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RESEARCH ARTICLE
Adverse childhood experiences and maternal self-efficacy:
Examining the mediating role of intimate partner violence
and the moderating role of caste membership in rural India
Zishan Jiwani1,4Grace Drylewski1Shipra Sharma2Marilyn Ahun3
Shobhali Thapa1Miriam Steele1
Department of psychology, New School
for Social Research, New York City, New
Yor k, U SA
Aga Khan Foundation, New Delhi, India
University of Montreal, Montreal,
Quebec, Canada
University of Wisconsin-Madison,
Madison, Wisconsin, USA
Correspondence
Zishan Jiwani, Department of Counseling
Psychology, University of
Wisconsin-Madison, Education
Building, Bascom Mall, Madison,
Wisconsin , United States
Email: zjiwani@wisc.edu
Abstract
Maternal self-efficacy (MSE) is associated with healthy functioning in moth-
ers and children globally. Maternal exposure to adverse childhood experiences
(ACEs) and intimate partner violence (IPV) is known to negatively impact MSE
in high-income countries; however, the association has not been examined in
low-and-middle-income countries, such as India, which face socioeconomic
risks including poverty, illiteracy, and discrimination based on caste member-
ship. The present study examines the mediating role of IPV in the association
between ACEs (specifically—emotional, physical, and sexual abuse, neglect,
household dysfunction, and discrimination) and MSE and tests caste member-
ship as a moderator. A community-based, cross-sectional survey was performed
with mothers with at least one child between and months in a rural
area in the North Indian state of Uttar Pradesh. A structural equation framework
was used to test the moderated-mediation model. Results from the moderated-
mediation model indicate that greater ACEs exposure was associated with lower
MSE and this association was mediated by IPV exposure for low-caste but not
high-caste mothers, even after controlling for wealth and literacy. These find-
ings add to existing evidence on ACEs exposure as a significant burden for rural
Indian mothers, negatively impacting parenting outcomes such as MSE. The
critical role of caste membership is also highlighted, providing implications for
future research.
KEYWORDS
adverse childhood experiences, caste system, intimate partner violence, maternal self-efficacy
1 INTRODUCTION
With more than million people living in extreme
poverty, India is at particular risk of having a large cohort
of children unable to reach their development potential
and failing to meet the UN Sustainable Development
Goals (SDGs; Black et al., ). Poor children and their
mothers face many adversities, including adverse child-
hood experiences (ACEs), intimate partner violence (IPV),
and socioeconomic and cultural risks such as discrimi-
nation based on their caste membership—all of which
can negatively impact child development and parenting
abilities (Baru et al., ; Black et al., ; Caldwell et al.,
; Jaffe et al., ; Springer et al., ). Parenting is a
546 © Michigan Association for Infant Mental Health. Infant Ment Health J. ;:–.wileyonlinelibrary.com/journal/imhj
JIWANI . 547
multifaceted skill involving responsive and sensitive care
that is attuned to the child’s signals and needs. Parenting
abilities are influenced by an individual’s own experience
of being parented, as well as their exposure to trauma
(Brazeau et al., ; Caldwell et al., ; Leerkes &
Crockenberg, ).
Maternal self-efficacy (MSE) is the conceptualization of
a mother’s self-estimation of her competency to parent and
this self-estimation influences the quality of care she is
able to provide her child (Teti & Gelfand, ). Several
studies have examined the risk and protective factors of
MSE as well as its impact on maternal and child outcomes
(Albanese et al., ). For example, prior research shows
that higher levels of MSE are linked to decreased psycho-
logical distress, greater parenting satisfaction, and more
sensitive and responsive caregiving, while lower levels of
MSE are correlated with increased risk of mental health
difficulties in mothers (Albanese et al., ; Azmoude
et al., ; Coleman & Karraker, ). High levels of MSE
have also been identified as protective against develop-
mental delays for children in at-risk family environments
(McDonald et al., ). Moreover, prior research con-
ducted in the United States and Australia has found
that mothers’ experiences of early childhood trauma and
later exposure to IPV are negatively associated with MSE
(Brazeau et al., ; Kohlhoff & Barnett, ).
While these findings are significant, the majority of this
research has been conducted in high-income countries,
and little is known on the associations of MSE and mater-
nal and child factors in low-and-middle-income countries
(Albanese et al., ;Fangetal.,). Additionally, stud-
ies have found that context-specific factors impact MSE,
underscoring the importance of examining the construct
across various settings and populations (Fang et al., ;
O’Neil et al., ). To address the aforementioned gap,
this paper examines the interplay between experiences of
ACEs (specifically—emotional, physical and sexual abuse,
neglect, household dysfunction, and discrimination), IPV,
and MSE in a population of low-income women from
rural India, in addition to the moderating role of caste
membership.
1.1 Literature review
A mother’s sense of self-efficacy describes the degree to
which she feels able to parent effectively. While MSE is not
a measure of parenting behavior, mothers with higher lev-
els of self-efficacy may interact more sensitively with their
babies, are more accurate at reading their infant’s cues, and
feel they have the requisite tools to comfort, soothe, and
nurture their children (Albanese et al., ; Wells-Parker
et al., ). According to Bandura’s (/) theory of
STATEMENT OF RELEVANCE
A large cohort of infants is at risk of not meet-
ing their developmental potential and a signifi-
cant effort is underway to invest in early child-
hood development, especially in low- and middle-
income countries. Most of these efforts have
focused on factors such as health, nutrition, and
responsive caregiving. This study demonstrates
that maternal exposure to trauma and violence
throughout the lifespan is an important consider-
ation as it can negatively impact parenting capac-
ities such as maternal self-efficacy. Additionally,
this study underlines the important role of social
constructs such as caste, which must be exam-
ined when designing and delivering interventions
in low-income contexts in India where mothers
and children on the margins of society are at a
disproportionate risk for familial violence.
self-efficacy, individuals with low levels of self-efficacy are
more likely to doubt their abilities, quicker to abandon
activities in which they feel unsuccessful, and slower to
recover from perceived setbacks. As such, mothers with
low levels of MSE, those who believe they lack the ability
to read their baby’s cues or adequately comfort their baby,
are more likely to give up if their initial attempts are inef-
fective; consequently, reinforcing a negative self-schema
regarding their efficacy as a mother (Teti & Gelfand, ).
Early experiences with parental figures provide the
foundation for a mother’s ability to parent as well as
her sense of self-efficacy (Brazeau et al., ; Leerkes &
Crockenberg, ). It has been found that women who
perceived their own caregivers to be sensitive and respon-
sive were more likely to display higher levels of MSE,
and conversely, women who experienced interpersonal
trauma during childhood showed an increased risk for low
MSE (Brazeau et al., ; Caldwell et al., ; Leerkes &
Crockenberg, ). Therefore, mothers who experienced
early trauma might have internalized representations of
parental figures as being unreliable or insensitive, thus
negatively impacting their ability to provide their chil-
dren with sensitive and responsive care (Lieberman, ;
Lyons-Ruth & Block, ;Mainetal.,).
In prior studies, early trauma—specifically ACEs
(including physical, emotional, and sexual abuse and
neglect)—has been found to negatively impact MSE
(Brazeau et al., ; Caldwell et al., ). ACEs have
been studied extensively around the world and are asso-
ciated with a host of negative physical and mental health
548 JIWANI .
difficulties including, but not limited to, chronic medical
conditions, psychiatric diagnoses, and poor social devel-
opment (Felitti et al., ; Kerker et al., ; Shonkoff
et al., ; Springer et al., ). Prolonged exposure to
ACEs has also been linked to changes in brain structure
and function, as well as biological impairments impacting
the body’s response to stress, resulting in cognitive impair-
ments and difficulty regulating emotion (Anda et al., ;
De Bellis & Abigail Zisk, ). Caldwell et al. () found
that childhood maltreatment indirectly predicted lower
parental self-efficacy, whereby maltreatment led to inse-
curity in close relationships—thus decreasing self-esteem
and later perceptions of parenting competence. These
findings support the hypothesis that ACEs influence the
development of a sense of self and self-esteem and later
generalize to perceptions of MSE (Leerkes & Crockenberg,
).
Though it has been examined less in India, ACEs have
been found to be associated with poor overall wellbeing,
higher risk of suicide and suicidal ideation, poor cogni-
tive development, lower self-esteem, and lower feelings of
security among various populations, (Damodaran & Paul,
; Escueta et al., ;Sahaetal.,; Santoro et al.,
; Singh et al., ). In addition to negatively impact-
ing one’s self-perceptions, ACEs may also negatively affect
decision making, reactivity to stress, and mental health,
all of which have the potential to negatively influence
parenting behaviors, parent-child interactions, and MSE
(Brazeau et al., ; Caldwell et al., ;Lyons-Ruth&
Block, ).
Research examining the long-term impact of ACEs has
found that, in addition to higher rates of mental and phys-
ical difficulties, those exposed to trauma in childhood
are more likely to experience IPV in adulthood (Felitti
et al., ; Springer et al., ; Stake et al., ). IPV
encompasses physical, sexual, and psychological abuse by
a current or former partner or spouse and disproportion-
ately affects women (World Health Organization, ).
Globally, women have an increased risk of IPV if they
have received fewer years of formal education, have been
exposed to ACEs (particularly if one’s mother was abused
by her partner), and if they live in an environment with
high levels of gender inequality and female subjugation
(Stake et al., ;WHO,). India has a high preva-
lence of IPV, with %−% of women reporting physical
and/or sexual IPV in their lifetime (Ahuja et al., ;
Bhattacharya et al., ; George et al., ). For Indian
women, IPV is also related to poorer socioeconomic sta-
tus and membership in low-caste communities (Dalal &
Lindqvist, ). Prior studies have found that exposure to
IPV is a significant stressor for parenting, and has been
linked to lower levels of MSE, poor dyadic functioning,
lower levels of maternal mental health, and poor child
health (Brazeau et al., ; Gou et al., ; Kan et al., ;
McMahon et al., ). Given the higher risk of IPV for
mothers exposed to a greater number of ACEs and the neg-
ative association between IPV and MSE, it is possible that
IPV might explain at least some of the association between
MSE and ACEs in certain contexts.
1.2 Caste as a moderator
The caste system in India is considered to be a critical
determinant of inequity across the lifespan and thus, may
potentially moderate the associations between ACEs, IPV,
and MSE, particularly in rural India (Baru et al., ;
Bhagavatheeswaran et al., ; Dabir & Nigudkar, ;
Dalal & Lindqvist, ; Leach & Sitaram, ). For exam-
ple, prior research has found that people who are part of
communities that are deemed to be low-caste tend to have
worse socioeconomic outcomes and fewer opportunities
for socioeconomic advancement (Baru et al., ;Desai&
Dubey, ). Considered to be the world’s oldest surviving
hierarchical social structure, the caste system is a complex
social construct that involves the classification of individ-
uals on the basis of family of origin (Human Rights Watch
[HRW], ). It has been suggested that the caste system
was not as rigid in its early history as it is in the current
day, but group differences were magnified and sharp-
ened during the British colonial rule of India (Sharma,
). Following independence, the Indian government
developed a classification system with four groups: Sched-
uled Castes,Scheduled Tribes,Other Backward Classes,and
General Caste, with the former three being considered
low-caste and the latter being considered high-caste (Baru
et al., ; Dalal & Lindqvist, ). Despite the legal pro-
hibition of discrimination based on caste, social norms,
particularly in rural regions, lead to complete segregation
and ostracization of low-caste populations (HRW, ).
There are several reasons to expect that mothers in high
versus low-caste groups may diverge in their experience
of ACEs, IPV, and MSE. In addition to poorer health
and social outcomes, studies have found that women in
low-caste communities are at greater risk of experiencing
IPV and are more likely to have experienced ACEs such as
child abuse, sexual violence, indigence, and discrimina-
tion (Bhagavatheeswaran et al., ; Dabir & Nigudkar,
; Dalal & Lindqvist, ; Leach & Sitaram, ).
Furthermore, at least one study has found that higher
levels of perceived caste discrimination are associated
with lower levels of self-determination. Specifically, these
individuals feel less in control of their lives and future than
those with lower levels of perceived caste discrimination
(Agarwal & Priyanka, ). Given the impoverished social
location of being low-caste, a status that is culturally and
JIWANI . 549
institutionally reinforced, it is possible that these mothers
may also feel less efficacious in their capacity to care for
their children and help them flourish.
The current study examines the impact of ACEs on MSE
in rural India. We hypothesize that increased exposure to
ACEs will be associated with lower levels of MSE. This
study also examines the potential mediating role of IPV
in this association. We hypothesize that greater exposure
to ACEs may increase the risk of IPV and that higher lev-
els of IPV will be negatively associated with MSE. Finally,
we anticipate that caste will moderate the associations
between ACEs, IPV, and MSE.
2METHODS
2.1 Procedure
Mothers were recruited in-person through community
centers and schools as well as over the phone using a snow-
ball sampling method. Participants were interviewed in
their homes by enumerators from the locally-situated Aga
Khan Foundation who partnered with the first author’s
institution on this study. Given the sensitive nature of the
questionnaire, enumerators were instructed to find a quiet
and private space to conduct interviews. If a suitable place
was not found, the enumerators were instructed to sched-
ule a different time for the interview. All questionnaires
were administered in Hindi. To ensure fidelity of the items,
an adaptation protocol was followed whereby items were
translated into Hindi and back-translated into English by
independent translators (Cha et al., ). Additionally,
questionnaires were reviewed by (blinded) Foundation’s
local team to ensure that items were linguistically accu-
rate and culturally relevant, and a pilot was conducted
with mothers before the commencement of data collection.
Data were collected between September and November
and informed consent was collected orally from
all participants. All procedures and questionnaires were
approved by The New School Institutional Review Board.
2.2 Participants
Three hundred and sixteen mothers between the ages of
and years (M=., SD =.) with at least one
child between and months in Bahraich District in
the northern Indian state of Uttar Pradesh participated
in the survey. Infant age ranged from to months
(M=., SD =.). A significant portion of the sample
(.%, n=) reported being unable to read or write.
All of the women were married. In terms of caste affilia-
tion, the largest group of women belonged to the General
caste (.%, n=), .% identified as Other Backward
Castes (n=), .% as Scheduled Caste (n=), and
.% as Scheduled Tribes (n=). According to the gov-
ernment of India definitions, Scheduled Caste,Scheduled
Tribe,andOther Backward Caste are considered marginal-
ized or low-caste and provided affirmative action benefits,
whereas general caste designation indicates high-caste
(Dalal & Lindqvist, ). Wealth (Krishnan, ;Kumar
et al., ; Mahapatro et al., ), education (Mahapatro
et al., ), and child’s sex (Aliabadi et al., ; Mahap-
atro et al., ) were identified as covariates on the basis
of prior associations with the exposure (ACEs), mediator
(IPV), and outcome (MSE) variables.
2.3 Measures
.. Adverse childhood experiences
ACEs were assessed using a translated version of the -
item questionnaire developed by Felitti et al. (). The
questions assessed the prevalence of emotional abuse (e.g.,
“Did a parent or other adult in the household often swear
at you, insult you, put you down, or humiliate you?”),
physical abuse (e.g., “Did a parent or other adult in the
household often push, grab, slap, or throw something at
you?”), sexual abuse (e.g., “Did an adult or person at least
years older than you ever touch or fondle you or have
you touch their body in a sexual way?”), neglect (e.g., “Did
you often feel that you didn’t have enough to eat, had to
wear dirty clothes, and had no one to protect you?”), and
household dysfunction (“Were your parents ever separated
or divorced?”) before the age of . An additional question
was added based on consultations with the local research
team regarding childhood experiences of discrimination
(“Did you ever feel put down by your parents or other
family members because of your gender or caste?”). Par-
ticipants responded yes or no to each question. A score of
was administered for each positive response by the partic-
ipant and added up. Scores ranged from to , and higher
scores indicated a higher number of ACEs (Cronbach’s
alpha [α]=.).
.. Intimate partner violence
IPV was assessed using seven items related to experiences
of victimization from the Conflict Tactics Scale- Short
Form (Straus & Douglas, ). The questions assessed
experiences of physical, sexual, and emotional violence in
intimate partner relationships, including emotional abuse
(e.g., “My partner insulted or swore or shouted or yelled
at me”), physical assault (e.g., “My partner punched or
550 JIWANI .
kicked or beat-me-up”), physical injury (e.g., “I had a
sprain, bruise, or small cut, or felt pain the next day
because of a fight with my partner”), and sexual coercion
(e.g., “My partner used force, like hitting, holding down, or
using a weapon, to make me have sex”). Participants indi-
cated if they had ever experienced any of these incidents
in their lifetime. A score of was assigned if a partici-
pant reported one or more lifetime occurrences for each
item. Scores ranged from to , and higher scores indicated
greater exposure to varying types of IPV (α=.).
.. Maternal self-efficacy
MSE was assessed using a maternal self-efficacy scale (Teti
&Gelfand,). The -item scale assesses mothers’ level
of confidence in being able to care for their child (e.g.,
“When your baby is upset, fussy or crying, how good are
you in soothing him or her?”). Items were rated on a
four-point scale ( “Not good at all” to “Very Good”). Pos-
sible scores ranged from to and were tabulated by
summing the responses to each item, with higher scores
indicating greater MSE (α=.).
.. Demographic information
This section included questions on age, caste affiliation,
literacy, marital status, number of children, number of
children under the age of months, and age and sex of
the child/children under months. Given the difficulty
of calculating income in rural India, a wealth index was
calculated using the house type (pucca—permanent struc-
ture, semi-pucca—semi-permanent structure, or kutcha—
impermanent home—typically made from mud and/or
sticks) and the number of rooms in the home. Physical
characteristics of a home have been used as a stand-in for
wealth by the Indian government (Census of India,)as
well as researchers (Kattula et al., ).
2.4 Data analysis
Analyses were conducted in Jamovi (The jamovi project,
) and Mplus (Muthén & Muthén, –). Struc-
tural equation modeling was used to assess the direct and
indirect effects (via IPV) of ACEs on MSE while adjust-
ing for the selected covariates. A significant indirect effect
was determined if the product of the coefficient of the
pathway from exposure (ACEs) to the mediator (IPV), and
the coefficient of the pathway from the mediator (IPV) to
the outcome (MSE), was significant (MacKinnon et al.,
). We tested the moderating role of caste in these mod-
els by comparing the fit of a freely estimated model (i.e.,
all estimated parameters allowed to freely vary between
high and low-caste) with the fit of a model in which all
estimated parameters were constrained to be equal across
caste groups (Kline, ) Additionally, % bias-corrected
bootstrap confidence intervals (CIs) were estimated based
on random samples (Preacher & Hayes, ).
3RESULTS
3.1 Preliminary analysis
Descriptive information about the mothers and children
arereportedinTable. Variables met assumptions of nor-
mality based on skewness and kurtosis cutoffs between
−and+ (George & Mallery, ). Mothers reported an
average of . (SD =.) ACEs. The most common ACE
reported was emotional abuse (n=, .%), followed
by physical abuse (n=, %), and witnessing IPV in the
home (n=, .%). In terms of exposure to IPV, moth-
ers most commonly reported physical assault (n=,
.%), followed by emotional abuse (n=, .%), threat
of violence or property destruction (n=, .%), and
sexual coercion (n=, .%). T-tests and Pearson’s r
correlations were conducted to understand the association
of exposure (ACEs), mediator (IPV), and outcome (MSE)
variables with covariates. No significant differences were
found across the variables with respect to illiteracy but
mothers with a male infant between the ages of and
months reported higher levels of IPV relative to those
with a female infant (Mdiff =-. CI [−., −.], t
() =−., p=.). We found no correlation between
wealth and ACEs, IPV or MSE, but it was included, given
that it was found to be correlated in prior studies (Table ).
We also found that mothers in low-caste communities had
a higher number of ACEs (Mdiff =-. CI [−., −.],
t() =−., p=.), greater exposure to IPV (Mdiff =-
. CI [−., −.], t() =−., p=.), and lower
levels of MSE (Mdiff =., CI [., .], t() =.,
p=.) relative to mothers in high-caste communities.
To assess the robustness of these results, we ran a multi-
ple regression model and found that the effect of caste on
ACEs, MSE, and IPV was significant even when control-
ling for wealth and literacy. Descriptive information for the
entire sample and by caste type is reported in Table .
3.2 Primary analysis
Results from an ordinary least squares regression model
(see Table ), indicated that more exposure to adversi-
ties in childhood was associated with lower levels of MSE
JIWANI . 551
TABLE 1 Descriptive frequencies
Sample (N=316) High-caste (n=123) Low-caste (n=193)
Mean SD Mean SD Mean SD
ACEs . . . . . .
IPV . . . . . .
MSE . . . . . .
Mother age (in years) . . . . . .
Wealth index . . . . . .
Literacy (.%) (.%) (%)
Child sex (male) (.%) (.%) (.%)
Child age (in months) . . . . . .
TABLE 2 Correlations between continuous variables in the model
Correlation matrix
MSE ACEs IPV
Participant
age
Wea lth
index
Number of
children
MSE Pearson’s r—
ACEs Pearson’s r−.*** —
IPV Pearson’s r−.*** .*** —
Participant age Pearson’s r−.** −. . —
Wealth index Pearson’s r. . −. −. —
Number of children Pearson’s r−.*. . .*** . —
Note:*p<., **p<., *** p<..
TABLE 3 Results from moderation analysis predicting MSE from ACEs across high and low caste groups
Full sample High caste Low caste
Estimate 95% CI pEstimate 95% CI pEstimate 95% CI p
Intercept . [., .] <. . [., .] <. . [., .] <.
ACEs −. [−., −.] <. −. [−., −.] . −. [−., .] .
Wealth . [−., .] . . [−., .] . −. [−., .] .
Literacy . [−., .] . . [−., .] . . [−.,.] .
Male gender . [−., .] . . [−., .] . . [−., .] .
Adj R-squared . . .
(b=-., % CI [−., −.], p<.). Caste mem-
bership moderated this association, whereby ACEs were
significantly associated with MSE for mothers in high-
caste communities (B=-., % CI [−., −.], p=.)
but non-significantly among mothers considered to be
low-caste (B=-., % CI [−., .], p=.).
.. Results from unadjusted model
Unadjusted mediated models were assessed for both rela-
tive and absolute model fit (Hu & Bentler, ). The model
fit the data well, with comparative fit index (CFI) =.,
Tucker–Lewis index (TLI) =., and root mean square
error of approximation (RMSEA) =.. In unadjusted
mediation models, exposure to ACEs was significantly
positively associated with IPV among women in both high-
caste (b=., % CI [., .], p<.) and low-caste
(b=., % CI [., .], p<.) communities. A sig-
nificant negative association was found between IPV and
MSE among low-caste mothers (b=−., % CI [−.,
−.], p=.) but not high-caste mothers (b=−., %
CI [−., .], p=.). When IPV was introduced as
a mediator into the model, the direct association between
ACEs and MSE was no longer significant in high-caste or
low-caste mothers.
552 JIWANI .
FIGURE 1 (a,b) Final model adjusted for covariates
.. Results from model adjusted for
covariates
Figure a and b shows the results when adjusted for
covariates. Model fit was less robust relative to the unad-
justed model, but still acceptable (CFI =., TLI =.
and RMSEA =.). A significant indirect association
was found between ACEs and MSE via IPV, such that
greater exposure to ACEs was associated with higher lev-
els of IPV, which were subsequently associated with lower
MSE among low-caste mothers (b=−., % CI [−.,
−.], p=.). No significant indirect effect of ACEs
on MSE was found among high-caste mothers (b=−.,
% CI [−., .], p=.). However, among high-caste
mothers, there was a significant total effect of ACEs on
MSE (b=-., % CI [−., −.], p<.), such that
higher ACEs accounted for lower MSE.
4DISCUSSION
This is the first study to examine the association between
ACEs and MSE in a rural Indian context. Given the estab-
lished association of MSE with mother-child interactions,
maternal wellbeing, and child development, this study
sought to understand how factors such as ACEs and IPV
may be associated with MSE in an understudied popu-
lation (Albanese et al., ;Fangetal.,). In line
with our hypothesis, exposure to ACEs was associated with
lower levels of MSE. Furthermore, we found that IPV fully
mediated this association but only for low-caste mothers.
Specifically, we found that while there was a significant
positive association between ACEs and IPV in both high
and low-caste mothers, IPV was only associated with MSE
in low-caste communities.
4.1 Association between ACEs and MSE
In line with Brazeau et al. () and Kohlhoff and Barnett
(), exposure to ACEs was associated with lower levels
of MSE. This finding adds to the existing literature on the
relevance of ACEs in India. Our study demonstrates that
exposure to ACEs increases a mother’s risk of experienc-
ing lower levels of MSE, thus contributing to the existing
literature on the impact of ACEs on long-term physiolog-
ical and psychological health (Damodaran & Paul, ;
Escueta et al., ;Sahaetal.,; Santoro et al., ;
Singh et al., ). Additionally, our findings shed light on
these associations in a population of rural Indian women—
an understudied group in research—as well as the role
of social factors, including caste. Notably, the negative
association between ACEs and MSE was stronger among
high-caste women, relative to women in low-caste commu-
nities, where the association only approached significance.
One possible reason for this distinction might be that
because low-caste women are more likely to face a greater
number of ongoing stressors (such as IPV), ACEs alone
explain a small proportion of the variance in MSE. On the
other hand, because high-caste women are less likely to
face stressors, the few stressors they do face may be more
strongly associated with outcomes such as MSE. However,
JIWANI . 553
further research is needed to better understand the reasons
for this difference.
4.2 IPV as a mediator
This study also highlights the mediating role of IPV in
the association between MSE and ACEs for low-caste
mothers. As expected, we found that women in low-caste
communities had significantly lower levels of MSE and
greater exposure to ACEs and IPV relative to women
in high-caste groups even when controlling for wealth
and literacy. These findings confirm prior research find-
ings that low-caste communities face a heavy burden
of discrimination across their lifespan in India (Bhaga-
vatheeswaran et al., ; Dabir & Nigudkar, ; Dalal
& Lindqvist, ; Leach & Sitaram, ). Furthermore,
this study confirms prior findings that low-caste women
are at greater risk for IPV (Dalal & Lindqvist, )and
suggests that experiences of emotional, physical, and sex-
ual violence by their partners may increase their risk of
developing insecure attitudes about their capacity to care
for their child. The findings from this study also sup-
port other research, which indicate that social context
must be considered when exploring parenting constructs
such as MSE (O’Neil et al., ; Valentino et al., ).
Overall, our findings provide a pathway to understand
how exposure to ACEs might impact MSE. However, IPV
did not mediate the association between ACE exposure
and MSE among high-caste mothers. This may be due
to the fact that high-caste women are less likely to expe-
rience IPV, and thus other accompanying factors, such
as mental health problems, may better explain the path-
way between ACE exposure and MSE (Brazeau et al.,
).
While affirming a number of findings in the existing
literature, this study also deviated from other findings in
a few important ways. First, unlike evidence from other
studies in India and other parts of the world, literacy and
wealth were not significantly associated with either MSE
or IPV in the present study (Fang et al., ; Krishnan,
; Kumar et al., ; Mahapatro et al., ). This may
be because the sample was from several villages in one
district and that the distribution of wealth or literacy was
not varied enough to capture these findings. Additionally,
Mahapatro et al. () found that having a female infant
is associated with greater IPV in a large national sam-
ple. In contrast, our findings indicate that having a male
infant between the ages of – months was associated
with greater exposure to IPV. Further research is needed
to explore the precise nature of the association between a
child’s sex and IPV.
4.3 Strengths and limitations
An important strength of the current study is the focus
on an understudied and vulnerable population. Our
research also extends previous findings from higher-
income countries by connecting ACEs and MSE, specif-
ically in rural India. However, there are a number of
limitations that must be acknowledged. First, the study
was cross-sectional. This limited our ability to establish
the direction of associations or make causal inferences. We
addressed the issue of directionality in part by asking par-
ticipants to report on the exposure (childhood), mediator
(adulthood), and outcome (present) variables in tempo-
rally different periods of their life (i.e., exposure questions
asked only about ACEs before the age of ; IPV questions
were focused on adulthood). However, the data on ACEs
and IPV were collected retrospectively, which may have led
to inaccurate recollection.
Furthermore, unlike other studies where participants
were able to respond anonymously through online sur-
veys, a large proportion of the sample was illiterate or
semi-literate, requiring the enumerators to ask difficult
questions regarding childhood trauma and IPV. We believe
this may have led to participant discomfort due to expe-
riences of loss or shame and thus may have contributed
to underreporting of ACEs and IPV. Other research stud-
ies conducted in low-and-middle-income countries have
also suggested that ACEs may have been underreported
in those studies (Fowler et al., ; Gomez et al., ).
Additionally, the enumerators reported perceiving partici-
pant discomfort with questions about prior abuse during a
debriefing session with two of the authors. Moreover, given
that many of the participants were unable to travel, the
interviews took place in participants’ homes. While every
effort was made to ensure privacy, it is possible that fear
of disclosure may have been present, potentially leading
to underreporting of ACEs and IPV. Finally, while efforts
were made to expand ACEs to ensure cultural relevance,
it is possible that some cultural considerations were not
captured by the ACEs survey.
While the current study found that IPV is a possible
mediator between ACEs and MSE among women in low-
caste communities, future research should examine this
effect longitudinally, using prospective data, to increase
confidence in the directionality of associations. Addition-
ally, this study did not identify a mediator for women in
high-caste communities, and thus further exploration is
warranted to understand the link between ACEs and MSE
in this population. Further research should also explore
the impact of MSE on important outcomes, including child
development and maternal mental health, especially in
contexts such as rural India, where there is little existing
554 JIWANI .
research on MSE. Finally, this study included women with
at least one child between the ages of and months.
Future research endeavors might consider exploring MSE
specifically in primiparous mothers, given that other stud-
ies attempting to understand factors associated with MSE
have focused on this group specifically (Azmoude et al.,
; Brazeau et al., ; Leerkes & Crockenberg, ).
4.4 Implications for infant mental
health
Given that more than million children under the age
of in developing countries are at an increased risk of
not meeting their developmental potential, a significant
effort is underway by governmental and intergovern-
mental institutions to invest in interventions aimed at
improving outcomes (Black et al., ; Chan et al., ).
These efforts have rightly focused on factors such as
nutrition, health, and responsive caregiving (Black et al.,
;Brittoetal.,; Yousafzai et al., ). Expand-
ing upon these important initiatives, the present study
highlights the importance of considering factors such as
ACEs and IPV in understanding barriers in the way of
mothers developing robust levels of maternal self-efficacy.
Parsing apart the complexities of these interrelated fac-
tors is an important step toward supporting mothers in
trusting their efficiency to care for their infants, thereby
supporting children in reaching their developmental
potential.
While interventions in South Asia and other low-
and-middle-income countries have focused on responsive
stimulation, integrated efforts to provide psychological
interventions which provide support for mothers who have
experienced physical, sexual, or emotional abuse may have
positive additive effects (Grantham-McGregor et al., ;
Steele & Steele, ; Yousafzai et al., ). Additionally,
as it is becoming more common in Western countries, it is
recommended that primary health providers in India con-
sider screening women for ACEs and IPV in the perinatal
period and provide culturally appropriate interventions to
ensure the wellbeing of mothers and children (Glowa et al.,
). Finally, this study also highlights the importance
of social context. Differences across caste and other social
group memberships should be taken into account when
developing and implementing interventions centered on
the wellbeing of mothers and children.
ACKNOWLEDGMENTS
Authors would like to acknowledge the enormous work of
the Aga Khan Foundation team including Aneeta Sahu,
Sayani Kushari, Nibedita Parida, Pratisha Singh, Sajima
Begum, Sunita Maurya, Suruchi Tiwari, Shabeena Begum,
and Arjun Sanyal without whom this research would not
have been possible. We also appreciate helpful comments
from Hannah Maté on an earlier version of the draft.
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
All procedures and questionnaires were approved by The
New School Institutional Review Board.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
DATA AVAILABILITY STATEMENT
Data available on request due to privacy/ethical restric-
tions.
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maternal self-efficacy: Examining the mediating
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