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’shistory of violence and experiences of domestic violence during pregnancy andto explore the possible association between such violence and various outcomemeasures as well as background factors. A further aim was to elucidate midwives’awareness of domestic violence among pregnant women as well as women’sexperiences and management of domestic violence during pregnancy.Design/Setting/Population: Paper I utilised material derived from a populationbasedmulti-centre cohort study. A total of 2652 nulliparous women at nineobstetric departments in Denmark answered a self-administrated questionnaireat 37 weeks of gestation. Among the total sample, 37.1% (985) women met theprotocol criteria for labour dystocia. In Paper II an inductive qualitative methodwas used, based on focus group interviews with sixteen midwives working inantenatal care in southern Sweden who were divided into four focus groups. InPaper III a grounded theory approach was used to develop a theoretical modelof ten women’s experiences of intimate partner violence during pregnancy. PaperIV was a cross-sectional study including a cohort of 1939 pregnant women whoanswered a self-administered questionnaire at their first visit to seventeen ANCsin south-west Scania in Sweden.Results: In paper I, 35.4 % (n = 940) of the total cohort of women reportedhistory of violence, and among these, 2.5 % (n = 66) reported exposure toviolence during their first pregnancy. Further, 39.5% (n = 26) of those had neverbeen exposed to violence before. No associations were found between historyof violence or experienced violence during pregnancy and labour dystocia atterm. However, among those women consuming alcoholic beverages during latepregnancy, women exposed to violence had increased odds of labour dystocia(crude OR 1.49, CI: 1.07 – 2.07) compared to women who were unexposedto violence. In Paper II, an overarching category ‘Failing both mother and theunborn baby’ highlighted the vulnerability of the unborn baby and the needto provide protection for the unborn baby by means of adequate care to thepregnant 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 empiricaldata formed a theoretical model, and the core category, ‘Struggling to survivefor the sake of the unborn baby’, constituted the main concerns of women whowere exposed to IPV during pregnancy. The core category also demonstratedhow the survivors handled their situation. Three sub-core categories wereidentified that were properties of the core category; these were: ‘Trapped inthe situation’, ‘Exposed to mastery’ and ‘Degradation processes’. In Paper IV,‘history of violence’ was reported by 39.5% (n = 761) of the women. Prevalenceof experience of domestic violence during pregnancy, regardless of type or levelof abuse, was 1.0 % (n = 18), and prevalence of history of physical abuse byactual intimate partner was 2.2 % (n = 42). The strongest factor associated withdomestic violence during pregnancy was history of violence (p < 0.001). Thepresence of several symptoms of depression was associated with a 7-fold risk ofdomestic violence during pregnancy (OR 7.0; 95% CI: 1.9-26.3).Conclusions: Our findings indicated that nulliparous women who have ahistory of violence or experienced violence during pregnancy do not appearto have a higher risk of labour dystocia at term, according to the definitionof labour dystocia used in this study. Additional research on this topic wouldbe beneficial, including further evaluation of the criteria for labour dystocia(Paper I). Avoidance of questions concerning the experience of violence duringpregnancy may be regarded as failing not only the pregnant woman but also theunprotected and unborn baby. Still, certain hindrances must be overcome beforethe implementation of routine enquiry concerning pregnant women’s experiencesof violence (Paper II). The theoretical model “Struggling to survive for the sakeof the unborn baby” highlights survival as the pregnant women’s main concernand explains their strategies for dealing with experiences of violence duringpregnancy. The findings may provide a deeper understanding of this complexmatter for midwives and other health care professionals (Paper III). The reportedprevalence of domestic violence during pregnancy in southwest Scania in Swedenis low. Both history of violence and the presence of several depressive symptomsdetected in early pregnancy may indicate that the woman also is exposed todomestic violence during pregnancy (Paper IV).