Mothers in the Military: Violence and Negative Perinatal Outcomes

Kathleen Kendall-Tackett, PhD, IBCLC, FAPA¹

1. Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo.

OPEN ACCESS

PUBLISHED: 31 October 2024

CITATION:Kendall-Tackett, K., 2024. Mothers in the Military: Violence and Negative Perinatal Outcomes Medical Research Archives, [online] 12(10). https://doi.org/10.18103/mra.v12i10.5900

COPYRIGHT © 2024 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v12i10.5900

ISSN 2375-1924

Abstract

Violence can affect more women, but some are particularly high risk. Women in the military have experienced more violence before, during, and after their time in the military compared to civilian women. Military women report higher rates of adverse childhood experiences, severe adverse childhood experiences, and partner violence. Military-specific traumas include combat deployment, sexual harassment, and sexual assault during military service. Given this level of violence exposure, it is not surprising that military women have higher rates of posttraumatic stress disorder (PTSD), depression, anxiety, eating disorders, and suicidal behavior. While at a global prevalence of 37% for military women, 24% for IPV in the general population, the increased number of women highlights some areas of vulnerability, especially during the perinatal period, that are often under recognized. Compared to civilians, women in the military are more likely to experience adverse outcomes for mothers and infants during pregnancy and postpartum. This article will explore these issues and provide recommendations for future studies and practice.

Keywords

• Military
• Violence
• Perinatal Outcomes
• PTSD
• Women Veterans

Introduction

Violence can affect more woman, but some are at particularly high risk. Women in the armed services have experienced more violence before, during, and after their time in the military compared to civilian women. Military women report higher rates of adverse childhood experiences, severe adverse childhood experiences, and partner violence. Military-specific traumas include combat deployment, sexual harassment, and sexual assault during military service. Given this level of violence exposure, it is not surprising that military women have higher rates of posttraumatic stress disorder (PTSD), depression, anxiety, eating disorders, and suicide attempts compared to age-matched civilians[1]. High rates of violence are particularly an issue for women in the perinatal period as they are associated with adverse outcomes for mothers and infants[2]. Military mothers have higher rates of perinatal depression, anxiety, and PTSD compared to civilians, and their infants have higher rates of preterm births and low birth weight.

Studies of violence in perinatal military women is relatively new, so the literature is not large. The findings we have so far, however, are concerning. Three types of violence disproportionally affect military women in general and during the perinatal period in particular: adverse childhood experiences, intimate partner violence, and military sexual trauma. This article is a narrative review that summarizes all recent research found on PubMed and PsychInfo regarding pregnant or postpartum women in the military. Some studies and review articles examining violence against civilian women and violence in general veteran populations were included for comparison.

Adverse Childhood Experiences

ADVERSE CHILDHOOD EXPERIENCES IN THE GENERAL POPULATION AND VETERANS

The Adverse Childhood Experiences (ACE) Study was the first to demonstrate the long-term effects of multiple types of childhood adversity. The original ACE Study included more than 17,000 patients in the Kaiser Permanente system, a health maintenance organization in San Diego, California[3]. The major findings were that ACEs were common (more than half the sample); that adversities have an additive effect: the more types someone experiences, the worse the adult outcomes; and that adversities in childhood increased the risk for serious adult physical health problems. Adverse childhood experiences (ACEs) include childhood physical and sexual abuse; emotional abuse; neglect (physical and emotional); and witnessing parental intimate partner violence; parental mental illness, substance use, and criminal activity[4]. Participants who had 4 or more ACEs had higher risk for cardiovascular disease, diabetes, cancer, and other conditions, and were more likely to die prematurely. Subsequent studies have linked ACEs to many other conditions, including chronic pain syndromes[5]. A more recent US study found that 64% of adults reported at least one ACE and 17% reported 4 or more[6]. A study of 1,062 French college students found an even higher ACE rate: 89% reported at least one, with 21% reporting 3 or more[7].

Among veterans, women report more ACEs than men. A study of post-9/11 male and female veterans (N = 9,566) found that 59% of female veterans and 39% of males had experienced at least one ACE[8]. In addition, 25% of female veterans experienced 4 or more ACEs compared to 12% of males. The most common ACEs for women included emotional abuse, family history of mental illness or alcohol abuse, and emotional neglect. Combat exposure and ACEs were both associated with poor mental health in male and female veterans.

Another large study compared male and female veterans (n = 38,633) to their age- and sex-matched civilian counterparts (n = 16,483) on adverse childhood experiences and current suicidal ideation or attempts[9]. Their conceptualization of ACEs differed from the original ACE study and included 22 traumatic events that occurred before age 18. Their study included their original list and added events such as food insecurity and

Female veterans reported more ACEs than their civilian counterparts (3.1 vs 2.4). In addition, female veterans were more likely to report 6 or more ACEs (15% vs 9%) compared to civilian women.

CONSEQUENCES OF ADVERSE CHILDHOOD EXPERIENCES

Health problems caused by ACEs cost an estimated $748 billion a year in North America and are associated with 5 of the 10 leading causes of death[6]. In addition, ACEs increase the risk for depression, anxiety, PTSD, substance use, and high-risk behavior. For example, a study of 882 young women (age range = 12–20) from an inner-city health practice found that 59% had experienced abuse or neglect and that all types of maltreatment increased the risk of depression, substance use, and high-risk sexual activity (unprotected sex, multiple partners, and partners 5+ years older).

Interestingly, one study found resilience in female veterans that they did not find in males: having a history of 1 to 2 ACEs did not increase women’s risk of mental health disorders, but it did for men[8]. The authors hypothesized that women’s earlier experiences may have enhanced their ability to cope rather than diminishing it. Unfortunately, women who experienced 4 or more ACEs had higher risk for PTSD, depression, anxiety, and alcohol abuse than non-abused women[9]. ACEs also compounded the negative effects of combat exposure.

Intimate Partner Violence

INTIMATE PARTNER VIOLENCE AND ITS SEQUELAE IN THE GENERAL POPULATION

Intimate partner violence (IPV) is also relatively common and neither pregnancy nor postpartum protects women from it. A recent meta-analysis of 201 studies (N = 250,099) examined the global prevalence of IPV[10]. IPV and pregnancy is the group most likely to have experienced lifetime IPV. Intimate partner violence can be physical, psychological, or sexual. All types lead to negative sequelae such as depression, anxiety, PTSD, and suicidality. White et al.[10] found a global prevalence of 37% for “any IPV,” and 24% for IPV in the past year for women 15 to 44. Among those who experienced physical violence, perinatal and help-seeking women had the highest risk of depression.

Recent data from 31 sites of the US Pregnancy Risk Assessment Monitoring Systems (PRAMS) found that 13% of women were depressed at 3 to 4 months postpartum in the aggregate sample[11]. However, the percentage dramatically increased (29% to 34%) if women were abused by their partners before or during pregnancy. The PRAMS data were consistent with previous studies on partner violence. For example, a New York study followed 884 women from their first prenatal visit to 6 weeks postpartum[12]. The strongest predictors of postpartum depression were physical or sexual abuse during pregnancy, a history of psychiatric disorders, and a psychiatric diagnosis at the first prenatal visit.

Partner violence can cause a wide range of physical injury, including head injury, and can lead to death. Partner violence can also lead to mental health sequelae, such as depression, anxiety, and PTSD—symptoms that last long past physical injuries. Pregnancy is an especially dangerous time to experience partner violence; it increases the risk of serious harm for both mother and baby. Intimate partner violence during pregnancy increases the risk of low birth weight, preterm birth, small for gestational age, gestational diabetes, maternal and neonatal death. Women are also at risk for depression, anxiety, PTSD, and suicidal ideation[13–14]. A review of 67 studies found that violence during pregnancy tripled the risk of postpartum depression[15]. Partner violence also increased the risk of PTSD, and prenatal and postpartum anxiety.

Violence and depression also appear to have a bidirectional relationship: violence increases the risk of depression and depressed women are 3 to 5 times more likely to be beaten by their partners while pregnant[15]. A study from Peru had similar findings; women with histories of childhood physical abuse had twice the rate for depression

during pregnancy and were 7 times more likely to experience partner violence[16]. These findings are somewhat difficult to interpret. Women—depressed or not—are not responsible for their partners’ actions. However, depression may lead to quarrels, which increases the risk of violence. This is a relationship that should be studied further.

INTIMATE PARTNER VIOLENCE IN VETERANS

Partner violence is also common among women veterans. One examination of Veterans Health Administration electronic medical records included a sample of 8,427 women who were screened for partner violence[17]. Out of this sample, 8% screened positive. A recent meta-analysis of 31 studies (N = 172,790) of predominantly US active-duty personnel and veterans found that 21% reported recent victimization, with psychological abuse being the most commonly reported[18].

Intimate partner violence has also been studied within perinatal military women. A study conducted between 2007 and 2009 reviewed 1,162 pregnant women who received prenatal care at a US Naval hospital[19]. Fifteen percent screened positive for past or current abuse and 1.5% reported abuse during their current pregnancy. Single or divorced women had significantly higher risk of physical or emotional abuse by their partners compared to married women. Their relationship status may reflect women leaving their abusive marriages/partnerships. In addition, a history of family abuse increased the risk of IPV in the past 12 months by almost 6 times (OR 5.99, 95% CI 2.99–11.99, p < .001). IPV was more common among enlisted personnel.

A study of 442 US veterans using Veterans Health Administration (VHA) maternity care benefits found that 14% reported IPV in the past year[20]. Mothers were interviewed during pregnancy and were part of a larger cohort study. Within this sample, they found significantly higher rates of depression, PTSD, anxiety disorders, bipolar disorder, and eating disorders. They also found higher rates of military sexual trauma; risky behavior during pregnancy, such as smoking, drinking, and using drugs; and greater use of VHA mental health services. Not surprisingly, they were significantly less likely to seek support from their spouse or partner. The women served predominantly in the army. The sample was 56% White, 27% Black, 21% Hispanic, and 18% “other.” Fifty-five percent of women reporting IPV were living with their partners compared to 86% in the non-IPV group.

Suicide is a serious threat for all returning veterans. Combat exposure and partner violence increases the risk. A study of 8,427 women veterans found that 3% of the total sample reported suicidal ideation or self-harm behaviors[17]. In contrast, women who screened positive for any type of IPV had double the risk for suicidal ideation or self-harm.

On a positive note, the Veterans Health Administration is screening more women for IPV. A recent retrospective study of VHA data from 2014 to 2020 found that only one agency was screening for IPV in 2014, but 82% of the agencies were by 2020[21]. In 2020, 154,000 women were screened for IPV, but the percentage was higher (8%) among women of childbearing age vs 6% of veterans in general. When using the more liberal scale cutoff of 6+ on the measure, the rates increased to 11% for women of childbearing age, and 7% for the general population of women in the Veterans Affairs (VA) health system[21].

Military Sexual Trauma

OVERVIEW OF MILITARY SEXUAL TRAUMA

Military sexual trauma (MST) is psychological trauma that results from sexual harassment, battery, or assault that occurred while in the military[22]. MST ranges from offensive or coercive remarks to rape and all types increase the risk for severe sequelae. Men and women who experience MST report feeling betrayed by individuals they trusted and the military as an institution[23]. Betrayal is a particularly salient issue in the military. Military culture is unique because soldiers must depend on each other to survive. Soldiers are away from normal sources of support, move often, and are subject to a hierarchical command

structure, which limits their access to outside help[24]. Women who deploy are more likely to report MST[25]. Military sexual trauma survivors who report their abuse face possible demotion, loss of support and unit cohesion, and unwanted assignments. They do not have the option to simply leave and are also at risk for additional violence[11].

A large retrospective study found that 23% of women veterans (n = 123,417) reported a history of military sexual trauma[26]. All women with a VA primary provider were included in the initial cohort. The mean age was 63 for the MST group and 67 in the no MST group, suggesting that MST is not a new problem in the military but one that has only recently come to prominence.

OUTCOMES

Military sexual trauma increases the risk of depression, anxiety, and PTSD. A study of 2,499 male and female veterans found that all types of military sexual trauma—harassment to assault— increased the severity of PTSD, depression, and suicidality above and beyond the effect of combat exposure. Harassment and assault combined caused more severe symptoms than harassment or assault alone[24]. A review of 43 studies compared symptoms related to combat exposure vs military sexual trauma to determine whether MST had an effect independent of combat[27]. Both combat and MST uniquely contributed to PTSD symptoms, but MST was more strongly related to depression and suicidality than combat. Combat, on the other hand, was more strongly related to alcohol use and other externalizing symptoms.

Military sexual trauma also increased the risk for chronic pain in a large, cohort study of female veterans[26]. Women who reported MST also reported significantly more chronic pain diagnoses including headaches, chronic pelvic pain, chronic back pain, and fibromyalgia. Military sexual trauma also increased the risk of incident hypertension in post-9/11 male and female veterans (N = 788,161)[28]. For women, MST resulted in a 20% greater risk, which was higher than it was for men. Risk was calculated after controlling for demographics, lifestyle, cardiovascular risk factors, and psychiatric disorders.

MILITARY SEXUAL TRAUMA IN PREGNANT AND POSTPARTUM WOMEN

Military sexual trauma also affects childbearing women and increases the risk for postpartum depression and anxiety, emotional problems, and suicidal ideation. A recent review of 16 articles examined the impact of military trauma on pregnancy outcomes[22]. Fourteen of the 16 studies found that military women were at higher risk for adverse pregnancy outcomes including preterm birth, low birth weight, gestational diabetes, hypertensive disorders of pregnancy, and perinatal mood and anxiety disorders. Black enlisted women had disproportionately higher rates of adverse pregnancy outcomes and PTSD compared to other military mothers.

A longitudinal study followed 620 U.S. female veterans delivering between pregnancy and 452 postpartum[29]. In this group, 30% reported military sexual harassment and 30% reported sexual assault. Seventy-one percent of women who were harassed were depressed compared to 41% of non-harassed women. Even the rates for non-harassed women are substantially higher than they are in civilian populations, but the rates for the harassed group are extraordinary[30]. In addition, 56% had PTSD and 56% had an anxiety disorder compared to 24% of non-harassed women. Among women who were sexually assaulted, 77% were depressed (vs 48% of non-assaulted women), 65% had PTSD (vs 30%), and 60% had anxiety disorders (vs 41%). These results show very high rates of depression, anxiety, and PTSD for all women in the military, with exceedingly high rates for women who have been sexually assaulted.

Another study included 1,005 veterans who had recently given birth. These women were part of a multi-site, mixed-methods study. In this group, 32% reported military sexual trauma-rape, and 51% reported military sexual trauma-harassment[31]. Forty percent reported PTSD (the US national rate for civilian women is 10%). Women who reported

MST and PTSD were more likely to describe their birth experiences negatively, but only 15% did. Depression was not related to birth experience. The sample was 57% White and 43% women of color.

Fifty-nine percent reported military sexual trauma, 36% reported combat exposure, and 55% reported at least one violent childhood trauma in another study of 911 women who reported on 1,752 unique pregnancies[25]. Fifty-two percent of the women identified as a racial/ethnic minority. During at least one pregnancy since entering the military, 29% reported a preterm birth (the US national average is 11%), 9% had a baby with low birth weight, and 45% had postpartum depression or anxiety. Military sexual trauma increased the risk of lower infant birth weight and postpartum depression, but only slightly increased the risk for preterm birth. For every one-unit increase on the sexual harassment scale, birth weight decreased by 17 g, odds of full-term birth dropped by 9%, and the effect was observed after controlling for age at pregnancy, race/ethnicity, childhood trauma, and combat exposure. Combat exposure did not increase the risk of negative birth outcomes. Nor did warfare exposure or race or ethnicity.

In a sample of 697 pregnant US veterans, military sexual trauma negatively affected mother-infant bonding[32]. Fifty-two percent reported harassment and 30% reported abuse or rape. Twenty-eight percent of women who experienced military sexual trauma were depressed. Military sexual trauma increased the risk of depression, which was related to poorer mother-infant bonding.

When women experience multiple types of violence

We can conclude from these studies that violence is common and pervasive for many military mothers. Several studies cited above noted considerable overlap between ACEs, partner violence, and military sexual trauma. This raises two important questions: Why are abuse survivors at higher risk for revictimization? And what is the cumulative effect of these traumas? Based on the literature we have so far, we cannot answer these questions for women in the military.

Previous studies with civilians suggest that when women experience child abuse and partner violence, they have more severe symptoms. A review of 43 studies found that civilian women abused as children or adults had more lifetime depression, and more depression during pregnancy and postpartum than non-abused women[33]. If women experienced abuse as both children and adults, their depression was more severe and lasted longer compared to women who experienced one type.

Another study included 239 low-income pregnant women who were part of a nurse home-visitation program following recent partner violence[34]. Forty-three percent reported physical, sexual, and psychological abuse within the past year, and 40% had PTSD. Looking at these data, it is reasonable to assume that multiple violent traumas would increase women’s PTSD. However, 65% of participants said that it was not partner violence, but other events that caused their symptoms. Interestingly, age was the strongest predictor of PTSD; 80% of women 30 or older had PTSD.

A military study also considered the overlap between partner violence and military sexual trauma. A study of 442 women who experienced partner violence (IPV women) had higher rates of MST-harassment than non-IPV women. But rates were high for both groups. Fifty percent of the non-IPV group experienced MST-harassment vs 65% of the IPV group. A similar pattern was observed for MST-rape: 29% for the non-IPV group vs 44% for the IPV group—shockingly high for both groups. Ninety-two percent had been deployed to the Gulf and 85% had a service-related disability (health conditions linked to their military service)[20].

Childhood abuse increases women’s vulnerability to the negative effects of military sexual trauma. A recent study included 268 treatment-seeking veterans (male and female)[21]. All had experienced MST, child sexual trauma, or both. Controlling for

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