Abstract
Background:
To investigate the association between intimate partner violence during pregnancy and maternal and neonatal outcomes.Methods:
This cross-sectional study was performed on 115 pregnant women referring to an academic center. Demographic data, maternal outcomes (vaginal bleeding during pregnancy, preterm delivery, intrauterine growth restriction, placental abruption, and premature rupture of membrane), and neonatal outcomes (birthweight and Apgar score) were evaluated. Domestic violence against pregnant women was ascertained by a validated domestic violence questionnaire. Finally, the association between domestic violence and maternal and/or neonatal outcomes was investigated.Results:
The prevalence of domestic violence against pregnant women was 67.8%. Psychological violence obtained the highest prevalence (64.3%), followed by economic (34.8%), sexual (18.3%), and physical (12.2%) violence. Regression analysis showed that there was a significant association between domestic violence and preterm labor (P = 0.048, r = 0.385) and between economic violence and placental abruption (P = 0.040, r = 0.391). Also, there was a significant relationship between vaginal bleeding and sexual violence (P = 0.022). Educational level significantly and inversely correlated with economic (r = -0.21) and physical (r = -0.19) violence.Conclusions:
The results of this study indicated that intimate partner violence was commonplace during pregnancy and affected neonatal and maternal outcomes. It is suggested to implement educational programs for healthcare workers and screen all pregnant women for exposure to intimate partner violence to reduce maternal and neonatal complications.Keywords
Domestic Violence Psychological Violence Economic Violence Sexual Violence Physical Violence Maternal Outcome
1. Background
Discrimination and violence against women are universal, trans-historical, and cultural phenomena in all human societies despite differences in religious, economic, and social issues (1, 2). Domestic violence is the most common form of violence with a high likelihood of recurrence, often perpetrated by the nearest family member, which is seldom reported to the police and is associated with enormous social, psychological, and economic complications (3).
The world health organization (4) defines violence against women as any act that can physically, mentally, or sexually harm them and restrict their freedom in life. If this type of behavior occurs within the family and between the husband and wife, it can be interpreted as domestic (or intimate partner) violence (4). Intimate partner violence includes physical, sexual, psychological, and economic aspects (5).
Pregnant women are amongst the most at-risk groups for domestic violence. The incidence or intensity of violence can increase during pregnancy, and many cases of domestic violence actually begin during this period (6, 7). Shifting toward parental roles, changes in communication patterns during pregnancy, decreased sexual relations, and misconceptions about pregnancy can contribute to the incidence of domestic violence during this period (6). In Iran, the average prevalence of domestic violence against pregnant women has been reported to be 51.5% (8). Domestic violence is associated with adverse pregnancy outcomes such as miscarriage, preterm labor, low birth weight, decreased maternal and neonatal affective communication, intrauterine growth restriction, placental abruption, and perinatal mortality (9-12). Also, women who experience violence during pregnancy are less likely to breastfeed and accomplish their parental roles (13). Domestic violence may increase the rate of mortality and morbidities among mothers, as well as stillbirth and pelvic inflammatory disease (14).
2. Objectives
Due to the high prevalence of domestic violence against pregnant women, it seems necessary to further divulge this issue in Iran. Therefore, we aimed to investigate the effects and consequences of intimate partner violence on maternal and neonatal outcomes.
3. Methods
3.1. Study Setting
This cross-sectional study was conducted on 115 women admitted to the postpartum ward of a teaching hospital in 2021. Postpartum women of any age who had a normal vaginal delivery or cesarean section with a single pregnancy were included. Women with chronic mental or medical diseases (diabetes, hypertension, preeclampsia, and collagen vascular, cardiovascular, or hepatorenal diseases) and those with a history of preterm labor or cervical insufficiency were excluded. Other exclusion criteria were drug or alcohol abuse, multiple gestations, a history of trauma or falling during pregnancy, and delivery before the gestational age of 28 weeks.
3.2. Data Gathering
The participants were selected by convenience sampling. After obtaining informed consent, in the presence of a midwife, data were collected by face-to-face interviews. The interviews were conducted by a trained healthcare worker during hospital admission and in the absence of the partner. Also, complementary data were extracted from hospital records.
Demographic and obstetrical information included age, gravidity, parity, income, the occupation of women and their partners, and level of education. The level of education was categorized into three levels: Illiterate, low-educated (high school graduates), and highly-educated (those with academic degrees or university students). Maternal outcomes (vaginal bleeding during pregnancy, preterm delivery, intrauterine growth restriction, placental abruption, and premature rupture of membrane), as well as neonatal outcomes (birthweight and Apgar score), were recorded.
The Domestic Violence Questionnaire (DVQ) was used to assess domestic violence during pregnancy. This tool was already modified to match the cultural and social characteristics of Iranian people by Tabrizi et al. and consisted of 26 questions scored on a 4-point Likert scale. The first 11 items were designed to assess psychological violence; five items were related to economic violence, seven items to physical violence, and three items to sexual violence. Each question had five options (i.e., never, rarely, somewhat, commonly, and always with scores ranging from zero to 4, respectively). The minimum possible score was 60, and the maximum score was 300. A score between 0 and 60 indicated low domestic violence; a score between 60 and 120 reflected moderate domestic violence and a score above 120 was interpreted as high domestic violence. Cronbach’s alpha coefficient of this questionnaire has been reported as 83% (15).
3.3. Statistical Analysis
Data were analyzed by SPSS software version 16 using descriptive (frequency, percentage, mean, and standard deviation) and inferential (those pertained to normally-distributed data) statistics. ANOVA and Pearson correlation coefficients were used for data with non-normal distribution. Also, Spearman correlation and chi-square tests were used to assess associations between qualitative variables.
3.4. Ethical Consideration
The protocol of the study was in accordance with the ethical principles of the Declaration of Helsinki. All participants agreed to participate in the study, and written informed consent was obtained from them. The study was approved by the Ethics Committee of Tehran University of Medical Sciences (code of approval: IR.TUMS.IKHC.REC.1397.131).
4. Results
Overall, 115 postpartum women were recruited in the study. The mean age of the participants was 29.80 years (the range of 17 - 44), and 87.8% of the women were younger than their husbands; 7 % of them were older than their spouses, and 5.2% of them were the same age as their partners. Most of the couples (67.8%) have been married for six years or more. The demographic and obstetrics data have been summarized in Table 1.
The Demographic and Obstetrics Data of the Participants
| Characteristics | No. (%) |
|---|---|
| Gravida | |
| 1 | 30 (26.0) |
| 2 | 56 (48.6) |
| > 2 | 29 (25.2) |
| Education (women) | |
| Illiterate | 30 (2.6) |
| Low-educated (high school) | 39 (45.2) |
| Highly-educated (university) | 46 (52.2) |
| Education (men) | |
| Illiterate | 40 (3.5) |
| Low-educated (high school) | 51 (45.2) |
| Highly-educated (university) | 44 (38.3) |
| Employment (women) | |
| Employed | 5 (4.3) |
| Unemployed | 110 (95.7) |
| Employment (men) | |
| Employed | 78 (67.8) |
| Unemployed | 37 (32.2) |
Maternal and neonatal outcomes have been listed in Table 2. The means ± SDs of gestation age at delivery and neonatal weight were 38 ± 3 weeks and 2974 ± 432 grams, respectively. Regarding the delivery route, 35 (30.4%) women had a vaginal delivery, and 80 (69.6) cases had a cesarean section.
Association Between Pregnancy Outcomes and Intimate Partner Violence
| Characteristics | No. (%) | r | P-Value |
|---|---|---|---|
| Preterm labor | 23 (20) | 0.385 | 0.048 |
| Placenta abruption | 6 (5.2) | 0.109 | 0.243 |
| Vaginal bleeding during pregnancy | 23 (20.0) | 0.039 | 0.686 |
| Premature rupture of the membrane | 26 (22.6) | 0.029 | 0.751 |
| Intrauterine growth restriction | 5 (4.3) | 0.023 | 0.809 |
Intimate partner violence was not observed against 37 (32.2%) women. On the other hand, 71 (61.7%) and 7 (6.1%) women experienced low and moderate domestic violence, respectively. Subgroup scores for different types of domestic violence have been provided in Table 3.
Subgroup Scores for Intimate Partner Violence
| Violence Subgroup | None | Low | Moderate | High |
|---|---|---|---|---|
| Psychological violence | 41 (35.7) | 63 (54.8) | 8 (7) | 3 (2.6) |
| Economic violence | 75 (65.2) | 35 (30.4) | 4 (3.5) | 1 (0.9) |
| Physical violence | 101 (87.8) | 9 (7.8%) | 3 (2.6) | 2 (1.7) |
| Sexual violence | 94 (81.7) | 20 (17.4) | 1 (0.9) | 0 |
Regression analysis revealed that there was a significant correlation between preterm labor (P = 0.048, r = 0.385) and domestic violence. Other pregnancy outcomes were not significantly associated with domestic violence. Subgroup analysis revealed that psychological violence was not significantly associated with vaginal delivery, preterm labor, intrauterine growth restriction, or premature rupture of the membrane. However, there was a significant correlation between placental abruption and economic violence (P = 0.040, r = 0.391) and between vaginal bleeding and sexual violence (P = 0.022).
Spearman correlation analysis showed that there was a correlation between low birth weight and economic violence against mothers (P = 0.047), but no significant correlation was found with other types of domestic violence. The spouse’s income had a significant inverse correlation with economic (P = 0.014) and physical (P = 0.044) violence. In other words, as the spouse’s income increased, the rate of economic and physical violence decreased.
Educational level significantly and inversely correlated with economic (r = -0.21) and physical (r = -0.19) violence. In other words, higher education levels reduced the rate of economic and physical violence. Also, there was a significant and inverse correlation between the spouse’s level of education and physical violence (r = - 0.23). The occupation of neither women nor their spouses had a significant correlation with any type of domestic violence.
5. Discussion
The results of this study indicated that although the prevalence of domestic violence against pregnant women was high (67.8%), its intensity was low in most cases. The probable reason can be the fact that women receive more support from their husbands during pregnancy, mitigating the intensity of violence. Obvious explanations for the incidence of intimate partner violence during pregnancy may be decreased sexual relations, misconceptions about pregnancy, and abnormal feelings of the spouse (16).
Our findings revealed that the highest prevalence belonged to psychological violence, followed by economic, sexual, and physical violence, respectively. These findings were in line with those of previous studies (17-19). Derakhshanpour et al. conducted a cross-sectional investigation on 500 pregnant and affirmed that psychological violence was the most common type of violence faced by women (54%), followed by verbal (31%), physical (24.8%), and sexual (6.8%) violence (20).
In the present study, we noticed a significant relationship between economic status and the level of domestic violence against pregnant women. The spouse’s income had a significant inverse correlation with economic and physical violence. In other words, as the spouse’s income increased, the rate of economic and physical violence decreased. These results were consistent with that of Salehi and Mehrallian (21). In the recent study, the researchers found that domestic violence was not significantly associated with the place of residence (city or village), education, and age at the time of marriage, but with the duration of marriage (significantly higher violence in couples whose marriages lasted more than five years), having a low economic status, and the husband being unemployed or addicted (21). Similarly, another syudy reported that the number of children, level of education, employment status, and antenatal care during pregnancy were associated with exposure to violence during pregnancy (22).
In our study, we observed that domestic violence was significantly correlated with preterm labor and preterm delivery. Violence can directly act as a risk factor for preterm delivery through physical trauma or indirectly through increasing maternal stress, resulting in inadequate access to health care services and risky behaviors such as smoking and using alcohol and drugs, which subsequently lead to adverse maternal and neonatal outcomes (23-25).
In this study, we found a significant association between sexual violence and vaginal bleeding. Consistent with this finding, Hassan et al., in a cohort study on 1300 pregnant women, revealed that domestic violence was significantly linked with the risk of abortion, cesarean delivery, and vaginal bleeding (26). We also observed a significant correlation between economic violence and placental abruption, for which we found no report in previous studies. In other words, an increase in economic violence predicted a rise in the incidence of placental abruption. Nevertheless, it should be noted that this relationship might have been affected by various confounders.
In our study, none of the various types of domestic violence were significantly associated with the type of delivery and hospitalization. However, some studies have acknowledged that domestic violence can affect hospitalization and the type of delivery. Thus, one of the most important consequences of violence can be an increase in the rate of emergency cesarean delivery (17). The probable explanations for the inconsistency between studies may be different sample sizes, study designs, and definitions of domestic violence (27, 28).
Violence during pregnancy is recognized as an important cause of maternal and neonatal mortality (29). The findings of different studies on the relationship between different types of domestic violence and maternal and neonatal outcomes are contradictory. Physical trauma can lead to undesirable pregnancy outcomes, such as placental abruption, premature rupture of membrane, preterm delivery, low birth weight, and abortion (30, 31). The indirect effects of violence due to increased stress in pregnant women should also be considered. Women experiencing violence are exposed to higher levels of stress, affecting hormonal responses and the immune system (32).
5.1. Conclusions
This study affirmed that domestic violence against pregnant women could adversely affect maternal and neonatal health. As a result, we should identify women who are at risk of domestic violence during pregnancy, develop relevant health guidelines to cope with this phenomenon and conduct routine screening programs (14, 33). Vulnerable pregnant women should be timely identified and offered educational and interventional programs by physicians and trained staff to reduce the prevalence and complications of domestic violence during pregnancy.
References
-
1.
Douki S, Nacef F, Belhadj A, Bouasker A, Ghachem R. Violence against women in Arab and Islamic countries. Arch Womens Ment Health. 2003;6(3):165-71. [PubMed ID: 12920614]. https://doi.org/10.1007/s00737-003-0170-x.
-
2.
Devries KM, Mak JY, Garcia-Moreno C, Petzold M, Child JC, Falder G, et al. Global health. The global prevalence of intimate partner violence against women. Science. 2013;340(6140):1527-8. [PubMed ID: 23788730]. https://doi.org/10.1126/science.1240937.
-
3.
Rakovec-Felser Z. Domestic Violence and Abuse in Intimate Relationship from Public Health Perspective. Health Psychol Res. 2014;2(3):1821. [PubMed ID: 26973948]. [PubMed Central ID: PMC4768593]. https://doi.org/10.4081/hpr.2014.1821.
-
4.
Violence against women. World Health Organization; 2022. Available from: https://www.who.int/news-room/fact-sheets/detail/violence-against-women.
-
5.
Mahenge B, Stockl H, Abubakari A, Mbwambo J, Jahn A. Physical, Sexual, Emotional and Economic Intimate Partner Violence and Controlling Behaviors during Pregnancy and Postpartum among Women in Dar es Salaam, Tanzania. PLoS One. 2016;11(10). e0164376. [PubMed ID: 27755559]. [PubMed Central ID: PMC5068783]. https://doi.org/10.1371/journal.pone.0164376.
-
6.
Habib S, Abbasi N, Khan B, Danish N, Nazir Q. Domestic Violence Among Pregnant Women. J Ayub Med Coll Abbottabad. 2018;30(2):237-40. [PubMed ID: 29938426].
-
7.
Goodwin MM, Gazmararian JA, Johnson CH, Gilbert BC, Saltzman LE. Pregnancy intendedness and physical abuse around the time of pregnancy: findings from the pregnancy risk assessment monitoring system, 1996-1997. PRAMS Working Group. Pregnancy Risk Assessment Monitoring System. Matern Child Health J. 2000;4(2):85-92. [PubMed ID: 10994576]. https://doi.org/10.1023/a:1009566103493.
-
8.
Raziani Y, Hasheminasab L, Gheshlagh RG, Dalvand P, Baghi V, Aslani M. The prevalence of intimate partner violence among Iranian pregnant women: a systematic review and meta-analysis. Scand J Public Health. 2022:14034948221119600. [PubMed ID: 36207824]. https://doi.org/10.1177/14034948221119641.
-
9.
Nur N. Association between domestic violence and miscarriage: a population-based cross-sectional study among women of childbearing ages, Sivas, Turkey. Women Health. 2014;54(5):425-38. [PubMed ID: 24795047]. https://doi.org/10.1080/03630242.2014.897676.
-
10.
Golmakani N, Azmoude E. Domestic violence in pregnancy, outcomes and strategies: a review article. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2013;15(42):13-22. https://doi.org/10.22038/ijogi.2013.571.
-
11.
Janssen PA, Holt VL, Sugg NK, Emanuel I, Critchlow CM, Henderson AD. Intimate partner violence and adverse pregnancy outcomes: a population-based study. Am J Obstet Gynecol. 2003;188(5):1341-7. [PubMed ID: 12748509]. https://doi.org/10.1067/mob.2003.274.
-
12.
Sigalla GN, Mushi D, Meyrowitsch DW, Manongi R, Rogathi JJ, Gammeltoft T, et al. Intimate partner violence during pregnancy and its association with preterm birth and low birth weight in Tanzania: A prospective cohort study. PLoS One. 2017;12(2). e0172540. [PubMed ID: 28235031]. [PubMed Central ID: PMC5325295]. https://doi.org/10.1371/journal.pone.0172540.
-
13.
Shamsi M, Bayati A. [Frequency and severity of domestic violence in pregnant women]. Journal of Gorgan University of Medical Sciences. 2012;13(4):67-75. Persian.
-
14.
Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health (Larchmt). 2015;24(1):100-6. [PubMed ID: 25265285]. [PubMed Central ID: PMC4361157]. https://doi.org/10.1089/jwh.2014.4872.
-
15.
Mohseni Tabrizi AR, Kaldi AR, Javadianzadeh M. [The study of domestic violence in marrid women addmitted to yazd legal medicine organization and welfare organization]. Tolooebehdasht. 2013;11(3):11-24. Persian.
-
16.
Levendosky AA, Bogat GA, Huth-Bocks AC, Rosenblum K, von Eye A. The effects of domestic violence on the stability of attachment from infancy to preschool. J Clin Child Adolesc Psychol. 2011;40(3):398-410. [PubMed ID: 21534051]. https://doi.org/10.1080/15374416.2011.563460.
-
17.
Bagherzadeh R, Keshavarz T, Sharif F, Dehbashi S, Tabatabaei HR. [Relationship between domestic violence during pregnancy and complications of pregnancy, type of delivery and birth weight on delivered women in hospital affiliated to Shiraz university of Medical Sciences]. Internal Medicine Today. 2008;13(4):51-8. Persian.
-
18.
Finnbogadottir H, Dykes AK, Wann-Hansson C. Prevalence and incidence of domestic violence during pregnancy and associated risk factors: a longitudinal cohort study in the south of Sweden. BMC Pregnancy Childbirth. 2016;16:228. [PubMed ID: 27530993]. [PubMed Central ID: PMC4988038]. https://doi.org/10.1186/s12884-016-1017-6.
-
19.
Nasir K, Hyder AA. Violence against pregnant women in developing countries: review of evidence. Eur J Public Health. 2003;13(2):105-7. [PubMed ID: 12803407]. https://doi.org/10.1093/eurpub/13.2.105.
-
20.
Derakhshanpour F, Mahboobi HR, Keshavarzi S. [Prevalence of domestic violence against women]. Journal of Gorgan University of Medical Sciences. 2014;16(1):126-31. Persian.
-
21.
Salehi S, Mehrallian HA. Prevalence and types of domestic violence against pregnant women referred to maternity clinics in Shahrekord, 2003. J Shahrekord Univ Med Sci. 2006;8(2):72-7.
-
22.
Doulatian M, Hesami K, Shams J, Alavi MH. Relationship between domestic violence during pregnancy with breastfeeding. Adv Nurs Midwifery. 2008;17(61):17-25.
-
23.
Neggers Y, Goldenberg R, Cliver S, Hauth J. Effects of domestic violence on preterm birth and low birth weight. Acta Obstet Gynecol Scand. 2004;83(5):455-60. [PubMed ID: 15059158]. https://doi.org/10.1111/j.0001-6349.2004.00458.x.
-
24.
Sanchez SE, Alva AV, Diez Chang G, Qiu C, Yanez D, Gelaye B, et al. Risk of spontaneous preterm birth in relation to maternal exposure to intimate partner violence during pregnancy in Peru. Matern Child Health J. 2013;17(3):485-92. [PubMed ID: 22527763]. [PubMed Central ID: PMC3565008]. https://doi.org/10.1007/s10995-012-1012-0.
-
25.
Meuleners LB, Lee AH, Janssen PA, Fraser ML. Maternal and foetal outcomes among pregnant women hospitalised due to interpersonal violence: a population based study in Western Australia, 2002-2008. BMC Pregnancy Childbirth. 2011;11:70. [PubMed ID: 21989086]. [PubMed Central ID: PMC3203083]. https://doi.org/10.1186/1471-2393-11-70.
-
26.
Hassan M, Kashanian M, Hassan M, Roohi M, Yousefi H. [Domestic violence: prevalence during pregnancy and associated maternal outcomes]. Studies in Medical Sciences. 2014;24(11):894-903. Persian.
-
27.
Murphy CC, Schei B, Myhr TL, Du Mont J. Abuse: a risk factor for low birth weight? A systematic review and meta-analysis. CMAJ. 2001;164(11):1567-72. [PubMed ID: 11402794]. [PubMed Central ID: PMC81110].
-
28.
Sharps PW, Laughon K, Giangrande SK. Intimate partner violence and the childbearing year: maternal and infant health consequences. Trauma Violence Abuse. 2007;8(2):105-16. [PubMed ID: 17545568]. https://doi.org/10.1177/1524838007302594.
-
29.
Pun KD, Rishal P, Darj E, Infanti JJ, Shrestha S, Lukasse M, et al. Domestic violence and perinatal outcomes - a prospective cohort study from Nepal. BMC Public Health. 2019;19(1):671. [PubMed ID: 31151395]. [PubMed Central ID: PMC6545012]. https://doi.org/10.1186/s12889-019-6967-y.
-
30.
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):22. [PubMed ID: 30803448]. [PubMed Central ID: PMC6388467]. https://doi.org/10.1186/s12978-019-0670-4.
-
31.
Shumway J, O'Campo P, Gielen A, Witter FR, Khouzami AN, Blakemore KJ. Preterm labor, placental abruption, and premature rupture of membranes in relation to maternal violence or verbal abuse. J Matern Fetal Med. 1999;8(3):76-80. [PubMed ID: 10338059]. https://doi.org/10.1002/(SICI)1520-6661(199905/06)8:3<76::AID-MFM2>3.0.CO;2-C.
-
32.
Mahapatro M, Nayar P, Roy S, Jadhav A, Panchkaran S. Domestic Violence during pregnancy as risk factors for stress and depression: The experience of women attending ANC at atertiary care hospital in India. Women Health. 2022;62(2):124-34. [PubMed ID: 35045785]. https://doi.org/10.1080/03630242.2022.2029670.
-
33.
Chisholm CA, Bullock L, Ferguson J2. Intimate partner violence and pregnancy: screening and intervention. Am J Obstet Gynecol. 2017;217(2):145-9. [PubMed ID: 28551447]. https://doi.org/10.1016/j.ajog.2017.05.043.