اثرات خشونت خانگی بر رشد و تغذیه کودک: بررسی مفهومی روش های تاثیر

Domestic violence against women is a global problem, and young children are disproportionate witnesses. Children’s exposure to domestic violence (CEDV) predicts poorer health and development, but its effects on nutrition and growth are understudied. We propose a conceptual framework for the pathways by which domestic violence against mothers may impair child growth and nutrition, prenatally and during the first 36 months of life. We synthesize literatures from multiple disciplines and critically review the evidence for each pathway. Our review exposes gaps in knowledge and opportunities for research. The framework also identifies interim strategies to mitigate the effects of CEDV on child growth and nutrition. Given the global burden of child malnutrition and its long-term effects on human-capital formation, improving child growth and nutrition may be another reason to prevent domestic violence and its cascading after-effects.

Domestic violence against women is a global problem. In North America and Europe, as well as Africa, Asia, Latin America, and the Middle East, 11%–71% of women have reported prior physical domestic violence (ICF Macro, 2010, Johnson et al., 2008 and Tjaden and Thoennes, 1998), and sexual and psychological forms often co-occur (Kishor & Johnson, 2004). Domestic violence against women is more likely in early marriage and pregnancy (Kishor & Johnson, 2004), and young children, who rely on their mothers as primary caretakers, are likely to be exposed. Global estimates of children’s exposure to domestic violence (CEDV) are lacking; however, some 15.5 million American children are exposed annually (McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006), and those under five years are disproportionate witnesses (Fantuzzo, Boruch, Beriama, Atkins, & Marcus, 1997). CEDV predicts poorer health and development in early childhood (Bair-Merritt et al., 2006, Kitzmann et al., 2003 and Wolfe et al., 2003), but its effects on nutrition and growth prenatally and through the toddler years (to 36 months) are understudied. This gap is surprising, given the global burden and consequences of malnutrition in these periods (Bhutta et al., 2008, Black et al., 2008 and Underwood, 2001). In poor countries, about 112 million children less than 5 years are underweight (weight-for-age z-score or waz <-2 SD from reference median), 178 million are stunted (height-for-age z-score or haz <-2 SD from reference median), and levels of stunting are 8%–50% ( Black et al., 2008). Vitamin-mineral deficiencies, especially of iron and zinc, are widespread and predict higher risks of child morbidity and mortality ( Black et al., 2008). Anemia, a low blood-hemoglobin [Hb] concentration often resulting from iron deficiency, affects roughly two billion people globally and especially pregnant women (∼50%) and young children (∼48% in 0–2 year-olds and 25% in 3–5 year-olds) ( Allen & Casterline-Sabel, 2001). Malnutrition prenatally and the first years of life has adverse effects across the life course, including low birth weight (LBW), infant morbidity and mortality, impaired early childhood growth and development, and various human-capital outcomes into adulthood ( Martorell, 1995, Martorell, 1997 and Ramakrishnan, 2001). Despite what is known separately about domestic violence and early malnutrition, their inter-relationships are understudied. We propose an evidence-based conceptual framework of the pathways by which CEDV may impair growth and nutrition prenatally through the toddler years. Our conceptual review integrates literatures from multiple disciplines, providing a synthesis of theory and research. We critically review the evidence for each pathway, identifying gaps in knowledge and opportunities for research. The framework helps to identify interim strategies, short of eliminating domestic violence, to mitigate the effects of CEDV on child growth and nutrition during these critical periods for subsequent human-capital formation. The rest of the paper is organized as follows. We first describe definitions of domestic violence and children’s exposure to it. We then discuss prior research on the effects of CEDV, noting its focus on developmental outcomes in school-aged children in North America (and its oversight of nutritional outcomes among younger children in poor regions). To motivate further our path framework, we review (limited) research in children generally under six years of the total effects of CEDV on growth and nutrition. We then describe our conceptual framework and review evidence for each pathway linking CEDV to poorer growth and nutrition in the prenatal, infant (0–11 months), and toddler (1–3 years) periods. We conclude with discussions of the findings, gaps in knowledge, and opportunities for research and intervention.

In sum, domestic violence against women is a global problem, as is malnutrition especially in pregnant women and young children. Because young children rely heavily on maternal care, their exposure to domestic violence is disproportionate among children. Such exposures have adverse effects on children’s development (see review above); yet, less is known about how such exposures affect growth and nutrition prenatally and during the first three years of life (Bair-Merritt et al., 2006), critical periods for subsequent human-capital formation. Even less is known about the pathways by which CEDV affects nutrition and growth during these periods. Our conceptual review exposes several drawbacks of prior studies. One drawback is the inconsistent measurement of domestic violence (Ellsberg, Heise, Pena, Agurto, & Winkvist, 2001), which stems from using diverse instruments (e.g., Revised Conflict Tactics Scale and the Abuse Assessment Screen) and variables (e.g., any versus only physical domestic violence). A related drawback is the infrequent direct measurement of children’s exposure, requiring assumptions about exposure based on the child’s age (Holden, 2003 and Edleson et al., 2007). Consequently, estimates of CEDV for the U.S. (McDonald et al., 2006) may be inaccurate, and estimates are lacking for poorer countries. A second drawback is the field’s over-reliance on small, purposive samples in the U.S. This geographic bias pervaded the studies reviewed, but was largest for studies of the effects of domestic violence on children’s stress-response (Table 2), prenatal and delivery care (Table 5), pregnancy outcome (Table 6), and infant and toddler care (Table 7). Geographic gaps in research were most apparent for African countries, which appeared in 0–2 studies for each outcome reviewed (Table 1, Table 2, Table 3, Table 4, Table 5, Table 6 and Table 7). This gap contradicts the burden of domestic violence (Hindin et al., 2008) and child malnutrition (Kothari & Abderrahim, 2010) in African countries. Fortunately, the national Demographic and Health Surveys (DHS) have collected data concurrently on child anthropometry and domestic violence in over 30 poorer countries, including in Africa. Such data expand opportunities to explore the influences of domestic violence on young child growth in nationally representative mother-child samples in such settings. A third drawback of research on CEDV is its uneven consideration of older and younger children and outcomes among younger children. The field has focused on older or mixed age groups of children (Table 1, Table 2 and Table 7), when the effects of CEDV may differ by age (Holden, 2003). Also, of the potential outcomes of CEDV in early childhood, some (e.g., pregnancy outcomes, Table 6) have received more attention than others (e.g., breastfeeding, Table 7). Finally, recent process models of the effects of CEDV have tended to explore only selected pathways of effect. These gaps in research complicate a comparative assessment of the pathways by which CEDV may affect growth and nutrition prenatally and through the toddler years. Despite these drawbacks, the findings from this conceptual review suggest that domestic violence may affect early childhood growth and nutrition through biological and behavioral pathways. The best (albeit geographically limited) evidence concerns the effects of prenatal domestic violence on LBW (Table 6), which strongly predicts subsequent growth. Also evident (in selected settings) is that maternal prenatal risk behaviors, mental impairments, and poor weight gain likely mediate the relationship between domestic violence and LBW. These findings and gaps in knowledge motivate several recommendations for research. First, efforts are needed to compute global estimates of CEDV from national surveys that provide data on birth histories, domestic violence, and if available, children’s exposure. Second, meta-analyses are needed of the effects of domestic violence on some of the better-studied intervening outcomes in early childhood, such as morbidity and immunization coverage. Third, existing cross-sectional data should be analyzed to address geographic and substantive gaps in research. DHS data on women and children could be matched to construct retrospective cohorts in multiple countries, including understudied countries in Africa. Although the DHS lack some potential mediators (maternal mental health) and confounders (co-occurring child maltreatment), partial path models could be estimated. Ultimately, large, population-based intergenerational studies of diverse populations are needed to assess fully the pathways by which domestic violence affects the nutrition and growth of children prenatally and through the toddler years. An ideal study design would be a multicountry prospective follow-up of pregnant women and their newborns, in which comparable data were collected on: various forms of domestic violence and its timing, direct questions on CEDV, intervening variables, confounders, and trajectories of child nutrition and growth prenatally through age three years. Our framework and recommendations for research expand scholarship on CEDV in several ways. First, we extend the focus of prior studies from developmental outcomes to nutrition and growth. Second, our focus on early childhood stresses the importance of malnutrition in this period for survival and functional outcomes into adulthood. Third, we provide the conceptual basis to explore the biological and behavioral pathways by which CEDV may affect nutrition and growth, as well as health and development, in young children. Fourth, our model stresses the needs for interdisciplinary research to capture fully the effects of CEDV in early life. Finally, we provide a general conceptual tool to assess whether domestic violence has common direct or indirect effects on early child growth and nutrition across countries and diverse subgroups in the U.S. Such research may further justify the global need to monitor and mitigate domestic violence against women. Existing systems that monitor childhood nutrition (De Onis and Blossner, 2003 and Polhamus et al., 2004) may identify children at risk of exposure to domestic violence. New systems also may be developed to monitor directly domestic violence against pregnant women and mothers. Health services for these groups may incorporate screening and treatment for domestic violence to mitigate its effects on maternal risk behaviors, mental impairments, and nutritional conditions predicting poor pregnancy outcomes. This agenda for research and monitoring should inform the efforts underway in U.S. governmental agencies, NGOs, and foundations to reduce the prevalence of domestic violence and to improve children’s nutrition and growth globally.