Abstract
This study analyzes the association between violence against women during pregnancy and intimate partner socioeconomic and behavioral characteristics. We conducted an analytical cross-sectional study with 327 postpartum women admitted to a maternity hospital in a city in Espírito Santo, Brazil using a questionnaire to collect data on intimate partner socioeconomic and behavioral characteristics. Intimate partner violence was assessed using questions based on the World Health Organisation instrument “Violence against Women (WHO VAW STUDY)”. Associations were tested using crude and adjusted Poisson regression. The prevalence of psychological violence during pregnancy was higher among women whose partners consumed alcohol, refused to use condoms, and were not the infant’s biological father. Physical violence was associated with women whose partners did not work and refused to use condoms. The prevalence of sexual violence during pregnancy was more than nine times higher among women with partners who refused to use condoms. The findings demonstrate that antenatal care is an opportune time to approach partners about health care and address violence. It is necessary to promote the utilization of health services by men in order to address risk factors for violence during pregnancy.
Key words: Intimate partner violence; Violence against women; Spouse abuse; Masculinity; Pregnancy
Resumo
Este estudo analisa a associação das violências contra a mulher durante a gestação segundo as características socioeconômicas e comportamentais do parceiro íntimo. Trata-se de um estudo transversal analítico em uma maternidade de um município do Espírito Santo com 327 puérperas, onde foram coletados dados sobre as características do parceiro íntimo. O instrumento da Organização Mundial da Saúde foi utilizado para rastrear a violência por parceiro íntimo na gestação. Foram obtidas as associações pela regressão de Poisson bruta e ajustada. Puérperas cujos parceiros consumiam bebida alcoólica, não eram os pais biológicos da criança e se recusavam a usar preservativo tiveram maior prevalência de violência psicológica na gestação. A violência física se associou às puérperas cujos parceiros não trabalhavam e se recusavam a usar preservativo. Puérperas com parceiros que se recusavam a usar preservativo tiveram prevalência nove vezes maior de sofrer violência sexual na gestação. Desse modo, o pré-natal se apresenta como um momento oportuno para abordar os parceiros quanto ao cuidado em saúde e enfrentamento à violência. É necessário ampliar o acolhimento dos homens pelos serviços de saúde para intervir nos fatores que favorecem a violência na gestação.
Palavras-chave: Violência por parceiro íntimo; Violência contra a mulher; Maus-tratos conjugais; Masculinidade; Gravidez
Introduction
The World Health Organisation report “The World Report on Violence and Health” defines Intimate partner violence (IPV) as any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors¹.
National and international studies show that victims of IPV are predominantly women and that women experience more serious forms of violence than men2,3. Data from the United States reveal that 36.0% of American women have experienced IPV during their lifetime3. In Brazil, a study undertaken in 15 state capitals and the Federal District reported that the prevalence of psychological violence ranged from 61.7% in Campo Grande to 85.6% in Belo Horizonte, while physical violence ranged from 13.2% in João Pessoa to 34.7% in Belém4. The prevalence of lifetime psychological, physical and sexual IPV in Vitória was 57.6%, 39.3%, and 18.0%, respecitvely5.
In light of the above, it is important to investigate gender asymmetry in relationships, as although social changes have taken place over time, we continue to witness the reproduction of inequalities in intimate relationships6. Traditionally the hegemonic concept of masculinity has been used to refer to ideas of men’s domination over women, virility, strength and power, characteristics that counterpose the attributes of femininity, such as fragility and submission. These characteristics are part of the social construction of masculine identity, demarcating expected and socially legitimate conduct, such violent behavior7,8.
With regard to perpetrators of IPV against women, a number of characteristics are associated with acts of violence. Women whose partners are unemployed, have a low level of education, consume alcohol, and are controlling, are more likely to experience violence9. Other factors that are precipitators of violence include jealousy, suspicions of infidelity, refusal to have sex, different approaches to raising children, and unplanned fatherhood8,10.
It is important to highlight that violence is a reality in the life of women and manifests itself throughout all stages of life, including pregnancy. There is no consensus in the literature as to whether pregnancy is a risk factor or protective factor against violence. Silva et al.11 point out that different types of violence can overlap, with around 11.0% of women experiencing psychological, physical and sexual violence during pregnancy. Other studies show that the prevalence of violence is similar before and during pregnancy, but during pregnancy there is a pronounced increase in psychological violence and reduction in physical violence. Another study showed that the incidence of IPV during pregnancy was 9.7%.
The consequences of IPV during pregnancy are greater as it directly affects the health of both the mother and infant. Studies show that pregnant women who experience IPV are more likely to develop symptoms of depression and post-traumatic stress disorder and have an increased risk of early cessation of breastfeeding and misscarriage12-14. Violence is also associated with newborn health outcomes, including prematurity, low birth weight, and fetal and neonatal death15.
In view of the complexity and impacts of violence against women, including violence during pregnancy, combined with the fact that men are the main perpetrators of IPV, the aim of the present study was to explore the association between violence against women during pregnancy and the socioeconomic and behavioral characteristics of the intimate partner.
Methodology
We conducted an analytical cross-sectional study with postpartum women admitted to a public maternity facility in Cariacica in the state of Espírito Santo between August and October 2017.
The eligibility criteria for participants were as follows: postpartum women admitted to the maternity facility for at least 24 hours after birth with a live baby (weighing > 500 grams) who had had an intimate partner during pregnancy. Intimate partner was defined as the woman’s partner/ex-partner, regardless of whether or not there was a formal commitment, and boyfriends, provided they had sexual relations.
The sample size was calculated using a prevalence of IPV violence during pregnancy of 20%16, adopting a 5% sampling error and 95% confidence interval, and adding 10.0% to account for sample losses and 30.0% for confounding factors, resulting in a final sample of 327 postpartum women.
We used a standardized questionnaire developed for the study with closed-ended questions devised to collect information on intimate partner socioeconomic (age, race/color, level of education, paid work) and behavioral (alcohol consumption, smoking, drug use, jealous behavior, controlling behavior and refusal to use a condom) characteristics, and whether the partner was the father of the newborn. The variables controlling behavior and jealousy were assessed using the following dichotomous question (yes/no): “Is he jealous?” and “Is he controlling?”
Information on the dependent variables (psychological, physical, and sexual violence during pregnancy) was collected using questions based on the World Health Organisation instrument “Violence against Women (WHO VAW STUDY)”. The instrument characterizes these different types of violence as follows: physical violence - physical aggression or the use of objects to cause injury; psychological violence - threatening behavior, humiliation and insults; and sexual violence - physically forced sexual relations or threats and humiliating acts. Victimization was classified according to type of violence based on yes answers to specific questions relating to each type of violence17.
The eligible postpartum women were invited to participate in the study and those who accepted signed an informed consent form. A copy of the form was given to the participant and another copy remained with the interviewer for filing. In the case of underage mothers, one of the parents or guardians signed the informed consent form. The interviews were conducted in a private area by previously trained interviewers, who undertook a pilot study in the same maternity facility a month before data collection. The training emphasized guidance on ethical aspects such as the appropriate application of the questionnaire.
The data were inputted into Microsoft Office Excel version 2010 by a previously trained digitizer. Data entry was crosschecked for possible inconsistencies. The data were analyzed using STATA 13 and the following descriptive statistics: raw frequencies, relative frequencies, and 95% confidence interval. To identify the distribution of violence during pregnancy and partner socioeconomic and behavioral characteristics we used the Pearson’s chi-squared test or Fisher’s exact test. To examine the association between the outcomes and exposures we ran a multivariate Poisson regression model including all variables with a p-value of < 0.20 and maintaining variables with a p-value of < 0.05. The results are presented using crude and adjusted prevalence ratios and their respective 95% confidence intervals.
The study protocol was approved by the research ethics committee (approval code 2.149.430).
Results
The majority of the partners were aged up to 40 years (89.3%) and were predominantly brown (44.8%) and had completed at least nine years of education (60.5%). Almost one- quarter (23.8%) did not have paid work. With regard to behavioral characteristics, 56.0% did not drink and 89.6% did not use drugs. Over half of the partners were reported to be jealous (51.4%), while 36.1% were considered controlling. Finally, 27.2% of the partners refused to use a condom and 95.7% were the father of the newborn (Table 1).
The results of the bivariate analysis presented in Table 2 show that the frequency of psychological, physical and sexual violence during pregnancy was higher in women whose partners refused to use a condom, while the prevalence of psychological and physical violence was higher among women whose partners did not have paid work. The frequency of psychological violence was higher in women with partners who consumed alcohol, were controlling, and were not the father of the newborn (p < 0.05).
After adjustment for possible confounding variables, the results show that the prevalence of psychological violence was 1.72 times higher in women whose partners consumed alcohol (PR: 1.72; 95%CI: 1.05-2.83) and 1.77 times higher among women whose partners refused to use a condom (PR: 1.77; 95%CI: 1.10-2.86) (Table 3).
Table 4 shows that the prevalence of physical violence during pregnancy was higher in women whose partners did not have paid work (PR: 2.70; 95%CI: 1.27-5.72) and refused to use a condom (PR: 2.22; 95%CI: 1.04-4.71).
Prevalence of sexual violence during pregnancy was 9.36 times higher among women whose partners refused to use a condom (PR: 9.36; 95%CI: 1.97-44.31) (Table 5).
Discussion
Our findings show that the prevalence of violence during pregnancy was higher among women whose partners consumed alcohol, did not work, refused to use a condom, and were not the father of the newborn. The variables race/color, use of illicit drugs, and having a jealous and/or controlling partner did not maintain their association after adjusted multivariate analysis.
Although women report experiencing violence in various life stages, violence during pregnancy is particularly worrying because it can have health consequences for both the mother and infant11. Faced with changes in routine, ambivalent feelings and the possibility of an unplanned pregnancy, pregnancy is period of profound change in which couples can either come closer together or grow apart18. Evidence shows that an unwanted pregnancy on the part of the partner is a factor that triggers marital conflict and violence7.
In the present study, the prevalence of psychological violence during pregnancy was 1.72 times higher in women whose partners consumed alcohol, which is similar to the findings of previous studies19,20. A study undertaken in Campinas in the state of São Paulo with pregnant women using primary health care services found that alcohol consumption in women whose partners consumed alcohol at least twice a week were more than twice as likely to experience psychological, physical violence, and/or sexual violence during pregnancy19. A study using data from the 1st Nationwide Survey on Alcohol Consumption Patterns in Brazil showed that the prevalence of alcohol consumption was four times higher in men who commit IPV21.
The association between alcohol consumption and intimate partner violence is therefore recognized9,22,23. Alcohol consumption can lead to tension between the couple, aggravating and intensifying violence. Alcohol consumption by the partner can act as a factor that externalizes an impulsive and aggressive personality and predisposition to violence22,23. However, it is known that violence is a complex and multifactorial phenomenon and that alcohol is not the only explanatory factor1.
Another characteristic that was associated with higher prevalence of physical violence during pregnancy was the partner not having paid work, which is similar to the findings of a study in Maringá in the state of Paraná, which reported that physical violence during pregnancy was more frequent among women with partners who were unemployed24. A study with 1,379 pregnant women in Campinas found that women whose partners were unemployed were more likely to experience physical/sexual violence during pregnancy19, while research with patients in primary care centers in Vitória in the state of Espírito Santo observed that the prevalence of physical IPV was 1.11 times higher in women whose partners did not have paid work9.
The social norms that establish gender roles assign men the role of provider. Men who do not have a job or source of income are more likely to make threats and commit physical violence as a way of dominating and exercising power over the woman and family8,10,25. In a study interviewing men being prosecuted for IPV, the respondents emphasized that providing for the family is a male activity and that women should not do paid work. Working women living with unemployed men may therefore be more likely to experience episodes of violence, including physical violence8,20.
In addition, pregnancy leads to an increase in the number of family members. For men who perpetrate violence against women, this factor may act as a threat to their masculinity, as they may find themselves unable to carry out the socially-conditioned function of partner/provider and father. The lack of policies that provide women and couples with the enabling conditions to perform the roles of motherhood and fatherhood in a responsible and safe manner may also act as an aggravating factor26.
Our findings also show that the prevalence of psychological, physical, and sexual violence was also higher among women whose partners refused to use a condom. Schraiber et al.27 found that women whose partners had refused to use a condom were 0.62 times more likely to experience violence during pregnancy. This association was also observed by a study with patients in Porto Alegre in the state of Rio Grande do Sul, which showed that the frequency of physical violence was greater in women whose partners refused to use a condom28.
Although sex in an intimate relationship is seen as obligatory by both men and women, the sexual desires of men tend to override those of women and the latter often find it difficult to negotiate sex, condom use and contraceptive methods. However, this conduct can lead to unwanted pregnancy. Women with less control over their sexual and reproductive health, where the man holds the decision-making power, experience privation and are prevented from deciding what is best for themselves26,28,29.
A study with health professionals showed that on occasions pregnant women go to the clinic accompanied by their partners with excessive doubts and concerns about sex during pregnancy, indicating difficulties in negotiating sex and the occurrence of sexual violence during pregnancy26. It is also worth highlighting that men are more likely to neglect their health than women as self-care is conventionally associated with women, exposing themselves and their partners to a series of risks30.
The findings of the present study show that the prevalence of psychological violence during pregnancy was 2.87 higher among women whose partners were not the biological father of the newborn. A study in two public maternity facilities showed that postpartum women with children from other relationships were 3.4 time more likely to experience physical violence during pregnancy24. Having children from other relationships can trigger disagreements as it generates insecurity and concerns of involvement with the ex-partner. The findings of a study with a group of men undergoing criminal prosecution for domestic violence revealed that some did not accept the cohabitation of children from previous relationships10.
After adjusting for possible confounding factors, the association between the variables having a jealous and controlling partner and violence during pregnancy was not maintained. However, studies show a strong association between IPV and controlling behavior9,31. A study in Ethiopia showed that pregnant women with a partner who had aggressive behavior were 2.8 times more likely to experience IPV during pregnancy (95%CI = 1.7-4.6)31, while a study in Vitória reported that the prevalence of violence was 1.96 times higher in women with a controlling partner (95%CI = 1.50-2.62)9. It is important to note that women often have difficulty in realizing that they are victims of IPV and may confuse controlling behavior and jealously with love and care32,33.
Controlling behavior is characterized by constant domination and monitoring, inhibiting forms of expression, ways of relating and dressing in clothes considered inappropriate by the partner8. Regardless of the type of behavior, controlling behavior distances the victim from their family and friends and other people who could potentially help them32. Although naturalized, controlling behaviors constitute a violation of women’s rights to come and go and to dignity, harming their well-being and quality of life8.
Another element that can trigger violence in jealously. Be it motivated by the partner’s social life and family or suspicion of infidelity, jealously involves gender issues that perpetuate possessiveness34. Jealously can be understood as a form of understanding traditional masculinity, as it legitimizes violence when pre-established gender attributes are not observed25.
This study has some limitations. First, the data were collected in the postpartum period, which is a time when women feel especially vulnerable, possibly resulting in the underestimation of the prevalence of violence. Second, the fact that answers to the questions on partner characteristics were responded by the postpartum women means that the answers, particularly those about behavioral characteristics, may be subject to participant bias. Finally, the fact that the study population was made up of women admitted to a public maternity facility means that the results should be interpreted with caution and should not be generalized to the overall population of postpartum women.
Conclusion
Our findings show an association between IPV during pregnancy and intimate partner socioeconomic and behavioral characteristics.
In view of the above, it is worth bearing in mind that the factors that determine the occurrence and permanence of IPV constitute a complex social dynamic in which social services must engage. The findings demonstrate the need to promote the utilization of health services by men in order to address social and behavioral risk factors for violence during pregnancy. With regard to pregnancy and the postpartum period, it is worth highlighting that the involvement partners from the beginning of antenatal care is essential, as it is an opportune time to approach men about health care and offer treatment.
With regard to aggressive partners, there is an urgent need to discuss how to approach this issue in health services and develop effective multi-sectorial actions that promote changes in behavior within family and social relations. In this respect, improving understanding among health professionals about IPV during pregnancy can help enable the adoption of individual and collective violence prevention and coping strategies. Finally, actions to change individual attitudes and behavior need to be developed in networks in order to safeguard rights and ensure the provision of adequate care.
Acknowledgements
Fundação de Amparo à Pesquisa e Inovação do Espírito Santo - FAPES (call for proposals FAPES/CNPq 04/2017. Code 80641393/2017).
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Publication Dates
-
Publication in this collection
04 May 2022 -
Date of issue
May 2022
History
-
Received
01 Dec 2020 -
Accepted
15 June 2021 -
Published
17 June 2021