Abstract

Little is known about the repercussions of intimate partner violence (IPV) on nutritional outcomes in pregnancy, especially regarding diet. The aim was to investigate whether the occurrence of physical IPV at any time during pregnancy is associated with gestational dietary patterns. 161 adult pregnant women were enrolled in a prospective cohort study in Rio de Janeiro, Brazil. Overall and severe physical IPV were measured to evaluate IPV at any time during pregnancy. Three gestational dietary patterns (“Healthy”, “Common-Brazilian”, and “Processed”) were established by principal component analysis. The effect of physical IPV was tested in relation to the score of adherence to each of the dietary patterns. The occurrence of overall and severe physical IPV at any time during pregnancy was 20.4% and 6.8%, respectively. Women living in intimate relationships in which overall and severe physical IPV occurred had an average increase of 0.604 units (95%CI 0.149-1.058) and 1.347 units (95%CI 0.670-2.024), respectively, in the Processed dietary pattern adherence score. No association with “Healthy” and “Common-Brazilian” dietary patterns was observed. Physical IPV was associated with greater adherence to a dietary pattern of lower nutritional quality.

Key words:
Nutrition; Intimate partner violence; Pregnancy; Cohort studies

Resumo

Pouco se sabe sobre as repercussões da violência por parceiro íntimo (VPI) nos desfechos nutricionais da gravidez, principalmente no que diz respeito à dieta. O objetivo foi investigar se a ocorrência de VPI física na gestação está associada aos padrões alimentares gestacionais. 161 gestantes adultas participaram de um estudo prospectivo no Rio de Janeiro, Brasil. A VPI física geral e grave foi medida para avaliar a VPI a qualquer momento durante a gravidez. Três padrões alimentares gestacionais (“Saudável”, “Brasileiro Comum” e “Processado”) foram estabelecidos pela análise de componentes principais. O efeito da VPI física foi testado em relação ao escore de adesão a cada um dos padrões alimentares. A ocorrência de VPI física geral e grave em qualquer momento da gestação foi de 20,4% e 6,8%, respectivamente. Mulheres que viviam em relacionamentos íntimos em que ocorreu VPI física geral e grave tiveram um aumento médio de 0,604 unidades (IC95% 0,149-1,058) e 1,347 unidades (IC95% 0,670-2,024), respectivamente, no escore de adesão ao padrão alimentar processado. Não foi observada associação com os padrões alimentares “Saudável” e “Brasileiro Comum”. A VPI física foi associada à maior adesão a um padrão alimentar de menor qualidade nutricional na gestação.

Palavras-chave:
Nutrição; Violência por parceiro íntimo; Gravidez; Estudos de coorte

Introduction

Pregnancy is characterized by psychological and social behavioral changes in the entire family. Stressful situations, such as exposure to violent environments, during this stage may influence pregnant women’s dietary behavior and health in the prenatal and postnatal periods, potentially leading to low birth weight in newborns¹1 Mezzavilla RS, Hasselmann MH. Physical intimate partner violence and low birth weight in newborns from primary health care units of the city of Rio de Janeiro. Rev Nutr 2016; 29(3):357-366. and perinatal death²2 Ferdos J, Rahman MM. Maternal experience of intimate partner violence and low birth weight of children: A hospital-based study in Bangladesh. PLoS One 2017; 12(10):1-13.

3 Lindsay KL, Buss C, Wadhwa PD, Entringer S. The Interplay Between Nutrition and Stress in Pregnancy: Implications for Fetal Programming of Brain Development. Biol Psychiatry 2019; 85(2):135-149.^-44 Pastor-Moreno G, Ruiz-Pérez I, Henares-Montiel J, Petrova D. Intimate partner violence during pregnancy and risk of fetal and neonatal death: a meta-analysis with socioeconomic context indicators. Am J Obstet Gynecol 2019; 222(2):123-133.. Violence in the domestic environment can be perpetrated by a family member, the pregnant woman’s intimate partner, or the pregnant woman against her partner⁵5 Wagman JA, Donta B, Ritter J, Naik DD, Nair S, Saggurti N, Raj A, Silverman JG. Husband's alcohol use, intimate partner violence, and family maltreatment of low-income postpartum women in Mumbai, India. J Interpers Violence 2018; 33(14):2241-2267.. Intimate partner violence (IPV) is defined as the intentional use of physical force or power, threatened or actual, against an intimate partner, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation⁶6 Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360(9339):1083-1088..

The prevalence of IPV during pregnancy varies widely in the literature. An international study with data from 19 United Nations member countries estimated that physical and/or sexual IPV during pregnancy varied from 2.0% in Australia to 13.5% in Uganda⁷7 Devries KM, Kishor S, Johnson H, Stöckl H, Bacchus LJ, Garcia-Moreno, Claudia Wattsg C. Intimate partner violence during pregnancy: analysis of prevalence data from 19 countries. Reprod Health Matters 2010; 18(36):158-170.. Regional methodological and cultural differences are indicated as the main explanations for these variations⁷7 Devries KM, Kishor S, Johnson H, Stöckl H, Bacchus LJ, Garcia-Moreno, Claudia Wattsg C. Intimate partner violence during pregnancy: analysis of prevalence data from 19 countries. Reprod Health Matters 2010; 18(36):158-170.. In Brazil, a representative national survey of 6,774 non-pregnant women living in 15 state capitals and the Federal District estimated that the prevalence of physical IPV ranged between 13.2% and 34.8% in the cities surveyed⁸8 Reichenheim ME, Moraes CL, Hasselmann MH. The magnitude of intimate partner violence in Brazil : portraits from 15 capital cities and the Federal District. Cad Saude Publica 2006; 22(2):425-437..

IPV during pregnancy can give rise to diverse negative reactions in pregnant women, such as anxiety symptoms and postnatal depression⁹9 Chen Y, Cheung S, Huang CC. Intimate Partner Violence During Pregnancy: Effects of Maternal Depression Symptoms and Parenting on Teen Depression Symptoms. J Interpers Violence 2020; 886260520967754.^,1010 Belay S, Astatkie A, Emmelin M, Hinderaker SG. Intimate partner violence and maternal depression during pregnancy: A community-based cross-sectional study in Ethiopia. PLoS One 2019; 14(7):1-15., vaginal infection, and spontaneous preterm labor¹¹11 Martin-De-las-heras S, Velasco C, De Dios Luna-Del-castillo J, Khan KS. Maternal outcomes associated to psychological and physical intimate partner violence during pregnancy: A cohort study and multivariate analysis. PLoS One 2019; 14(6):1-11., as well as giving rise to dietary disorders¹²12 Bartlett BA, Iverson KM, Mitchell KS. Intimate partner violence and disordered eating among male and female veterans. Psychiatry Res 2018; 260:98-104.. There is still a paucity of studies in the literature concerning the association between IPV and nutritional outcomes, in particularly with regard to diet. The existing literature shows a positive association between the occurrence of IPV during pregnancy and insufficient weight gain at the end of pregnancy²2 Ferdos J, Rahman MM. Maternal experience of intimate partner violence and low birth weight of children: A hospital-based study in Bangladesh. PLoS One 2017; 12(10):1-13.^,1313 Berhanie E, Gebregziabher D, Berihu H, Gerezgiher A, Kidane G. Intimate partner violence during pregnancy and adverse birth outcomes: A case-control study. Reprod Health 2019; 16(1):1-9.^,1414 Moraes CL, Amorim AR, Reichenheim ME. Gestational weight gain differentials in the presence of intimate partner violence. Int J Gynecol Obstet 2006; 95(3):254-260.. This evidence indicates that malnutrition resulting from the occurrence of IPV impacts maternal health directly and indirectly on the child’s health¹⁵15 Dimasuay KG, Boeuf P, Powell TL, Jansson T. Placental responses to changes in the maternal environment determine fetal growth. Front Physiol 2016; 7:12., which may lead to intrauterine growth restriction¹⁶16 Lobato G, Reichenheim ME, Moraes CL, Peixoto-Filho FM, Migowski LS. Psychologic intimate partner violence and the risk of intrauterine growth restriction in Rio de Janeiro. Int J Gynecol Obstet 2018; 143(1):77-83., delayed psychomotor development¹⁷17 Jansson T. Placenta plays a critical role in maternal-fetal resource allocation. Proc Natl Acad Sci USA 2016; 113(40):11066-11068., and immune system deficiency¹⁸18 Briana DD, Boutsikou T, Baka S, Boutsikou M, Stamati L, Hassiakos D, Gourgiotis D, Malamitsi-Puchner A. Perinatal role of hepcidin and iron homeostasis in full-term intrauterine growth-restricted infants. Eur J Haematol 2013; 90(1):37-44.. To the best of our knowledge, there is no study in the literature that has investigated the repercussions of IPV on dietary patterns, especially during pregnancy.

In the present study, we aimed to investigate whether the occurrence of physical IPV at any time during pregnancy is associated with gestational dietary patterns among adult pregnant women attending a public health center in Rio de Janeiro, Brazil. We hypothesized that the occurrence of physical IPV results in higher adherence to a pattern of lower nutritional quality.

Methods

Design and participants

This was a prospective cohort study with low-risk adult pregnant women attending an antenatal clinic at a municipal health center in Rio de Janeiro, Brazil. Pregnant women were recruited between November 2009 and October 2011, when they accessed the antenatal service for the first time or during the immune-positive pregnancy test. The study protocol comprised three visits during pregnancy, 5^th-13^th (baseline), 24^th-26^th and 34^th-36^th weeks, and one between 30 and 45 days after childbirth. All interviews were conducted at the primary care facility, in a room designated for the study. Interviews were scheduled beforehand (except the recruitment interview) and were carried out face to face in a standardized manner by trained interviewers.

All pregnant women attending the health center were approached, and those who met the following inclusion criteria were invited to take part in the study: i) being between 5 and 13 weeks of gestational; ii) being between 20 and 40 years of age; iii) not having chronic diseases (except obesity) or infectious diseases; iv) present a singleton pregnancy; v) living in the health center’s catchment area, and vi) having antenatal follow-up at the study center.

A total of 299 pregnant women agreed to participate. After the first trimester clinical evaluation, 45 women were excluded due to a confirmed prepregnancy diagnosis of chronic (n=12) and infectious disease (n=9), gestational age >13 weeks at the baseline visit (n=15), declined prenatal care or were transferred to other units (n=5), or twin pregnancy (n=4). Thus, the first trimester sample comprised 254 eligible pregnant women. Over the study period, 25 miscarriages and five stillbirths were recorded, resulting in an initial sample of 224 pregnant women. There were 33 losses on the second trimester visit, four of whom were recovered at the third trimester appointment. Finally, data on dietary intake were incomplete in six cases, and the interview on IPV was missing an additional 28 cases. The final cohort with complete data in the third trimester comprised of 161 pregnant women (63.4% of the eligible participants) (Figure 1).

Ethical approval

This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Research Ethics Committee of the Institute of Psychiatry of the Federal University of Rio de Janeiro (Certification of Submission for Ethical Appraisal - CAAE No. 0012.0.249.000-09; dated on 04/08/2009) and the Ethics Committee of the Municipal Secretary of Health of the city of Rio de Janeiro (CAAE No. 0139.0.314.000-09; dated on 13/08/2009). Written informed consent was obtained from all participants before the study.

Intimate partner violence

The Portuguese version of the Conflict Tactics Scales (CTS-1)¹⁹19 Hasselmann MH, Reichenheim ME. Cross-cultural adaptation of the Portuguese version of the Conflict Tactics Scales Form R (CTS-1) used to assess marital violence: semantic and measurement equivalence. Cad Saude Publica 2003; 19(4):1083-1093. was administered at the 34^th-36^th gestational weeks to retrospectively evaluate physical IPV occurrence at any time during pregnancy. CTS-1 evaluates strategies used by couples to solve possible disagreements and, indirectly, capture situations of IPV. The scale comprised of 18 items covering three tactics for dealing with conflicts: i) negotiation, consisting of the use of discussion, using moderate and reasonable language (items a-c); ii) verbal aggression, characterized by use of insults and threats with the intention of symbolically hurting and attacking the other person (items d-f, h-j); iii) “physical violence”, use of physical force to deal with conflicts. Physical violence has two subscales, minor physical violence (characterized by the use of physical force on objects or on the victim, such as seizing/pushing/slapping; items k-m), and severe physical violence (characterized by use of physical force on the victim with the possibility of resulting in physical harm or which leaving the victim unable to carry out mechanical tasks, such as beating/burning/strangling; items n-s). All the questions on tactics used to deal with the couple’s conflicts were answered by the pregnant women, replying first about the reactions of their intimate partners in conflict situations, and then replying about their own reactions in these situations. All the questions had the following response options: sometimes reacted like that; often reacted like that; reacted like that in the past, but not in recent months; never reacted like that. The first two options were considered “yes” regarding the occurrence of IPV.

The evaluated outcomes were i) overall physical IPV, which consists of practicing at least one act of IPV (minor or severe) on the physical violence scale, and ii) severe physical IPV. IPV was considered present when there was a positive reply to at least one of the questions, whether the woman was the victim or the perpetrator.

Dietary patterns

Gestational dietary habits were assessed using a semi-quantitative food frequency questionnaire (FFQ) administered at the 34^th-36^th weeks of gestation covering the last 6 months of pregnancy. This instrument consisted of 82 food items with eight frequency options: >3 times/day, 2-3 times/day, 1 time/day, 5-6 times/week, 2-4 times/week, 1-3 times/week, never or hardly ever²⁰20 Sichieri R, Everhart JE. Validity of a Brazilian food frequency questionnaire against dietary recalls and estimated energy intake. Nutr Res 1998; 18(10):1649-1659.. Three dietary patterns were previously derived using principal component analysis²¹21 Eshriqui I, Vilela AAF, Rebelo F, Farias DR, Castro MBT, Kac G. Gestational dietary patterns are not associated with blood pressure changes during pregnancy and early postpartum in a Brazilian prospective cohort. Eur J Nutr 2016; 55(1):21-32.: “Healthy” characterized by milk, dairy products, fruit, fruit juice, green vegetables and pulses (chickpeas and lentils), fresh fish, cakes and biscuits, and “mate” tea; “Common-Brazilian” characterized by rice, beans, onion, garlic, sweet pepper, eggs, bread, butter, and margarine; and “Processed” characterized by chicken and pork meats, sweets, pasta, root and tuber vegetables, snacks (pizzas and savory snacks), processed meats and sodas, and lower consumption of coffee and red meat. Each pregnant woman was given a score for her adherence to each of the three dietary patterns identified. Negative scores indicate less adherence while positive scores indicate more adherence.

For descriptive analysis, the women were classified in a specific pattern only. High adherence to each dietary pattern was classified according to the score’s quintiles. When women were classified in the fifth quintile of a specific dietary pattern, they were considered to have high adherence for that pattern. In cases when a pregnant woman was classified in the fifth quintile of two patterns, she was kept in the pattern with the highest score²²22 Vilela AAF, Farias DR, Eshriqui I, Vaz JS, Franco-Sena AB, Castro MB, Olinto MT, Machado SP, Silva AAM, Kac G. Prepregnancy healthy dietary pattern is inversely associated with depressive symptoms among pregnant Brazilian women. J Nutr 2014; 144(10):1612-1618..

Socioeconomic, demographic and behavioral variables

Socioeconomic, demographic, obstetric and behavioral information were collected using a standardized questionnaire applied at the baseline interview. The following information was included in the analysis: age (years), schooling (years of formal completed education), total per capita family income (in US$), alcohol consumption (yes, no), and current smoking habit (yes, no).

Psychiatric assessment

Psychiatric interviews were conducted using the Mini International Neuropsychiatric Interview (MINI) (DSM-IV; version 5.0.0)²³23 Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC. The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59(Supl. 20):22-33., an instrument with a standard model of a brief (15-30 min) structured interview for the evaluation of the presence of Axis I psychiatric disorders according to the Diagnostic and Statistical Manual of Mental Disorders²⁴24 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5(r)). Virgínia: American Psychiatric Publishing; 2013.. This instrument is divided into modules (A-P), each containing questions that represent different psychiatric disorders. The participants must answer yes or no to each of the questions. All women were interviewed at the study baseline. The interviews were performed by a psychiatry resident and graduate students in mental health (Master’s and PhD students) who were trained for this purpose. In the present study, we used the data relating to major depression (yes, no) and generalized anxiety (yes, no).

Statistical analyses

The baseline characteristics of the study cohort were described using means and standard deviations or medians and 95% confidence intervals. The categorical variables were described by absolute numbers and frequencies. These variables were stratified according to the established dietary patterns identified on the basis of the greater adherence to each dietary pattern. ANOVA was used to test for differences between mean values of the variables, while the Chi-square or Fisher’s test (n<5) was used to compare the frequencies of the categorical variables.

Crude and adjusted linear regression models were performed to test for the association between the occurrence of overall and severe physical IPV during pregnancy and the scores of adherence to each of the dietary patterns. For these analyses, all pregnant women were considered in each dietary pattern. ß coefficients, 95% confidence intervals (95%CI) and Wald heterogeneity test p values were calculated using a <5% statistical significance level.

To identify confounding factors for the complete adjusted model, we created a Directed Acyclic Graph (DAG) - a technique that represents hypothetical causal relationships between variables, allowing the identification of the minimum but sufficient set of covariates to remove confounding factors from the statistical analysis and help avoid inappropriate adjustments²⁵25 Cortes TR, Faerstein E, Struchiner CJ. Utilização de diagramas causais em epidemiologia: Um exemplo de aplicação em situação de confusão. Cad Saude Publica 2016; 32(8):1-13.. In the present investigation, the following variables were included in the adjusted models according to the DAG results: age, per capita family income, schooling, first trimester current alcohol consumption, first trimester tobacco smoking, major depression, and generalized anxiety (Figure 2).

Furthermore, we performed analyses of women included in the current analyses and those excluded to assess the effects of losses of follow-up using Student’s t-test or Kruskal Wallis and chi-square test of proportions for selected sociodemographic variables (age, per capita family income, schooling, first trimester current alcohol consumption, first trimester tobacco smoking, major depression, and generalized anxiety) with the aim of ruling out possible selection bias. All statistical analyses were performed using Stata 15.0® (Stata Corp., College Station, Texas, USA).

Results

The mean age of the 161 pregnant women included in the study was 26.7 (SD=5.4) years, schooling was 8.6 years (SD=2.9), and the median total per capita family income was US$ 263.9 (95%CI 137.5-687.8). Alcohol consumption was reported by 15.5% and current smoking habits were reported by 5.0%. Major depression was observed in 14.3% and generalized anxiety in 8.7% of pregnant women (Table 1). Women not included in the present analysis due to losses of follow-up at the third trimester presented a higher proportion of major depression (28.9%) compared to those women who completed the cohort follow-up (14.3%) (Table 2).

The occurrence of overall and severe physical IPV at any time during pregnancy was 20.4% and 6.8%, respectively. Pregnant women with higher adherence to the “Healthy” dietary pattern had higher per capita family income (US$ 355.30, 95%CI 146.1-791.7) than those with higher adherence to the “Common-Brazilian” (US$ 251.3, 95%CI 136.1-527.8) and “Processed” (US$ 266.7, 95%CI 138.9-588.9) dietary patterns (p=0,041). Women who had higher adherence to the “Healthy” dietary pattern less frequently reported gestational overall physical IPV (7.1%) compared to the “Common-Brazilian” (23.9%) and the “Processed” (26.5%) dietary patterns (p=0.036) (Table 1).

In crude and adjusted linear regression models, a significant association between physical IPV at some point during pregnancy and “Processed” dietary pattern was observed. The pregnant women exposed to overall physical IPV during pregnancy had a mean increase of 0.604 units (95%CI 0.149; 1.058) in their score for adherence to the “Processed” dietary pattern. Similarly, those exposed to severe physical IPV during pregnancy had a mean increase of 1.347 units (95%CI 0.670; 2.024) of adherence to this pattern. There was no significant crude or adjusted association between overall and severe IPV at some point during pregnancy with the “Healthy” and “Common-Brazilian” dietary patterns (Table 3).

Discussion

This study has three main findings. First, women who reported being exposed to physical IPV at any time during pregnancy had higher scores for adherence to the “Processed” dietary pattern, and this adherence was higher for those women who reported severe physical IPV compared to those who were exposed to overall physical IPV.

The women who reported gestational overall physical IPV tended to have lower scores for adherence to the “Healthy” dietary pattern. Physical IPV at some point during pregnancy was positively associated with the “Processed” dietary pattern, while there were no significant associations between the other two dietary patterns and physical IPV. To our knowledge, this is the first study that examined the association of physical IPV and gestational dietary patterns, and the first to provide evidence that physical IPV at any time in pregnancy may be associated with a higher adherence to a processed dietary pattern.

This study reveals that exposure to physical IPV during pregnancy had negative repercussions on pregnant women’s dietary habits regardless of its severity. Such exposures favored greater adherence to the “Processed” dietary pattern, comprised predominantly of processed meat, snacks, sweets, and sodas. These types of food have a high energy density but low nutritional quality, i.e., they are poor in vitamins and minerals while being high in sugar, sodium, trans and saturated fat content. The higher adherence to the “Processed” dietary pattern may indicate that pregnant women with greater exposure to physical IPV (overall and severe) were somehow precluded from choosing a better qualify nutrition.

Physical violence is a type of stressor exposure that produces higher levels of cortisol, which, in turn, acts on the brain’s reward system and may trigger excessive consumption or preference for hyperpalatable food²⁶26 Penaforte FR, Matta NC, Japur CC. Associação entre estresse e comportamento alimentar em estudantes universitários. Demetra Aliment Nutr Saude 2016; 11(1):225-238.. High palatability foods, such as those belonging to the “Processed” dietary pattern, have positive effects that are both neurochemical (they stimulate serotonin and dopamine) and psychological (through affective memory) on mood and well-being²⁷27 Mills JG, Thomas SJ, Larkin TA, Deng C. Overeating and food addiction in Major Depressive Disorder: Links to peripheral dopamine. Appetite 2020; 148:104586.. Therefore, this may be one of the pathways that explain why women who experience physical violence in their intimate relationships display greater adherence to a diet composed mainly of foods rich in sodium, sugar, saturated and hydrogenated fats, additives and preservatives, and poor essential micronutrients.

Although psychological outcomes owing to IPV were not evaluated (i. e., stress), it is possible that pregnant women who have experienced IPV may have greater emotional impairment¹⁰10 Belay S, Astatkie A, Emmelin M, Hinderaker SG. Intimate partner violence and maternal depression during pregnancy: A community-based cross-sectional study in Ethiopia. PLoS One 2019; 14(7):1-15., thus hindering the process of dietary awareness to plan/make a nutritionally balanced meal. In turn, the main characteristic of processed food is that it is quick and practical to prepare, thus encouraging its consumption by people unable to pay more attention to what they eat²⁸28 Contini C, Romano C, Scozzafava G, Casini L. Food Habits and the Increase in Ready-to-Eat and Easy-to-Prepare Products. In: Kotzekidou P, editor. Food Hygiene and Toxicology in Ready-to-Eat Foods. Thessaloniki: Elsevier Inc.; 2016. p. 3-14..

Women exposed to severe physical IPV had higher scores for adherence to the “Processed” dietary pattern when compared to those who were exposed to overall physical IPV. Despite the adjusted analysis taking depressive/anxiety disorders into consideration, pregnant women who perpetrated and/or suffered severe physical IPV may have other forms of psychological suffering because of the severity and, possibly, the chronicity of this form of violence. Given that the severity of IPV increases with time of exposure, the impact of severe physical IPV may have been greater on women’s adherence to the “Processed” dietary pattern. Taken together, depending on the severity of the body injury, urgent/emergency medical care may need to be sought out. However, by turning the violence suffered in the intimate sphere public, the prejudice and stigma many women face in healthcare services can bring additional psychological suffering²⁹29 Acosta DF, Lúcia V, Gomes DO, Oliveira DC, Calcagno G. Ethical and legal aspects in nursing care for victims of domestic violence. Texto Context Enferm 2017; 26(3):1-9..

Dietary patterns were also associated with family income in both the crude and adjusted analyses. According to the results, the higher the family income, the greater the adherence to the healthy diet pattern, regardless of having experienced IPV during pregnancy. The healthy pattern is characterized by fresher products, such as dairy products, fruit, green vegetables, fresh fish and, consequently, more expensive. It is expected that those with greater purchasing power have greater adherence to a healthier diet. Furthermore, although schooling has not been associated, it is possible that pregnant women with greater family income are more aware of adequate nutrition and have economic structure to access this pattern of diet³⁰30 Chai W, Fan JX, Wen M. Association of individual and neighborhood factors with home food availability: Evidence from the National Health and Nutrition Examination Survey (NHANES). J Acad Nutr Diet 2018; 118(5):815-823..

The strength of the current study lies in its investigation of an association not yet established by the literature and the highlighting of the adversity that IPV brings to health, with particular emphasis on diet. Another aspect was the collection of prospective data on the period during pregnancy, which enabled the identification of the temporality of the occurrence of the events. Even though the reporting of the exposure and the outcome was retrospective in relation to events occurring throughout pregnancy, both instruments used have been validated and were administered by a trained team, thus ensuring the reliability of the information collected. Although the quality of the study protocol ensured the internal validity of the results, these were limited to a single public health center and their extrapolation should be done with caution.

Another limitation relates to the loss to follow-up over the monitoring period, which is a commonly observed disadvantage of prospective studies³¹31 Biele G, Gustavson K, Czajkowski NO, Nilsen RM, Reichborn-Kjennerud T, Magnus PM, Stoltenberg C, Aase H. Bias from self selection and loss to follow-up in prospective cohort studies. Eur J Epidemiol 2019; 34(10):927-938., especially with parturient women³²32 Bacchus L, Mezey G, Bewley S. Domestic violence : prevalence in pregnant women and associations with physical and psychological health. Eur J Obstet Gynecol Reprod Biol 2004; 113:6-11.. Despite active tracing of the pregnant women by telephone to confirm appointments and make new ones, approximately 10% of the sample was lost to follow-up. The small sample size may have prevented us from detecting other associations between physical violence and dietary patterns due to lack of power. In addition, our analytical sample presented a lower proportion of women with major depression when compared to the initial cohort, which could underestimate our results.

Finally, our findings reveal that the occurrence of physical IPV among adult pregnant women exists and was associated with greater adherence to the “Processed” dietary pattern. The data reinforce that physical IPV is a problem that has repercussions in various areas of the lives of those who experience it, including shifting away from a healthy diet. Health services, including antenatal care programs, need to consider social incidents experienced by pregnant women as health determinants and provide appropriate care following their identification. Together with the legal sector, health services can act as a detection, support, and follow-up mechanism for IPV cases.

Acknowledgments

We are extremely grateful to all women who took part in the study, and to all staff at the Heitor Beltrão Health Center, Brazil.

References

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