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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.36 no.spe Porto Alegre  2015

http://dx.doi.org/10.1590/1983-1447.2015.esp.57320 

Original Articles

Intimate partner violence in pregnancy: identification of women victims of their partners

Lisiane Camargo Quialheiro de Oliveiraa 

Mariana de Oliveira Fonseca-Machadob 

Juliana Stefanelloc 

Flávia Azevedo Gomes-Sponholzc 

a Universidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto (EERP/USP), Programa de Pós-Graduação Enfermagem em Saúde Pública. Ribeirão Preto, São Paulo, Brasil.

b Universidade Federal de São Carlos (UFSCAR), Departamento de Enfermagem, São Carlos, São Paulo, Brasil.

c Universidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto (EERP/USP), Departamento de Enfermagem Materno-Infantil e Saúde Pública. Ribeirão Preto, São Paulo, Brasil.

ABSTRACT

Objective

To identify women in situations of violence by intimate partners during the current pregnancy among users of prenatal care services.

Methods

Observational, cross-sectional study conducted from May 2012 to May 2013 in a prenatal service in Ribeirão Preto - SP, with 358 pregnant women from the 36th week of pregnancy. Data were collected through interviews. The adopted techniques and methods were univariate analysis, frequency distribution, measures of central tendency and variability, and the chi-square and Student’s t-test.

Results

Violence by an intimate partner during pregnancy was identified in 63 women (17.6%) aged between 15 and 42 years. Of the total, 39.7% were Catholic and 87.3% were non-smokers. Most of the women were unmarried and unemployed. Only 20 of the women felt they had suffered some form of violence during their lifetime.

Conclusion

These results will enable the creation of strategies to recognize, intervene, where necessary, and support victims.

Key words: Spouse abuse; Pregnancy; Nursing; Millennium Development Goals

INTRODUCTION

Intimate partner violence (IPV) is defined by the World Health Organization (WHO) as “an experience of one or more acts of violence perpetrated by a current or past partner from the age of fifteen years”(1). It characterizes a violation of human rights and is recognized as a global public health problem(2). In this context, IPV occurs in an intimate relationship and causes physical, sexual or psychological harm due to acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours caused by current partners or ex-partners(1). The WHO, by means of a multicenter study conducted in 10 countries, revealed that between 15.0% and 71% of women have been victims of physical or sexual abuse, or both, by the intimate partner at some point in their lives. An estimated 30% of all women who have had an intimate partner have suffered IPV(3) and two-thirds of all women will still be exposed to IPV at some point in their lives(4).

In view of the implications of IPV on the health of women, we stress the importance of identifying the factors that can increase or decrease the risk of the occurrence of this problem and support primary prevention(5). These factors include bad socioeconomic conditions, lower age, lower educational level, not living with the companion, childhood abuse, alcohol abuse and drug abuse by the partner(6).

A worrying aspect with regard to the health of women in situations of violence is the continuation of aggression during pregnant, although protection and care are expected at this stage of their lives(7). Women who are the victims of at least one act of physical violence during pregnancy are more likely to follow inadequate prenatal care(8).

The number of victims of violence identified in the health services is still low. In general, health workers are not trained to identify IPV since during the prenatal consultation violence is not considered in the conduct of women if there are no full complaints of violence or any associated symptoms(9).

IPV is directly associated with female morbidity and mortality(10), and to the consequences for the newborn, such as miscarriage, preterm labour, foetal distress and low birth weight(6).

During prenatal consultations, it is possible to monitor and treat adverse effects of IPV(7), thus contributing to the achievement of numbers three, four and five of the Millennium Development Goals (MDGs), that is, to eliminate gender disparity, reduce the child mortality rate and reduce maternal mortality, respectively(11).

This study is justified due to the scarcity of studies that investigate IPV during the gestational period. Although women are believed to be physically and emotionally sensitive during this period, pregnancy is an opportune moment to investigate violence to the extent that, for many women, this is the only time to establish contact and a link with the health service(12).

The objective of this study is to identify women from users of a prenatal service who are suffering from violence by an intimate partner during the current pregnancy.

METHODS

This study is part of a doctoral thesis that was defended at the school of nursing of Ribeirão Preto, University of São Paulo, in 2014, with the general objective of verifying the effects of IPV during pregnancy on the mental health of women who used a prenatal care service(13).

This is an observational, cross-sectional study conducted at a centre of women’s health, the Centro de Referência em Saúde da Mulher/MATER (CRSM/MATER), in the city of Ribeirão Preto, São Paulo. This institution is maintained with budgetary resources of the State Secretariat of Health of the State of São Paulo and the unified health system (SUS), under the administration of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto with consent of the Fundação de Apoio ao Ensino e Pesquisa.

About one-third of the deliveries of the SUS in Ribeirão Preto occur at the MATER, which is integrated to the Nascer project of the Municipal Health Secretariat of Ribeirão Preto. This institution recommends that the prenatal monitoring of pregnant women in primary care should occur until the 36th week of pregnancy and, subsequently, in public hospitals until the end of the pregnancy-puerperal cycle.

The base of the study population consisted of pregnant women receiving prenatal monitoring at the CRSM/MATER from the 36th week of pregnancy. The sample was obtained from the reference population and through systematic probability sampling. To calculate the sample size, we considered a finite population of 1600 pregnant women, a 30.7% prevalence of intimate partner violence during pregnancy, based on the international literature(14), and an accuracy of 5% for an estimate with 95% confidence. Based on these data and using the application Power Analysis and Sample Size (PASS), version 2002, we obtained a sample of 272 pregnant women. Based on this sample size, the calculated sampling interval was four participants. The sequential process started from the second pregnancy on the first day of data collection, which was obtained by means of a draw using the Statistical Package for Social Sciences (SPSS).

The participants were included in the study according to the following criteria: women in prenatal follow-up in CRSM/MATER, aged between 15 and 49 years, who have or have had a relationship with an intimate partner during pregnancy, regardless of cohabitation, and who reside in the city of Ribeirão Preto.

We excluded the pregnant women who claimed they were not in any kind of intimate relationship in the current pregnancy, who were residing outside the city of Ribeirão Preto and who were under the age of 14 years or over the age of 49.

Data were collected using two instruments. The first instrument was a demographic characterization tool, which was created with 23 structured questions based on the previous experiences of researchers and on national and international scientific literature. Once completed, this instrument was subjected to validation of content and appearance by three judges who are experts in the field. The suggestions were reviewed and the instrument underwent minor modifications based on the opinions of the judges. This committee of judges judged the breadth of the issues, their representativeness, content and relevance to the characteristics that would be evaluated. The issues addressed in the instrument were: date of birth, self-referred skin colour, education, religion, occupation, smoking and drinking habits, illicit drug use, marital status, relationship time in months, family income, family provider.

The second instrument was used to identify and characterize the situation of violence. It was adapted from the original version and validated in Brazil for the “World Health Organization Multi-country Study on Women’s Health and Domestic Violence Against Women” that addresses psychological, physical and sexual violence perpetrated by intimate partners against women in different social contexts(3). We used the adapted and validated version with the pregnant women assisted at the CRSM-MATER, which proved to be appropriate for the proposed objectives(15).

The data were collected in the first prenatal consultation of the pregnant women at the CRSM/MATER in the third trimester of pregnancy, from the 36th week. Every day, we inspected the agenda of the receptionist to identify any new cases in prenatal care. In the waiting room, and immediately after reception of the users and all routine procedures, the pregnant women were invited to participate and notified as to the nature and objectives of the research.

At this point the chaperones were not present. The interviews were conducted in the service itself, in a private area, without the presence of chaperones, and after completion of all the activities of the pregnant women at the clinic, according to the service routine and respecting the will of the women.

Confidentiality and the anonymity of the participants was guaranteed. In the cases where IPV was identified, the attending physician of the clinic was notified in order to determine the need for monitoring, referral or a consultation liaison with the psychology service of the CRSM/MATER.

All participants were given brochures about violence containing the list of protection services for women in Ribeirão Preto and region. At the time of the interview, when necessary or if requested by the women, the participants were referred to a comprehensive care support service for people in situations of violence or conditions of risk, through the social support network of Ribeirão Preto.

The data was stored in a spreadsheet using Excel Mac 2011, and validated via double entry to eliminate possible errors and ensure the reliability of data compilation. For statistical analysis, we used the SPSS programme, version 21.0. The data were subjected to univariate analysis. The qualitative variables were presented in the form of absolute and relative frequency distribution. For the quantitative variables, we calculated measures of central tendency, standard deviation and variance.

This study observed the standards and regulatory guidelines for research involving human beings established by Resolution 196/96 of the National Health Council. The design of this research was approved by the board of directors of the CRSM/MATER, through its research committee, and by the committee of ethics in research (CEP) of the EERP/USP, under protocol number 1377/2011. The research was conducted within the ethical standards, in conformity with human dignity. Those who agreed to participate in the study formalized their agreement by signing the informed consent statement or the term of consent for minors. As this research investigates the occurrence of violence, the legal representative could be the attacker of the minor and may refuse to authorize the participation of the minor in the study. Both terms contained the research procedures and the security parameters for the study subjects. A signed copy of the term was retained by the researcher and the other was handed to the interviewed participant.

RESULTS

Data were collected from May 2012 to May 2013, from a final sample of 358 pregnant women. Of the 358 pregnant women, 63 (17.6%) were exposed to some type of intimate partner violence during pregnancy.

The age of these 63 pregnant women ranged from 15 to 42 years, averaging 24.5 ± 6.3 years and a median of 24.0. The number of years of study ranged from 2 to 15, and the average schooling of the pregnant women in a situation of IPV was 8.8 ± 2.4 years.

The group of pregnant women in a situation of IPV was composed mostly (69.8%) of single women, of which 68.3% lived with a companion. Ten of these women ended the relationship during pregnancy and 10 had a partner with whom they were not living. The average duration of the relationship with the current or last partner was 56.5 ± 44.0 months, ranging from seven to 156 months.

Regarding skin colour, 26 (41.3%) pregnant women in a situation of IPV during pregnancy claimed they had brown skin and 16 (25.4%) stated they had black skin.

We note that, among the 63 pregnant women assaulted by an intimate partner during pregnancy, 25 (39.7%) were Catholic and 23 (36.5%) were Evangelical. The majority (60.3%) did not have formal or informal employment.

In relation to smoking, 55 (87.3%), of the 63 women in a situation of IPV stated they did not have the habit of smoking. In this context, the average number of cigarettes per day consumed by the eight women who smoked was 13 ± 8.2.

In relation to the use of alcoholic beverages, the majority (81%) did not have this habit, and with regard to the use of illicit drugs, none of the pregnant women in a situation of IPV during pregnancy were drug users.

The monthly family income averaged 2.5 ± 1.9 minimum salaries, which ranged from one to 11. In 49.2% of cases, the family provider was the companion.

Of the 63 women who suffered IPV during pregnancy, the majority (81%) stated that their relationship with their partner was mostly good, however, when questioned about the coexistence with the companion during the pregnancy, 41.3% reported that the relationship had worsened, 30.2% stated that there had been no changes and 28.6% claimed that the relationship had improved.

With respect to the type of IPV suffered by the 63 women during pregnancy, 60 (95.2%) suffered psychological violence, 23 (36.5%) suffered physical violence and one (1.6%) suffered sexual violence.

DISCUSSION

The study population was characterized by 17.6% of participants in a situation of violence, which corroborates the results of a study conducted in Campinas, where 19.6% of the participants were also in a situation of IPV during pregnancy(16).

The study group was characterised by having young adult pregnant women with an average age of 24.5 years. These data confirm those found in other studies conducted in other areas of Brazil, such as Rio de Janeiro and Maringá(17), where the average age of participants in a situation of violence was 24.4 and 25.3 years, respectively.

In our research, the pregnant women suffering from IPV presented an average of 8.8 years of education. This result is similar to the results found in a study in Recife, where the majority (63.1%) of women had less than nine years of education(18).

Regardless of marital status, the majority of the pregnant women suffering from IPV lived with the intimate partner, and the average duration of the relationship with the current or last partner was 56.5 months. This result is lower than the results found in a study carried out in Recife, where 83.7% of the women lived with their companions, also regardless of marital status(18).

With respect to the self-referred skin colour, most of the women (66.7%) considered themselves as “not white”, of which 41.3% stated they had brown skin and 25.4% stated they had black skin. This result is also lower than the same study conducted in Recife, where 80.4% of the women referred to themselves as “non-white”(18).

With regard to religious beliefs, in our study there was a predominance of the Catholic women, followed by Evangelical women. A similar result was found in a study carried out in Guatemala, where 51% declared themselves Catholic, followed by 35% who said they were Evangelical(19). The majority did not have formal or informal employment. Similarly, the same study in Guatemala found that 81% of the pregnant women stated they were housewives(19).

With respect to behavioural variables, we found that during pregnancy, most participants did not smoke, did not consume alcoholic beverages and did not use illegal drugs. These results corroborate those found in Guatemala, where 81% of the women victims of IPV were non-smokers and only 2% used illicit drugs(18). With regard to the habit of ingesting alcohol, our results confirm the results found in a study conducted in Campinas(16), where approximately 95% did not habitually consume alcohol.

The majority (81%) of the 63 women who suffered from IPV during pregnancy stated that their relationship with their partner was mostly good, however, when questioned about the coexistence during pregnancy, most (41.3%) of the women reported that the relationship had worsened. This result shows that the occurrence of violence during pregnancy is often considered contradictory by the women since pregnancy is a period in which they are physically and psychologically sensitive because of the numerous transformations that occur in their bodies, and should therefore be a moment of tranquillity and peaceful coexistence with their companions(13).

With respect to the types of violence, psychological violence was most prevalent in the study, and was referred to by 16.8% of the participants, followed by physical violence (6.4%) and sexual violence (0.3%). The proportionality of such data is similar to the results of an integrative review, where the authors found a prevalence of psychological violence in 24.8% of the analyzed studies, followed by physical violence in 22.5% of the studies and sexual violence in 2.7% of the studies(11).

In this study review, the authors cite the numerous negative results of IPV for both mother and child. Among the cited results, maternal morbidity and mortality is the fifth MDG for the reduction of the maternal mortality ratio by three-quarters(11.20). One of the action suggestions of the World Health Organization for the achievement of this goal is to provide a pleasant, affectionate and peaceful environment for pregnant women at home, in their daily lives, and at work(20).

CONCLUSION

Of the women interviewed, 17.6% were in situation of IPV during pregnancy, of which 95.2% suffered psychological violence, 36.5% suffered physical violence and one (1.6%) suffered sexual violence. However, the majority did not believe they had suffered violence during their lifetime.

The results of this study reveal the importance of identifying cases of violence during pregnancy, and of preparing health professionals to address the topic.

We must take into account the contribution of nursing professionals in terms of enabling access to social and institutional support services when they detect cases of violence in pregnancy. This approach is a direct contribution to gender equity and women’s rights, and to the third millennium goal, which addresses the promotion of gender equality and the empowerment of women.

The effects of IPV on child health, another factor that should be taken into account by health professionals in general, are directly related to infant mortality. The fourth MDG, which is to reduce by two thirds the mortality rate of children under five years of age, is also directly linked to VPI in pregnancy due to the interference with neonatal outcomes(20).

However, there is a scarcity of studies in national scientific literature that address the identification of women in situations of violence during pregnancy, and of well-elaborated instruments to track these victims.

We believe that the identification and characterization of women in situations of violence by intimate partners during pregnancy, and the factors associated with this situation, will contribute to the recognition of cases by health professionals and provide further visibility of this violence as a public health problem. This recognition will lead to the creation of environments that encourage victims and their families to talk about violence, the development of strategies and protocols to identify and intervene in cases of IPV, and the provision of help and support to those in need, including rapid response channels that are integrated with other social facilities.

As limitations of the study, we must consider that some of the pregnant women may have been ashamed or afraid to talk about IPV, despite the guaranteed privacy and safety. Therefore, the prevalence found in this study should be considered as a minimum estimate.

The statistical inference must also be taken into consideration as a limitation, since data were collected only in the city of Ribeirão Preto, which restricts the generalization of the population.

In the context of research, this theme is current and recent in the scientific community, and has become increasingly present in academia, thus encouraging researchers to address the subject and use practices based on evidence to better prepare health workers to specifically identify pregnant women suffering from violence by their partners.

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Received: July 30, 2015; Accepted: November 12, 2015

Author’s address: Lisiane Camargo Quialheiro de Oliveira. Rua Álvares Cabral, 542/301 14010-080 Ribeirão Preto – SP. E-mail: lisi.quialheiro@gmail.com

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