Impacts of domestic violence on child growth and nutrition: A conceptual review of the pathways of influence Kathryn M. Yount a, * , Ann M. DiGirolamo b , Usha Ramakrishnan a a Hubert Department of Global Health, Department of Sociology, Emory University,1518 Clifton Rd. NE, Room 7029, Atlanta, GA 30322, United States b Care U.S.A., United States article info Article history: Available online 12 April 2011 Keywords: Domestic violence Early childhood growth Early childhood malnutrition Review abstract 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. Ó 2011 Elsevier Ltd. All rights reserved. Introduction 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%e71% of women have reported prior physical domestic violence (ICF Macro, 2010; Johnson et al., 2008; Tjaden & 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 dispro- portionate witnesses (Fantuzzo, Boruch, Beriama, Atkins, & Marcus, 1997). CEDV predicts poorer health and development in early childhood (Bair-Merritt, Blackstone, & Feudtner, 2006; Kitzmann, Gaylord, Holt, & Kenney, 2003; Wolfe, Crooks, McIntyre-Smith, & Jaffe, 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; 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%e50% (Black et al., 2008). Vitamin-mineral deficiencies, espe- cially 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 espe- cially pregnant women (w50%) and young children (w48% in 0e2 year-olds and 25% in 3e5 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, 1997; 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. * Corresponding author. Tel.: þ1 404 727 8511; fax: þ1 404 727 4590. E-mail address: kyount@sph.emory.edu (K.M. Yount). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2011.02.042 Social Science & Medicine 72 (2011) 1534e1554