltzman LE, Christopher HJ, Gilbert BC, Goodwin MM. Physical abuse around the time of pregnancy: an examination of prevalence and risk factors in 16 states. Matern Child Health J. 2003;7(1):31-43. DOI:10.1023/A:1022589501039 as well as evaluated its impact on the physical and mental health of women²2 .Ansara D, Cohen MM, Gallop R, Kung R, Schei B. Predictors of women’s physical health problems after childbirth. J Psychosom Obstet Gynaecol. 2005;26(2):115-25. DOI:10.1080/01443610400023064^,1616 .Ludermir AB, Lewis G, Valongueiro SA, Araújo TVB, Araya R. Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet. 2010;376(9744):903-10. DOI:10.1016/S0140-6736(10)60887-2 and their children.⁶6 .Durand JG, Schraiber LB, França-Júnior I, Barros C. Repercussão da exposição à violência por parceiro íntimo no comportamento dos filhos.Rev Saude Publica. 2011;45(2):355-64. DOI:10.1590/S0034-89102011005000004 However, postpartum IPV has been studied by few researchers.⁴4 .Charles P, Perreira KM. Intimate partner violence during pregnancy and 1-year postpartum. J Fam Viol. 2007;22(7):609-19. DOI:10.1007/s10896-007-9112-0^,88 .Gartland D, Hemphill SA, Hegarty K, Brown SJ. Intimate partner violence during pregnancy and the first year postpartum in an Australian pregnancy Cohort study. Matern Child Health J.2011;15(5):570-78. DOI:10.1007/s10995-010-0638-z

9 .Gielen AC, O’Campo PJ, Faden RR, Kass NE, Xue X. Interpersonal conflict and physical violence during the childbearing year. Soc Sci Med. 1994;39(6):781-7. DOI:10.1016/0277-9536(94)90039-6

10 .Guo SF, Wu JL, Qu CY, Yan RY. Domestic abuse on women in China before, during, and after pregnancy. Chin Med J (Engl). 2004;117(3):331-6.

11 .Hedin LW. Postpartum, also a risk period for domestic violence.Eur J Obstet Gynecol Reprod Biol. 2000;89(1):41-5. DOI:10.1016/S0301-2115(99)00164-5^-1212 .Hellmuth JC, Gordon KC, Stuart GL, Moore TM. Risk factors for intimate partner violence during pregnancy and postpartum. Arch Womens Ment Health. 2013;16(1):19-27. DOI:10.1007/s00737-012-0309-8^,1717 .Macy RJ, Martin SL, Kupper LL, Casanueva C, Guo S. Partner violence among women before, during, and after postpartum: multiple opportunities for intervention. Womens Health Issues. 2007;17(5):290-9. DOI:10.1016/j.whi.2007.03.006^,11 .Abramsky T, Watts CH, Garcia-Moreno C, Devries K, Kiss L, Ellsberg M, et al. What factors are associated with recent intimate partner violence? findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health. 2011;11:109. DOI:10.1186/1471-2458-11-109⁸8 .Gartland D, Hemphill SA, Hegarty K, Brown SJ. Intimate partner violence during pregnancy and the first year postpartum in an Australian pregnancy Cohort study. Matern Child Health J.2011;15(5):570-78. DOI:10.1007/s10995-010-0638-z^,2323 .Stewart DE. Incidence of postpartum abuse in women with a history of abuse during pregnancy. CMAJ. 1994;151(11):1601-4.

Postpartum IPV prevalence varies from 8.3% in China¹⁰10 .Guo SF, Wu JL, Qu CY, Yan RY. Domestic abuse on women in China before, during, and after pregnancy. Chin Med J (Engl). 2004;117(3):331-6. to 24.2% in Sweden.¹¹11 .Hedin LW. Postpartum, also a risk period for domestic violence.Eur J Obstet Gynecol Reprod Biol. 2000;89(1):41-5. DOI:10.1016/S0301-2115(99)00164-5 The incidence of any type of postpartum IPV (psychological, physical and sexual) found in a population-based study by Guo et al¹⁰10 .Guo SF, Wu JL, Qu CY, Yan RY. Domestic abuse on women in China before, during, and after pregnancy. Chin Med J (Engl). 2004;117(3):331-6. (2004), in China, was around 2.5%. Whereas Hedin¹¹11 .Hedin LW. Postpartum, also a risk period for domestic violence.Eur J Obstet Gynecol Reprod Biol. 2000;89(1):41-5. DOI:10.1016/S0301-2115(99)00164-5(2000) observed an incidence of 69.0% in a sample of 132 women attended, eight weeks after childbirth, in three prenatal clinics in Sweden. The incidence of physical violence was found in less than 1.0% of women in the United States¹⁸18 .Martin SL, Mackie L, Kupper LL, Buescher PA, Moracco KE. Physical abuse of women before, during, and after pregnancy. JAMA.2001;285(12):1581-4. DOI:10.1001/jama.285.12.1581 in a population-based study, and at 11.0%,⁹9 .Gielen AC, O’Campo PJ, Faden RR, Kass NE, Xue X. Interpersonal conflict and physical violence during the childbearing year. Soc Sci Med. 1994;39(6):781-7. DOI:10.1016/0277-9536(94)90039-6 in a sample of 175 women receiving care at a prenatal clinic at a university hospital. These differences may have been influenced by the different methodologies, instruments, sample compositions and the postpartum period in which the interview was conducted, which compromised the comparability, especially with respect to the types of violence studied.

Intimate partner violence against women of reproductive age constitutes a public health problem and has attracted interest from scientific and political fields. Nevertheless, no articles on the incidence and risk factors for postpartum IPV in Brazil were found up to the conclusion of this study.

The risk factors for IPV during pregnancy and postpartum are similar to those found in other periods of life: younger women,⁹9 .Gielen AC, O’Campo PJ, Faden RR, Kass NE, Xue X. Interpersonal conflict and physical violence during the childbearing year. Soc Sci Med. 1994;39(6):781-7. DOI:10.1016/0277-9536(94)90039-6^,1818 .Martin SL, Mackie L, Kupper LL, Buescher PA, Moracco KE. Physical abuse of women before, during, and after pregnancy. JAMA.2001;285(12):1581-4. DOI:10.1001/jama.285.12.1581 with no partner,⁴4 .Charles P, Perreira KM. Intimate partner violence during pregnancy and 1-year postpartum. J Fam Viol. 2007;22(7):609-19. DOI:10.1007/s10896-007-9112-0 lower education⁸8 .Gartland D, Hemphill SA, Hegarty K, Brown SJ. Intimate partner violence during pregnancy and the first year postpartum in an Australian pregnancy Cohort study. Matern Child Health J.2011;15(5):570-78. DOI:10.1007/s10995-010-0638-z and precarious socioeconomic conditions,²²22 .Sonis J, Langer M. Risk and protective factors for recurrent intimate partner violence in a cohort of low-income inner-city women. J Fam Viol. 2008;23(7):529-38. DOI:10.1007/s10896-008-9158-7 use of alcohol and illicit drugs by the woman and her partner,⁴4 .Charles P, Perreira KM. Intimate partner violence during pregnancy and 1-year postpartum. J Fam Viol. 2007;22(7):609-19. DOI:10.1007/s10896-007-9112-0partner’s aggressive behavior outside the home,¹1 .Abramsky T, Watts CH, Garcia-Moreno C, Devries K, Kiss L, Ellsberg M, et al. What factors are associated with recent intimate partner violence? findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health. 2011;11:109. DOI:10.1186/1471-2458-11-109^,2222 .Sonis J, Langer M. Risk and protective factors for recurrent intimate partner violence in a cohort of low-income inner-city women. J Fam Viol. 2008;23(7):529-38. DOI:10.1007/s10896-008-9158-7 length of the relationship,²²22 .Sonis J, Langer M. Risk and protective factors for recurrent intimate partner violence in a cohort of low-income inner-city women. J Fam Viol. 2008;23(7):529-38. DOI:10.1007/s10896-008-9158-7 difficult communication with the partner,¹⁶16 .Ludermir AB, Lewis G, Valongueiro SA, Araújo TVB, Araya R. Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet. 2010;376(9744):903-10. DOI:10.1016/S0140-6736(10)60887-2 fights between the couple,¹⁹19 .Saltzman LE, Christopher HJ, Gilbert BC, Goodwin MM. Physical abuse around the time of pregnancy: an examination of prevalence and risk factors in 16 states. Matern Child Health J. 2003;7(1):31-43. DOI:10.1023/A:1022589501039 partner suspicion of infidelity,¹²12 .Hellmuth JC, Gordon KC, Stuart GL, Moore TM. Risk factors for intimate partner violence during pregnancy and postpartum. Arch Womens Ment Health. 2013;16(1):19-27. DOI:10.1007/s00737-012-0309-8 physical violence by the woman against her partner without being assaulted first²⁴24 .Swan SC, Snow DL. The development of a theory of women’s use of violence in intimate relationships. Violence Against Women.2006;12(11):1026-45. DOI:10.1177/1077801206293330 and controlling behavior by a partner.⁷7 .Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet.2006; 368(9543):1260-69. DOI:10.1016/S0140-6736(06)69523-8^,2222 .Sonis J, Langer M. Risk and protective factors for recurrent intimate partner violence in a cohort of low-income inner-city women. J Fam Viol. 2008;23(7):529-38. DOI:10.1007/s10896-008-9158-7 Another IPV risk factor is the experience of woman or partner, in childhood or adolescence, with IPV against their mother or personal experience (direct) of violence perpetrated by a relative during childhood or adolescence, indicating another serious problem – the transgenerational transmission of violence.⁵5 .DOliveira AFPL, Schraiber LB, França-Júnior I, Ludermir AB, Portella AP, Diniz CS, et al. Fatores associados à violência por parceiro íntimo em mulheres brasileiras. Rev Saude Publica. 2009;43(2):299-310. DOI:10.1590/S0034-89102009005000013^,66 .Durand JG, Schraiber LB, França-Júnior I, Barros C. Repercussão da exposição à violência por parceiro íntimo no comportamento dos filhos.Rev Saude Publica. 2011;45(2):355-64. DOI:10.1590/S0034-89102011005000004

The aim of this study was to evaluate the incidence of intimate partner violence during postpartum and identify its risk factors.

METHODS

This cohort study was performed at the Distrito Sanitário II (one of the six health areas) in a poor region of the city of Recife, PE, in the Northeastern region of Brazil.

All pregnant women (n = 1,133), aged from 18 to 49 years old, who were enrolled in the Brazilian Family Health Strategy of the district were considered eligible. Twelve of these women did not complete the questionnaire: five were homeless, three moved away from the study area and four could not be found by the interviewers despite several visits. Once the losses were accounted for, 1,121 (98.9%) pregnant women were interviewed. 1,057 of these women were interviewed again during postpartum. Sixty-four women dropped out between pregnancy and postpartum, two of these for being unable to attend the second interview, three deaths, 37 who changed their address, four who ended up living on the street, 13 who moved to areas controlled by drug dealers and five who refused to participate. The 64 women who were not interviewed during postpartum had lower education (p = 0.001), but no statistically significant difference was observed regarding the frequency of violence during pregnancy, or with any other socioeconomic and demographic variables.

The first contact with the pregnant women was made during their prenatal consultation. The pregnant women were identified from the prenatal care records of 42 Family Health Strategy teams. Records from community health agents were also evaluated so as to include women not receiving antenatal care at the family health strategy units. The preferred option was for the prenatal interview to take place at the health unit, but some women were interviewed at home, when requested.

The women, during their postpartum period, were contacted during childcare consultations or at home, following the same pattern that was established for interviews during pregnancy. Most of the interviews were held at the interviewees’ homes between May and December 2006.

The 518 women who reported IPV before and during pregnancy were excluded to estimate the incidence, leaving 539 women who were reinterviewed up to 12 months after childbirth.

Two questionnaires were applied: one during pregnancy and the other during the postpartum period. Data were collected between July 2005 and December 2006 by female interviewers.

Confidentiality and privacy for those interviewed were guaranteed. Regardless of whether or not the women had experienced IPV, all received specific information on social services, health, legal and law enforcement, which were made available in the study area. Services that provide assistance to female victims of violence were solicited to provide help to any women interviewed who was suffering from domestic violence.

The IPV-related questions were prepared referring to the questionnaire of the World Health Organization Multi-country Study on Women’s Health and Domestic violence against women, which has already been validated in Brazil.²⁰20 .Schraiber LB, Latorre MRD, França-Junior I, Segri NJ, D’Oliveira AFPL. Validade do instrumento WHO/VAW STUDY para estimar violência de gênero contra a mulher. Rev Saude Publica. 2010;44(4):658-66. DOI:10.1590/S0034-89102010000400009

The intimate partner was defined as a partner or former partner whom the woman is living or used to live with, regardless of any formal union and whom the woman was having or had had sexual relations with.¹⁶16 .Ludermir AB, Lewis G, Valongueiro SA, Araújo TVB, Araya R. Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet. 2010;376(9744):903-10. DOI:10.1016/S0140-6736(10)60887-2

Questions to identify physical violence were characterized as physical aggression or use of weapons or objects to cause injury; psychological violence as threatening behavior, humiliation or insult; and sexual violence as sexual relations imposed by physical force or threats and any imposed acts that were considered humiliating. Women who answered “Yes” to at least one of the questions that referred to each type of violence were considered a positive case. The time of every report of violence was explored about its occurrence before and during pregnancy and postpartum. Additional information about the study methods are reported in other publications.⁷7 .Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet.2006; 368(9543):1260-69. DOI:10.1016/S0140-6736(06)69523-8^,1616 .Ludermir AB, Lewis G, Valongueiro SA, Araújo TVB, Araya R. Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet. 2010;376(9744):903-10. DOI:10.1016/S0140-6736(10)60887-2

The analysis was guided by a theoretical and conceptual model (Figure 1), which describes the hierarchical relationships between postpartum IPV risk factors, divided into three levels of determinants (proximal, intermediate and distal).²⁵25 .Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26(1):224-7. DOI:10.1093/ije/26.1.224

Level 1 (distal) included sociodemographic characteristics of the woman and her partner: age (< 20 years; ≥ 20 years), race/skin color (white; non-white), years in education (< 9 years; ≥ 9 years) and employment status (inactive; active). The following variables were also taken into account for the woman: currently living with partner (yes; no), housing status (owner; not owner) and own income (yes; no).

Level 2 (intermediate) included behavioral variables, with answers (yes; no) about the women: tobacco use, alcohol abuse and illicit drug use; and answers (yes; no) about the partner: alcohol abuse, illicit drug use and aggressive behavior outside the home.

Level 3 (proximal) included the dynamics of the relationship: relationship duration (≤ 1 year; > 1 year), fights between the couple (≥ 1 time/month; < 1 time/month), physical violence committed by the women against her partner without being assaulted first (yes; no), communication with the partner (good; difficult), and controlling behavior by the partner (none; moderate; high). More detailed descriptions of these last two variables can be found in published literature.¹⁶16 .Ludermir AB, Lewis G, Valongueiro SA, Araújo TVB, Araya R. Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet. 2010;376(9744):903-10. DOI:10.1016/S0140-6736(10)60887-2 Analysis was performed using Stata, version 10.1 software. Poisson regression was used to estimate crude and adjusted relative risk (RR), and the 95% confidence interval of the association between postpartum IPV and the explanatory variables.

The analysis strategy for the hierarchical model of determination, following the distal-proximal order, which made it possible to evaluate whether the effect of risk factors on postpartum IPV, was direct or mediated by other factors.⁵5 .DOliveira AFPL, Schraiber LB, França-Júnior I, Ludermir AB, Portella AP, Diniz CS, et al. Fatores associados à violência por parceiro íntimo em mulheres brasileiras. Rev Saude Publica. 2009;43(2):299-310. DOI:10.1590/S0034-89102009005000013^,2525 .Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26(1):224-7. DOI:10.1093/ije/26.1.224 Model 1 included variables from levels 1, 2 and 3, which were adjusted by the variables at the same level. In model 2, variables from level 2 were adjusted for the variables from the same level and for those that remained in model 1. In model 3, variables from level 3 were adjusted for those that remained in models 1 and 2.

The statistically significant variables (p ≤ 0.05) in model 1 were kept in the subsequent models. The previously tested block, which lost its significance when included in a new block, remained in the model.

When the three hierarchical levels are considered, the model presents: a) estimates for the effects of sociodemographic characteristics of the woman and her partner on postpartum IPV, not mediated by variables from the intermediate and proximal levels (dashed and dotted arrows in Figure 1); b) estimates for the effects of sociodemographic characteristics of the woman and her partner on the relationship dynamics, not mediated by the intermediate level (dashed arrow); c) estimates for the effects of the behavior of the woman and her partner on postpartum IPV, adjusted for variables from the distal level and not mediated by variables from the proximal level (dotted arrow); and d) estimates for the effects of the variables of the relationship dynamics on the postpartum IPV, adjusted for variables from the distal and intermediate levels.

This research was approved by the Ethics Committee at the Federal Universidade Federal de Pernambuco (Protocol 303/2004). All participants signed an informed consent term.

RESULTS

The incidence of some kind of postpartum IPV (Figure 2) was 9.3% (95%CI 7.0;12.0), with isolated psychological violence being more common (4.3%; 95%CI 2.8;6.4) than overlapping psychological and physical violence (3.3%; 95%CI 2.0;5.3) and psychological and/or physical and/or sexual violence (1.7%; 95%CI 0.8;3.0). Sexual violence was the least frequent and all the cases occurred in the first 40 days of postpartum.

The risk of postpartum IPV was most common among women without own income, those who had less than nine years of education, who were not living with their intimate partner when the interview was held or whose partners abused alcohol and used illicit drugs (Table 1). Postpartum IPV was also more common in women, who had been in their relationship for less than one year, those with a very controlling partner, those who reported having frequent fights with their partner or who had committed physical assaults against their partner without being assaulted first (Table 1).

Table 2 shows the results of the hierarchical analysis. The risk of postpartum IPV was higher for women with low education (RR = 2.6; 95%CI 1.3;5.4) with no personal income (RR = 1.7; 95%CI 1.0;2.9), which physically attacked the partner without being assaulted first (RR = 2.0; 95%CI 1.2;3.4), had a very controlling partner (RR = 2.5; 95%CI 1.1;5.8) and had frequent fights with their partner (RR = 1.7; 95%CI 1.0;2.9).

The association between alcohol abuse by the partner and postpartum IPV lost statistical significance when adjusted for factors related to sociodemographic conditions.

DISCUSSION

This is the first known Brazilian cohort study to estimate the incidence and risk factors for postpartum IPV. The data show a high incidence of postpartum IPV associated with gender inequality in the relationship.

The incidence of postpartum IPV was higher than that found by Guo et al¹⁰10 .Guo SF, Wu JL, Qu CY, Yan RY. Domestic abuse on women in China before, during, and after pregnancy. Chin Med J (Engl). 2004;117(3):331-6. (2004) and by Martin et al¹⁸18 .Martin SL, Mackie L, Kupper LL, Buescher PA, Moracco KE. Physical abuse of women before, during, and after pregnancy. JAMA.2001;285(12):1581-4. DOI:10.1001/jama.285.12.1581 (2001), who evaluated postpartum physical violence. However, it was lower than the incidence of physical violence found by Gielen et al⁹9 .Gielen AC, O’Campo PJ, Faden RR, Kass NE, Xue X. Interpersonal conflict and physical violence during the childbearing year. Soc Sci Med. 1994;39(6):781-7. DOI:10.1016/0277-9536(94)90039-6 (1994) and the three types of violence cited by Hedin (2000).¹¹11 .Hedin LW. Postpartum, also a risk period for domestic violence.Eur J Obstet Gynecol Reprod Biol. 2000;89(1):41-5. DOI:10.1016/S0301-2115(99)00164-5

As in other studies the overlapping of different types of violence was frequent.¹⁰10 .Guo SF, Wu JL, Qu CY, Yan RY. Domestic abuse on women in China before, during, and after pregnancy. Chin Med J (Engl). 2004;117(3):331-6. The highest incidence of psychological violence alone or overlapping with other types had been reported in some studies,⁴4 .Charles P, Perreira KM. Intimate partner violence during pregnancy and 1-year postpartum. J Fam Viol. 2007;22(7):609-19. DOI:10.1007/s10896-007-9112-0^,1717 .Macy RJ, Martin SL, Kupper LL, Casanueva C, Guo S. Partner violence among women before, during, and after postpartum: multiple opportunities for intervention. Womens Health Issues. 2007;17(5):290-9. DOI:10.1016/j.whi.2007.03.006 but differs from a study performed in China,¹⁰10 .Guo SF, Wu JL, Qu CY, Yan RY. Domestic abuse on women in China before, during, and after pregnancy. Chin Med J (Engl). 2004;117(3):331-6. that found psychological violence to be less common than sexual or physical violence. The low percentage of psychological violence reported in some studies may reflect cultural influences and structured relationships in gender inequality, which make it difficult for women to recognize situations that are considered psychological abuse. According to Charles and Perreira⁴4 .Charles P, Perreira KM. Intimate partner violence during pregnancy and 1-year postpartum. J Fam Viol. 2007;22(7):609-19. DOI:10.1007/s10896-007-9112-0(2007), the high percentage of psychological violence during postpartum can be due to high levels of stress and discord, which are associated with the significant life changes that occur for a woman or a couple when a new child is born.

In this study, all episodes of sexual violence reported occurred in the first 40 days after childbirth. Macy et al¹⁷17 .Macy RJ, Martin SL, Kupper LL, Casanueva C, Guo S. Partner violence among women before, during, and after postpartum: multiple opportunities for intervention. Womens Health Issues. 2007;17(5):290-9. DOI:10.1016/j.whi.2007.03.006(2007) found a higher percentage of sexual violence in the first month of postpartum. For Jasinski¹³13 .Jasinski JL. Pregnancy and domestic violence: a review of the literature. Trauma Violence Abuse. 2004;5(1):47-64. DOI:10.1177/1524838003259322 (2004), this may result of less interest of women in sexual activity in the immediate postpartum, which is possibly a result of their special hormonal state following childbirth. In addition, Ansara et al²2 .Ansara D, Cohen MM, Gallop R, Kung R, Schei B. Predictors of women’s physical health problems after childbirth. J Psychosom Obstet Gynaecol. 2005;26(2):115-25. DOI:10.1080/01443610400023064 (2005) showed that women who have recently given birth may experience physical problems, ranging from fatigue to pain in various parts of the body, especially for those who are victims of IPV. Women also face problems of psychosocial adjusting to motherhood and difficulties regarding lack of support and understanding of the dynamics of puerperium, particularly from their partner.

A varied group of potential risk factors for postpartum IPV emerged during the bivariate analysis. However, during the hierarchical analysis, remained associated with the incidence of postpartum IPV women with low education, without own income and those who physically abused their partner without being assaulted first; frequent fights between the couple and controlling behavior by the partner.

The risk of postpartum IPV found in this study was higher for women who had less than nine years of schooling, which suggest the importance of education for empowerment, self-confidence and an active stance in society. Women’s higher levels of schooling can also be one of the factors that make them more vulnerable to IPV,⁹9 .Gielen AC, O’Campo PJ, Faden RR, Kass NE, Xue X. Interpersonal conflict and physical violence during the childbearing year. Soc Sci Med. 1994;39(6):781-7. DOI:10.1016/0277-9536(94)90039-6 highlighting the gender inequality that permeates violent relationships and the importance of promoting equal access to education for men and women.¹1 .Abramsky T, Watts CH, Garcia-Moreno C, Devries K, Kiss L, Ellsberg M, et al. What factors are associated with recent intimate partner violence? findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health. 2011;11:109. DOI:10.1186/1471-2458-11-109

The lack of women’s financial autonomy demonstrated by not having own income was associated with incidence of postpartum IPV, probably for making the woman more dependent upon the man, for her own and her children’s survival. This vulnerability¹⁴14 .Jewkes R. Intimate partner violence: causes and prevention. Lancet. 2002;359(9315):1423-9. DOI:10.1016/S0140-6736(02)08357-5 hinders the possibilities of negotiating changes in the relationship, of separating from the partner or of seeking help when assaulted. In addition, women living in poverty are exposed to more severe and frequent IPV. Financially independent women can become more empowered in certain contexts, but not in those where women’s economic activity can be understood as a challenge to male identity of power and control.¹1 .Abramsky T, Watts CH, Garcia-Moreno C, Devries K, Kiss L, Ellsberg M, et al. What factors are associated with recent intimate partner violence? findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health. 2011;11:109. DOI:10.1186/1471-2458-11-109^,1414 .Jewkes R. Intimate partner violence: causes and prevention. Lancet. 2002;359(9315):1423-9. DOI:10.1016/S0140-6736(02)08357-5

Couples who quarreled frequently showed increased risk of postpartum IPV. For Jasinski¹³13 .Jasinski JL. Pregnancy and domestic violence: a review of the literature. Trauma Violence Abuse. 2004;5(1):47-64. DOI:10.1177/1524838003259322 (2004), couples with a newborn child often experience sleepless nights, and the changes in family dynamics may cause arguments between the couple, especially regarding sexual activity, which can lead to increased sexual violence. Other factors, suggested by Stewart²³23 .Stewart DE. Incidence of postpartum abuse in women with a history of abuse during pregnancy. CMAJ. 1994;151(11):1601-4. (1994), are increasing financial responsibility, women’s physical changes and couples adjusting to their new roles of father and mother and other family relationships. This context, which includes interpersonal conflict, dissatisfaction with the relationship, poor communication and difficult for problem solving strengthens the role of the relationship dynamics between the couple regarding the incidence of IPV.³3 .Bell KM, Naugle AE. Intimate partner violence theoretical considerations: moving towards a contextual framework. Clin Psychol Rev. 2008;28(7):1096-107. DOI:10.1016/j.cpr.2008.03.003

The association of controlling behavior with postpartum IPV, found during this study, was also shown in other studies on IPV.¹1 .Abramsky T, Watts CH, Garcia-Moreno C, Devries K, Kiss L, Ellsberg M, et al. What factors are associated with recent intimate partner violence? findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health. 2011;11:109. DOI:10.1186/1471-2458-11-109^,77 .Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet.2006; 368(9543):1260-69. DOI:10.1016/S0140-6736(06)69523-8^,2222 .Sonis J, Langer M. Risk and protective factors for recurrent intimate partner violence in a cohort of low-income inner-city women. J Fam Viol. 2008;23(7):529-38. DOI:10.1007/s10896-008-9158-7 Controlling behavior may reflect the increased vulnerability for IPV of women living in social contexts of gender inequality.¹⁴14 .Jewkes R. Intimate partner violence: causes and prevention. Lancet. 2002;359(9315):1423-9. DOI:10.1016/S0140-6736(02)08357-5

Physical aggression perpetrated by the woman against her partner was also reported by Swan and Snow²⁴24 .Swan SC, Snow DL. The development of a theory of women’s use of violence in intimate relationships. Violence Against Women.2006;12(11):1026-45. DOI:10.1177/1077801206293330 (2006) as a strong risk factor for violence against women. These authors consider contextual factors to understand the reasons that lead a woman assaulting her partner. They argue that this action can be an expression of the woman’s desire to defend herself and their children from physical harm; but it can also go beyond self-defense and include anger, revenge and the desire to control the partner.

In a study by Guo et al¹⁰10 .Guo SF, Wu JL, Qu CY, Yan RY. Domestic abuse on women in China before, during, and after pregnancy. Chin Med J (Engl). 2004;117(3):331-6. (2004), 44.6% of women responded all suffered aggressions, using active strategies to maximize their security, whereas a study by Silva et al²¹21 .Silva RA, Araújo TVB, Valongueiro S, Ludermir AB. Facing violence by intimate partner: the experience of women in an urban area of Northeastern Brazil. Rev Saude Publica. 2012;46(6):1014-22. DOI:10.1590/S0034-89102013005000007 (2012) shows a higher percentage (85.0%). Some studies that evaluated the bidirectionality of violence between partners found that the frequency of IPV perpetrated by women was higher, but resulting serious injury was more common when the man was the perpetrator.²⁴24 .Swan SC, Snow DL. The development of a theory of women’s use of violence in intimate relationships. Violence Against Women.2006;12(11):1026-45. DOI:10.1177/1077801206293330

Alcohol abuse by the partner was associated with postpartum IPV, but lost statistical significance when adjusted to the socioeconomic conditions. The association between alcohol abuse by the partner and IPV is still controversial. This association depends on the different ways of measuring alcohol use, types of samples and violence, individual partner characteristics, situational variables and relationship factors.¹1 .Abramsky T, Watts CH, Garcia-Moreno C, Devries K, Kiss L, Ellsberg M, et al. What factors are associated with recent intimate partner violence? findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health. 2011;11:109. DOI:10.1186/1471-2458-11-109^,1212 .Hellmuth JC, Gordon KC, Stuart GL, Moore TM. Risk factors for intimate partner violence during pregnancy and postpartum. Arch Womens Ment Health. 2013;16(1):19-27. DOI:10.1007/s00737-012-0309-8^,1414 .Jewkes R. Intimate partner violence: causes and prevention. Lancet. 2002;359(9315):1423-9. DOI:10.1016/S0140-6736(02)08357-5

This study has several advantages: it is a population-based cohort study on gender violence and complements previous results from prospective studies on postpartum IPV;⁸8 .Gartland D, Hemphill SA, Hegarty K, Brown SJ. Intimate partner violence during pregnancy and the first year postpartum in an Australian pregnancy Cohort study. Matern Child Health J.2011;15(5):570-78. DOI:10.1007/s10995-010-0638-z^,1010 .Guo SF, Wu JL, Qu CY, Yan RY. Domestic abuse on women in China before, during, and after pregnancy. Chin Med J (Engl). 2004;117(3):331-6.^,1212 .Hellmuth JC, Gordon KC, Stuart GL, Moore TM. Risk factors for intimate partner violence during pregnancy and postpartum. Arch Womens Ment Health. 2013;16(1):19-27. DOI:10.1007/s00737-012-0309-8^,1717 .Macy RJ, Martin SL, Kupper LL, Casanueva C, Guo S. Partner violence among women before, during, and after postpartum: multiple opportunities for intervention. Womens Health Issues. 2007;17(5):290-9. DOI:10.1016/j.whi.2007.03.006^,1818 .Martin SL, Mackie L, Kupper LL, Buescher PA, Moracco KE. Physical abuse of women before, during, and after pregnancy. JAMA.2001;285(12):1581-4. DOI:10.1001/jama.285.12.1581^,2323 .Stewart DE. Incidence of postpartum abuse in women with a history of abuse during pregnancy. CMAJ. 1994;151(11):1601-4. it evaluates three kinds of violence; the questionnaire used is internationally recognized,⁷7 .Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet.2006; 368(9543):1260-69. DOI:10.1016/S0140-6736(06)69523-8 it is validated in Brazil²⁰20 .Schraiber LB, Latorre MRD, França-Junior I, Segri NJ, D’Oliveira AFPL. Validade do instrumento WHO/VAW STUDY para estimar violência de gênero contra a mulher. Rev Saude Publica. 2010;44(4):658-66. DOI:10.1590/S0034-89102010000400009 and gauges violence based on specific acts, which increases the reliability of the results; and it has a theoretical-conceptual hierarchical model that aims to integrate contextual dimensions to understand why violence in intimate relationships exists.³3 .Bell KM, Naugle AE. Intimate partner violence theoretical considerations: moving towards a contextual framework. Clin Psychol Rev. 2008;28(7):1096-107. DOI:10.1016/j.cpr.2008.03.003

Some limitations should be considered. Violence perpetrated by an intimate partner is a complex, delicate and intimate topic. Thus, women’s psychological resources used to deal with the trauma suffered and their difficulties and obstacles that result from this experience can interfere with their willingness to talk about it. Women may not always recognize their experience of IPV when questioned in some situations, or they can minimize the importance of IPV by considering it to be natural,¹⁵15 .Kiss L, d’Oliveira AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and the help-seeking behaviors of women who experience violence. Health Hum Rights.2012;14(1):E64-77. which may contribute to the seriousness of these actions being underestimated. In addition to these factors, which are intrinsic to woman, others may cause violence to be underestimated, such as: the non-empathetic interviewer-interviewee relationship, the interview location, the woman’s insecurity about interview confidentiality, the current relationship with the partner, the sense of fear regarding the partner-aggressor and the protection that the woman gives the partner based on her desire to maintain the relationship, especially if he is the father of the child; and among many other factors, the stigma and the shame of being assaulted.⁸8 .Gartland D, Hemphill SA, Hegarty K, Brown SJ. Intimate partner violence during pregnancy and the first year postpartum in an Australian pregnancy Cohort study. Matern Child Health J.2011;15(5):570-78. DOI:10.1007/s10995-010-0638-z With the objective of minimizing those limitations, interviewers selected had experience in dealing with “violence against women” and were properly trained and monitored during the field work.

In Brazil, the social and institutional responses to demands from women’s movements have resulted in greater IPV awareness. However, cases reported by women and cases identified and reported by institutions and health professionals still continue to be underestimated.¹⁵15 .Kiss L, d’Oliveira AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and the help-seeking behaviors of women who experience violence. Health Hum Rights.2012;14(1):E64-77. The high observed incidence of VPI during postpartum may still be underestimated and shows that postpartum is a not period of security for either the woman or her child. Women reporting violence is dependent on, as well as various other factors, the socioeconomic conditions of women and their partners. It is also dependent on personal concepts and sociocultural contexts, in which hierarchy is more or less legitimized, which contributes to the increase or decrease in reports of violence.⁴4 .Charles P, Perreira KM. Intimate partner violence during pregnancy and 1-year postpartum. J Fam Viol. 2007;22(7):609-19. DOI:10.1007/s10896-007-9112-0^,77 .Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet.2006; 368(9543):1260-69. DOI:10.1016/S0140-6736(06)69523-8^,1515 .Kiss L, d’Oliveira AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and the help-seeking behaviors of women who experience violence. Health Hum Rights.2012;14(1):E64-77.^,1818 .Martin SL, Mackie L, Kupper LL, Buescher PA, Moracco KE. Physical abuse of women before, during, and after pregnancy. JAMA.2001;285(12):1581-4. DOI:10.1001/jama.285.12.1581

This study showed a high incidence of IPV, which involved a complex network of risk factors, with emphasis on the quality of the affective-sexual relationship. In this sense, to reduce the incidence of IPV, in addition to the public policy of protection and assistance to women, preventive measures that foster conflict mediation and seek social and gender equity would be needed. In this context, another important aspect is that, in addition to women, children are also exposed to IPV during their vulnerable and early stage of development. Therefore, childcare consultations are opportunities for the health professional to build a trusting relationship with the mother, which can facilitate strategies for disclosing violence and enable to find ways of empowerment for women to face the cycle of violence.

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