Exposure to domestic violence during pregnancy : impact on outcome, midwives’ awareness, women´s experience and prevalence in the south of Sweden

Sammanfattning: Objective: The overall aim of this thesis was to investigate pregnant women’s history of violence and experiences of domestic violence during pregnancy and to explore the possible association between such violence and various outcome measures as well as background factors. A further aim was to elucidate midwives’ awareness of domestic violence among pregnant women as well as women’s experiences and management of domestic violence during pregnancy. Design/Setting/Population: Paper I utilised material derived from a populationbased multi-centre cohort study. A total of 2652 nulliparous women at nine obstetric departments in Denmark answered a self-administrated questionnaire at 37 weeks of gestation. Among the total sample, 37.1% (985) women met the protocol criteria for labour dystocia. In Paper II an inductive qualitative method was used, based on focus group interviews with sixteen midwives working in antenatal care in southern Sweden who were divided into four focus groups. In Paper III a grounded theory approach was used to develop a theoretical model of ten women’s experiences of intimate partner violence during pregnancy. Paper IV was a cross-sectional study including a cohort of 1939 pregnant women who answered a self-administered questionnaire at their first visit to seventeen ANCs in south-west Scania in Sweden. Results: In paper I, 35.4 % (n = 940) of the total cohort of women reported history of violence, and among these, 2.5 % (n = 66) reported exposure to violence during their first pregnancy. Further, 39.5% (n = 26) of those had never been exposed to violence before. No associations were found between history of violence or experienced violence during pregnancy and labour dystocia at term. However, among those women consuming alcoholic beverages during late pregnancy, women exposed to violence had increased odds of labour dystocia (crude OR 1.49, CI: 1.07 – 2.07) compared to women who were unexposed to violence. In Paper II, an overarching category ‘Failing both mother and the unborn baby’ highlighted the vulnerability of the unborn baby and the need to provide protection for the unborn baby by means of adequate care to the pregnant woman. Also, the analysis yielded five categories: 1) ‘Knowledge about ‘the different faces’ of violence’ 2) ‘Identified and visible vulnerable groups’, 3) ‘Barriers towards asking the right questions’, 4) ‘Handling the delicate situation’ and 5) ‘The crucial role of the midwife’. In Paper III, the analysis of the empirical data formed a theoretical model, and the core category, ‘Struggling to survive for the sake of the unborn baby’, constituted the main concerns of women who were exposed to IPV during pregnancy. The core category also demonstrated how the survivors handled their situation. Three sub-core categories were identified that were properties of the core category; these were: ‘Trapped in the situation’, ‘Exposed to mastery’ and ‘Degradation processes’. In Paper IV, ‘history of violence’ was reported by 39.5% (n = 761) of the women. Prevalence of experience of domestic violence during pregnancy, regardless of type or level of abuse, was 1.0 % (n = 18), and prevalence of history of physical abuse by actual intimate partner was 2.2 % (n = 42). The strongest factor associated with domestic violence during pregnancy was history of violence (p < 0.001). The presence of several symptoms of depression was associated with a 7-fold risk of domestic violence during pregnancy (OR 7.0; 95% CI: 1.9-26.3). Conclusions: Our findings indicated that nulliparous women who have a history of violence or experienced violence during pregnancy do not appear to have a higher risk of labour dystocia at term, according to the definition of labour dystocia used in this study. Additional research on this topic would be beneficial, including further evaluation of the criteria for labour dystocia (Paper I). Avoidance of questions concerning the experience of violence during pregnancy may be regarded as failing not only the pregnant woman but also the unprotected and unborn baby. Still, certain hindrances must be overcome before the implementation of routine enquiry concerning pregnant women’s experiences of violence (Paper II). The theoretical model “Struggling to survive for the sake of the unborn baby” highlights survival as the pregnant women’s main concern and explains their strategies for dealing with experiences of violence during pregnancy. The findings may provide a deeper understanding of this complex matter for midwives and other health care professionals (Paper III). The reported prevalence of domestic violence during pregnancy in southwest Scania in Sweden is low. Both history of violence and the presence of several depressive symptoms detected in early pregnancy may indicate that the woman also is exposed to domestic violence during pregnancy (Paper IV).