Intimate Partner Violence and Pregnancy, an Intervention Study in

Intimate Partner Violence and Pregnancy, an Intervention Study in

Intimate Partner Violence and Pregnancy, an Intervention Study in Perinatal Care
Intimate Partner Violence
and Pregnancy,
an Intervention Study
in Perinatal Care
An-Sofie Van Parys
Doctoral Thesis submitted to the Faculty of Medicine and Healh Sciences,
Ghent University
PhD Supervisors:
Prof. dr. Marleen Temmerman
Prof. dr. Hans Verstraelen
docthasvp.indd 3
12/09/16 12:36
Intimate Partner Violence and Pregnancy, an Intervention Study in Perinatal Care An-­‐Sofie Van Parys Doctoral thesis submitted to the Faculty of Medicine and Health Sciences, Ghent University September 2016 PhD Supervisor: Prof. Dr. Marleen Temmerman Department of Uro-­‐gynaecology, Faculty of Medicine and Health Sciences Ghent University, Ghent, Belgium PhD Co-­‐supervisor: Prof. Dr. Hans Verstraelen Department of Uro-­‐gynaecology, Faculty of Medicine and Health Sciences Ghent University, Ghent, Belgium Intimate Partner Violence and Pregnancy, an Intervention Study in Perinatal Care. An-­‐Sofie Van Parys PhD Supervisor: Prof. Dr. Marleen Temmerman Department of Uro-­‐gynaecology, Ghent University ISBN: 9789078128441 Ghent University / International Centre for Reproductive Health (ICRH) Ghent University Hospital/ Women’s Clinic De Pintelaan 185 UZP 114 B-­‐9000 Ghent (Belgium) [email protected] Supervisor: Prof. Dr. Marleen Temmerman Department of Uro-­‐gynaecology, Ghent University Faculty of Medicine and Health Sciences Ghent University Co-­‐supervisor: Prof. Dr. Hans Verstraelen Department of Uro-­‐gynaecology, Ghent University Faculty of Medicine and Health Sciences Ghent University Guidance comity: Prof. Dr. Kristien Roelens Department of Uro-­‐gynaecology, Ghent University Faculty of Medicine and Health Sciences Ghent University Prof. Dr. Fred Louckx Department of Sociology, Vrije Universiteit Brussel Faculty of Economic and Social Sciences & Solvay Business School, Vrije Universiteit Brussel Members of the jury: Prof. Dr. Gilbert Lemmens Prof. Dr. Steven Weyers Prof. Dr. Lesley Verhofstadt Prof. Dr. Katrien Beeckman Dr. Wendy Christiaens Dr. Heidi Stoeckl Chairperson of the jury: Prof. Dr. Dimitri Beeckman and Prof. Dr. Martine Cools ‘try to keep on keeping on’ (First Aid Kit, my silver lining) 5
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Dankwoord Een doctoraat schrijven is een proces dat ik al eens graag vergelijk met een zwangerschap of met het uitbroeden van een ei. Het vraagt tijd, uithoudingsvermogen, motivatie, toewijding, bloed, zweet en tranen. Het is iets waar ik jaren van gedroomd heb om het te mogen doen en waarvoor ik bijzonder dankbaar ben dat ik het heb kunnen doen. Het is een project waarmee je opstaat en waarmee je gaat slapen. Er zijn momenten waar je het einde van de tunnel niet meer ziet, maar gelukkig zijn er dan promotoren, collega’s, familie en vrienden die voor je klaar staan. Grote dank ben ik verschuldigd aan Marleen Temmerman, onder jouw vleugels heb ik enorm veel kansen gekregen en heb ik met vallen en opstaan geleerd wat het betekent om een wetenschapper te zijn. Ook Hans Verstraelen wil ik oprecht bedanken, je bent in de loop van de jaren uitgegroeid tot een soort mentor-­‐figuur voor mij. Ik heb steeds op jouw steun kunnen blijven rekenen en kon altijd op jou terugvallen, zeker ook in de moeilijke momenten. Dank zij jouw streven naar perfectie, heb ik het gevoel mijn grenzen verlegd te hebben en gegroeid te zijn als wetenschapper. De ‘bospaden en herten-­‐metaforen’ hebben naast inzichten gecreëerd ook regelmatig op de lachspieren gewerkt, wat eveneens van groot belang is gebleken. Dank ook aan Kristien Roelens, één van de pioniers in het onderzoek naar partnergeweld en zwangerschap op onze dienst. Ik heb kunnen voortbouwen op jouw werk en heb altijd op jouw steun kunnen rekenen. Onze samenwerking heeft veel kansen gecreëerd en deuren voor mij geopend. Ik hoop dat we in de toekomst de geoliede tandem kunnen blijven die we momenteel zijn. Ik wil ook graag Fred Louckx van harte bedanken. Van bij het prille begin van mijn academische carrière ben je een rots in de branding geweest voor mij. Dank zij jouw wijze woorden en welgemeende steun, ben ik in mezelf blijven geloven en geraakt waar ik nu ben. Grote dankbaarheid ben ik ook verschuldigd aan alle collega’s op ICRH en in het bijzonder aan Ines Keygnaert, Kristien Michielsen, Heleen Vermandere, Olivier Degomme, Dirk Van Braeckel, Els Leye, en Sara De Meyer. Ik heb erg veel van jullie geleerd en samenwerken met jullie heeft me altijd bijzonder veel voldoening en plezier gegeven. Ilse Delbaere, Inge Tency en alle collega’s van de Vrouwenkliniek en in het bijzonder Marijke Trog, Régine Goemaes, Ann Van Holsbeeck, Anne Huygevelt, Marleen Remmery, Ellen Roets, Maaike 7
Vandenbroucke , Heleen Demaegd, Martine Meulebroek en Steven Weyers. Dank voor alle ondersteuning en hulp in de voorbije jaren. Een speciaal woord van dank gaat ook uit naar alle moedige vrouwen die deelnamen aan de studie(s). Ik hoop dat ze de kracht vinden om hun dromen en verlangens te realiseren. Ik hou er eveneens aan alle secretaressen, vroedvrouwen en artsen te bedanken die me geholpen hebben om de vrouwen aan te spreken en warm te maken om deel te nemen aan de studie. Zonder jullie steun was het allemaal niet mogelijk geweest. Ik wil ook heel graag mijn mama bedanken voor de onvoorwaardelijke steun en het eeuwige geloof in mijn kunnen, zelf doorheen alle moeilijke momenten in je leven. Zonder jou was dit nooit gelukt! Ook Katrien, Tom en mamie ben ik verschrikkelijk dankbaar om er altijd voor mij te zijn, te luisteren naar mijn gezaag (of ten minste te doen alsof ;-­‐) en altijd in mij te blijven geloven. Eskelien, Lore, Johannes, Bram, Jef, Tuur, Niel, Yun & Leona, dank voor het warme nest en de dagelijkse beslommeringen. Als laatste, maar daarom zeker niet minder belangrijk, wil ik mijn liefste lief Pieter bedanken. Als doctorerende metgezel, heb ik me altijd volledig door jouw begrepen en gesteund gevoeld. Jouw analytische blik, alle kritische vragen, de oneindige energie voor anderen en onvoorwaardelijke liefde maken een beter mens van mij. Korneel en Josefien, jullie helpen me om de dingen te in perspectief te plaatsen en de dingen los te laten. Dankzij jullie ken ik de kracht van moederliefde, wat me blijft motiveren om te zoeken naar manieren om de wereld te verbeteren voor moeders, vaders en kinderen. Deze thesis betekent het afsluiten van een erg boeiende periode in mijn leven, maar tegelijkertijd is het een opening naar nieuwe kansen en ontmoetingen waarvan ik hoop minstens evenveel te mogen leren. 8
Table of contents Dankwoord ............................................................................................. 7 List of Tables ......................................................................................... 15 List of Figures ........................................................................................ 16 List of Abbreviations ............................................................................. 19 Summary .............................................................................................. 19 Background and objectives .............................................................. 19 Methods ........................................................................................... 19 Results .............................................................................................. 20 Prevalence .................................................................................... 20 Associated factors ........................................................................ 21 Interventions ................................................................................ 21 Conclusion and recommendations ................................................... 21 Samenvatting ........................................................................................ 23 Achtergrond en objectieven ............................................................. 23 Methodologie ................................................................................... 23 Resultaten ........................................................................................ 24 Prevalentie ................................................................................... 24 Geassocieerde factoren ................................................................ 25 Interventies .................................................................................. 28 Conclusie en aanbevelingen ............................................................. 26 1.
Definitions and concepts ........................................................... 29 1.1. Definition of interpersonal violence .................................. 29 1.2. Definition of intimate partner violence ............................. 31 1.3. Pregnancyl associated IPV ................................................ 33 2.
Prevalence .................................................................................. 35 9
2.1. Lifetime prevalence ............................................................ 35 2.2. Pregnancyl associated prevalence .................................... 35 2.3. Evolution of pregnancyl associated IPV ............................ 37 3.
Risk factors ................................................................................ 40 3.1. Individual risk factors ......................................................... 42 3.1.1. Age .............................................................................. 42 3.1.2. Civil/marital status ...................................................... 42 3.1.3. Education .................................................................... 43 3.1.4. Employment ................................................................ 43 3.1.5. Income ........................................................................ 44 3.1.6. Substance abuse ......................................................... 45 3.1.7. Lifetime abuse ............................................................. 45 3.1.8. Ethnicity ...................................................................... 46 3.1.9. Rural/Urban Residence ............................................... 47 3.1.10. Housing problems ..................................................... 47 3.1.11. Pregnancyl related determinants ............................ 47 a.
Pregnancy intention and termination ........................... 47 b.
Parity ............................................................................. 48 3.2. Relationship and interpersonal risk factors ....................... 48 3.3. Societal, cultural and community risk factors .................... 50 3.4. Conclusion .......................................................................... 53 4.
Consequences of IPV ................................................................. 55 4.1. Physical health consequences ............................................ 56 4.1.1. Obstetrical and reproductive consequences .............. 57 4.1.2. Foetal or neonatal consequences ............................... 59 4.2. Psychological or mental health consequences .................. 59 10
4.3. Health consequences of IPV perpetration .........................60 4.4. Economic consequences .................................................... 60 5.
Theoretical frameworks for IPV associated with pregnancy ..... 62 5.1. Feminist theory .................................................................. 65 5.2. Family sociology theory ..................................................... 67 5.3. Evolutionary psychology .................................................... 69 5.4. Stress theory ...................................................................... 70 5.5. Social learning theory ......................................................... 72 5.6. Attachment theory ............................................................. 73 5.6.1. Double binding ............................................................ 76 5.7. Conclusion .......................................................................... 78 6.
Interventions in perinatal care ...................................................81 6.1. Screening / routine inquiry ................................................ 82 6.2. Interventions ...................................................................... 86 6.3. Help seeking behaviour ..................................................... 88 6.3.1. Model of help seeking and change ............................. 88 6.3.2. Stages of change model .............................................. 90 6.3.3. Determinants in help seeking behaviour .................... 93 7.
Conclusion ................................................................................. 96 Chapter 2: Methodology ...................................................................... 99 1.
General objective ...................................................................... 99 2.
Specific objectives ..................................................................... 99 Prevalence .................................................................................... 99 Associated factors ........................................................................ 99 Interventions ................................................................................ 99 3.
Methodology BIDENSl study ................................................... 100 11
4.
Methodology MOMl study .................................................... 101 4.1. Setting and context of Belgian perinatal health care ....... 102 4.2. Prevalence study ..............................................................103 4.3. Intervention study ............................................................ 104 4.3.1. Setting and study population .................................... 104 4.3.2. Allocation concealment / randomization .................. 105 4.3.3. Sample size ................................................................ 106 4.3.4. Intervention .............................................................. 106 4.3.5. Measures ................................................................... 108 5.
Methodology systematic literature review ............................ 108 6.
Ethical aspects ......................................................................... 109 Chapter 3: Results .............................................................................. 113 Paper 1: Prevalence of emotional, physical and sexual abuse among pregnant women in six European countries ................................... 115 Paper 2: Prevalence and evolution of intimate partner violence before and during pregnancy: a crossl sectional study ..................125 Paper 3: Intimate partner violence and psychosocial health, a cross-­‐
sectional study in a pregnant population ....................................... 137 Paper 4: A History of abuse and operative delivery – results from a European multil country cohort study .......................................... 147 Paper 5: Intimate partner violence and pregnancy: a systematic review of interventions .................................................................. 159 Paper 6: Impact of a referral card based intervention on intimate partner violence, psychosocial health, help-­‐seeking and safety behaviour during pregnancy and postpartum, a randomised controlled trial ................................................................................ 171 Chapter 4: Discussion ......................................................................... 225 1.
Prevalence ............................................................................... 225 12
1.1. Lifetime prevalence .......................................................... 225 1.2. Pregnancyl associated prevalence .................................. 226 2.
Associated factors ................................................................... 229 2.1. IPV and psychosocial health ............................................. 229 2.2. History of abuse and operative delivery ......................... 231 3.
Interventions ........................................................................... 233 3.1. IPV .................................................................................... 233 3.2. Helpl seeking behaviour ................................................. 236 3.3. Perceived helpfulness of the intervention ....................... 239 3.4. Strengths and weaknesses ............................................... 240 Chapter 5: Conclusion and recommendations ................................... 243 5.1. Prevalence ............................................................................ 243 5.2. Associated factors ................................................................ 244 5.3. Interventions ........................................................................ 246 Reference list ...................................................................................... 251 Annexes .............................................................................................. 289 Annex 1: BIDENS questionnaire ...................................................... 290 Annex 2: MOM study protocol ....................................................... 303 Annex 3: MOM questionnaire ........................................................ 327 Annex 4: Referral card .................................................................... 345 Annex 5: Interview guide (first interview) ...................................... 349
Annex 6: Ethical approval BIDENSl study ...................................... 367 Annex 7: Ethical approval MOMl study ..........................................375 13
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List of Tables Table 1: Overview theoretical frameworks for IPV associated with pregnancy Table 2: Overview effective interventions matched with stages of change (Frasier et al., 2001) 15
List of Figures Figure 1: Violence typology (WHO, 2002) Figure 2: Overview risk factors Figure 3: Impact of abuse during pregnancy on pregnancy outcomes (Coker et al., 2004) Figure 4: Model of help-­‐seeking and change (Liang et al., 2005) Figure 5: Timeline MOM-­‐study 16
List of Abbreviations AAS: Abuse Assessment Screen ACOG: American College of Obstetricians and Gynaecologists aOR: adjusted Odds Ratio APS: Abbreviated Psychosocial Scale BIDENS: Belgium, Iceland, Denmark, Estonia, Sweden and Norway CAPI: Child Abuse Potential Inventory CDC: Centres for Disease Control CG: Control Group CS: Caesarean Section CTS2S: Conflict Tactics Scale ES: Effect Size IG: Intervention Group IPV: Intimate Partner Violence MOM: Dutch acronym for ‘moeilijke momenten’, mother OR: Odds Ratio PRAMS: Pregnancy Risk Assessment Monitoring System QOL: Quality Of Life RCT: Randomised Controlled Trial SD: Standard Deviation SES: Sociol Economic Status STI’s: Sexually Transmitted Infections WHO: World Health Organisation
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Summary Background and objectives Healthy women, men and children are the building blocks of a strong world. While infant and maternal mortality continues to decline, the burden of morbidity in the perinatal period remains a major concern. Psychosocial health and partner violence are two major determinants of poor perinatal outcome and have repeatedly been described as an extensive public health problem with crucial societal and health implications. However, the impact of violence related factors such as fear of childbirth and psychosocial health on the mode of delivery remains little investigated. So far, most studies have focused on the identification and consequences of abuse/violence. There is a lacuna with regards to research on interventions in the health sector to reduce the magnitude and impact of intimate partner violence (IPV). As such, this study contributes to the need to identify effective interventions and how to adopt them within the perinatal care context. Therefore, next to assessing prevalence, determinants and associated obstetric outcomes, our objective is to assess the effect of a perinatal health sector embedded intervention for IPV. Methods This research is based on two studies: the BIDENS-­‐study and the MOM-­‐study. The BIDENS-­‐study is a longitudinal cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Sweden and Norway) aiming at assessing violence related factors that may influence pregnant women’s fear of childbirth and mode of delivery. In Belgium, we recruited in three antenatal care clinics between 2008 and 2010. Women were invited when attending antenatal care, and asked to complete a questionnaire containing items on socio-­‐economic background, mental health, violence/abuse, negative life events, fear of childbirth and obstetric history. Birth outcome data was collected from hospital records. The MOM-­‐study is a Belgian multi-­‐centre study consisting of two phases. The first phase was a cross-­‐sectional prevalence study, and the second phase a single-­‐blind randomized controlled trial (RCT). From June 2010 to October 2012, women seeking antenatal care in eleven Belgian hospitals were invited to participate and handed a questionnaire. The objective of the first phase was to assess the prevalence of physical, psychological and sexual partner 19
violence 12 months before and/or during pregnancy and to provide insight into the evolution of IPV. Participants reporting IPV were randomised into the intervention study aiming at investigating the effect of handing out a referral card, on the evolution of IPV, psychosocial health, help-­‐seeking and safety behaviour during and after pregnancy. Participants in the Intervention Group (IG) received a referral card with contact details of services providing assistance and tips to increase safety behaviour. Participants in the Control Group (CG) received a “thank you” card. Follow-­‐up data on the evolution of IPV, psychosocial health, help-­‐seeking and safety behaviour were obtained through telephone interview at 10-­‐12 months and 16-­‐18 months after receipt of the card. Both groups received the necessary care and support of antenatal caregivers, our intervention aimed at assessing the added value of handing out a referral card. Results Prevalence Our results indicated that violence is a prevalent problem among pregnant women in Belgium as well as in the other five European countries. Lifetime prevalence varied across the six countries (n= 7174) and ranges from 23.2 to 45.4%, with Belgium at the lowest end of the continuum for all forms of abuse/violence. Partners or ex-­‐partners accounted for the largest share of all violence reported and psychological abuse was the type of IPV of that is reported most frequently. In Belgium, physical partner violence before as well as during pregnancy was reported by 2.5% of the respondents (n = 1894), sexual violence by 0.9%, and psychological abuse by 14.9%. The overall percentage of IPV was 14.3% in the 12 months before pregnancy and 10.6% during pregnancy. Our data showed that both physical partner violence and psychological partner abuse are significantly lower during pregnancy. Associated factors First, we found a significant correlation between IPV and poor psychosocial health: lower psychosocial health scores were associated with increased odds of reporting IPV. A decrease of 10 points on the psychosocial health scale (total of 140) increased the odds of reporting IPV by 55 %. The association between overall psychosocial health and IPV remained significant after 20
adjusting for socio-­‐demographic status. When accounting for the 6 psychosocial health subscales (depression, anxiety, self-­‐esteem, mastery, worry and stress) simultaneously, only depression and stress remained significantly associated with IPV. Second, our research showed a limited correlation between a history of abuse/violence and mode of delivery. Having experienced sexual violence as an adult increases the risk of an elective Caesarean Section (CS) among primiparae, in particular for non-­‐obstetrical reasons. Among multiparous women, a history of physical violence increases the risk of an emergency CS. Interventions Over a timeline of 1.5 years we observed a significant decline in the prevalence of IPV by 31.4% and a significant increase of psychosocial health (5.4/140) in both the intervention and control group. More than one fifth of all women in our study sought formal help and 70.5% sought informal help. Women reporting IPV showed significantly more formal and informal help-­‐
seeking behaviour compared to women not reporting IPV. A third of the women took at least one safety measure, and when IPV was reported, safety measures were taken significantly more frequently. The questionnaire and the interview in this study were perceived as moderately to highly helpful by more than a third of our study group which was significantly higher than the helpfulness of the referral card. Although the benefit of the referral card appeared to be more substantial in the IG, it borderline missed statistical significance. Overall, we found that being questioned about IPV has an impact on our respondents, yet were unable to attribute any of the above findings directly to handing out the referral card. Conclusion and recommendations Our findings demonstrate that a substantial proportion of pregnant women report a history of abuse/violence. Psychological partner abuse appears to be the most frequent type of violence reported. The IPV prevalence rates in our study are slightly lower than in other Western studies and physical partner violence and psychological partner abuse is found to be significantly lower during pregnancy. Inspired by these findings we call for a thorough methodological and scientific debate on the definitions of IPV and a corresponding added nuance in terminology, taking the complex context and mutuality into account that are particularly relevant within the perinatal 21
period. It is also crucial to raise public awareness on abusive/violent behaviour within the context of an intimate relationship. Sensitization campaigns promoting positive and non-­‐violent communication starting from early childhood can substantially contribute to reversing the normalization of abuse/violence and eliminating IPV. Our research also demonstrated that IPV and psychosocial health are strongly associated. We believe that future research is necessary to deepen the understanding of the multitude of factors involved in the complex interactions between IPV and psychosocial health. Because of the important role of psychosocial health found in our study, we would like to join the growing number of authors that advocate the inclusion of IPV within a broader psychosocial health assessment as a standard part of antenatal care. We have also shown that the correlation between a history of abuse/violence and mode of delivery is limited. However, further longitudinal and large-­‐scale research is needed to explore the complex array of factors that are involved and shed more light on the impact of abuse/violence on obstetric outcome. The intervention part of this research showed that the detection of even low severity mutual IPV can be a helpful tool in the battle against IPV, though combining the identification with simply the distribution of a referral card is probably not the best means of achieving that goal. Being questioned on IPV has an undeniable impact, acting upon that matter may however require the involvement of a healthcare professional rather than a list of resources. Future interventions should be multifaceted, and thus simultaneously address several factors (such as psychosocial health, substance abuse, social support, cultural norms), delineate different types of violence (intimate terrorism vs. mutual violence), involve informal networks, control for effect of the measurement as such and include a tailored intervention programme adapted to the specific needs of couples experiencing IPV. 22
Samenvatting Achtergrond en objectieven Gezonde vrouwen, mannen en kinderen zijn de bouwstenen voor een sterke wereld. Ondanks de aanhoudende daling van kinder-­‐ en moedersterfte, blijft de morbiditeit in de perinatale periode een groot probleem. Psychosociale gezondheid en partnergeweld zijn twee belangrijke determinanten die het welzijn in de perinatale periode bedreigen en werden reeds herhaaldelijk beschreven als een omvangrijk gezondheidsprobleem met cruciale maatschappelijke en gezondheidsimplicaties. De impact van geweld gerelateerde factoren en psychosociale gezondheid op de manier van bevallen werd nog maar weinig onderzocht. Tot nu toe focusten de meeste studies echter op de identificatie en de gevolgen van misbruik/geweld. Er is een gebrek aan grootschalige interventiestudies binnen de gezondheidszorg die de omvang en de impact partnergeweld reduceren. Deze studie wil net hieraan bijdragen en duidelijkheid verschaffen over welke interventies effectief zijn en dus toegepast dienen te worden in de perinatale zorgcontext. Daarom is onze doelstelling, naast de het onderzoek naar prevalentie, determinanten en geassocieerde obstetrische outcome, het effect van een interventie voor partnergeweld nagaan in de perinatale zorgcontext. Methodologie Dit onderzoek bestaat uit twee studies: de BIDENS-­‐studie en de MOM-­‐studie. De BIDENS-­‐studie is een longitudinale cohortstudie in zes Europese landen (België, IJsland, Denemarken, Estland, Zweden en Noorwegen) met als doel geweld-­‐gerelateerd factoren en de invloed daarvan op angst voor de bevalling en de manier van bevallen in kaart brengen. In België rekruteerden we in 3 prenatale raadplegingen van maart 2008 tot augustus 2010. Vrouwen werden aangesproken wanneer ze zich aanmeldden op de prenatale raadpleging en vroegen hen een vragenlijst in te vullen die items bevatte over socio-­‐
demografische achtergrond, mentale gezondheid, misbruik/geweld, negatieve levensgebeurtenissen, angst voor de bevalling en obstetrische achtergrond. Gegevens over de bevalling werden uit de medische dossiers gehaald. De MOM-­‐studie is een Belgische multicentrische studie die uit uit twee fases bestaat. De eerste fase was een cross-­‐sectionele prevalentiestudie, de tweede fase is een enkelblinde gerandomiseerde gecontroleerde studie (RCT). Van juni 2010 tot oktober 2012 werden vrouwen op de prenatale raadpleging van 23
elf Belgische ziekenhuizen uitgenodigd om deel te nemen en een vragenlijst overhandigd. Het doel van de eerste fase was het in kaart brengen van de prevalentie en de evolutie van fysiek, seksueel en psychisch partnergeweld 12 maanden voor en tijdens de zwangerschap en inzicht verschaffen in de evolutie van het geweld. Participanten die partnergeweld (als slachtoffer) rapporteren, werden gerandomiseerd in de interventiestudie met als doel het het effect na te gaan van het overhandigen een verwijskaart op de evolutie van partnergeweld, psychosociale gezondheid, hulpzoekend-­‐ en veiligheidsgedrag. Deelnemers in de interventie groep (IG) ontvingen een verwijskaart met daarop contactgegevens van hulpverlening en tips om de veiligheid te bevorderen. Deelnemers in de controle groep (CG) ontvingen een bedankingskaart. Gegevens omtrent de evolutie van het partnergeweld, de psychosociale gezondheid, het hulpzoekend en veiligheidsgedrag werden door middel van een telefonisch interview bevraagd op 10-­‐12 maanden en 16-­‐18 maanden na de ontvangst van de kaart. Beide groepen ontvingen de nodige zorgverlening en ondersteuning, het doel van de interventiestudie was nagaan wat de toegevoegde waarde was van het overhandigen van een verwijskaart. Resultaten Prevalentie Ons onderzoek toonde aan dat geweld een prevalent probleem is bij zwangere vrouwen in België, maar evenzeer in de andere 5 Europese landen. De prevalentie van misbruik/geweld over de levensloop verschilt in de zes Europese landen (N= 7174) en varieert tussen de 23,2 en 45,4%, waarbij België zich aan het laagste eind van het continuüm bevindt. Partners en ex-­‐
partners hebben het grootste aandeel in het geweld en psychisch misbruik wordt het meest gerapporteerd. In België werd fysiek partnergeweld zowel voor als tijdens de zwangerschap werd gerapporteerd door 2,5%, 0,9% seksueel geweld en psychisch misbruik door 14,9% van de respondenten (N= 1894). Partnergeweld in de 12 maanden voor de zwangerschap bedroeg 14,2% en tijdens de zwangerschap 10,6%. Onze data toonden aan dat zowel fysiek partnergeweld en psychisch partner misbruik significant lager liggen tijdens de zwangerschap in vergelijking met de periode 12 maanden voor de zwangerschap. 24
Geassocieerde factoren Ten eerste vonden we een sterke correlatie tussen het ervaren van partnergeweld (als slachtoffer) en een zwakke psychosociale gezondheid: lage psychosociale gezondheid scores zijn gecorreleerd met hogere odds voor het rapporteren van partnergeweld (als slachtoffer). Een daling van 10 punten op de schaal van psychosociale gezondheid (in totaal 140) deed de odds op het melden van partnergeweld (als slachtoffer) met 55% stijgen. De correlatie tussen psychosociale gezondheid in het algemeen en partnergeweld (als slachtoffer) bleef onveranderd na correctie voor socio-­‐demografische status. Wanneer we keken naar de 6 subschalen voor psychosociale gezondheid (depressie, angst, zelfvertrouwen, beheersing, zorgen en stress) tegelijk, bleven echter enkel depressie en stress significant geassocieerd met het rapporteren van partnergeweld (als slachtoffer). Ten tweede toonde ons onderzoek aan dat de correlatie tussen misbruik/geweld tijdens de levensloop en de manier van bevallen beperkt is. Seksueel geweld als volwassene ervaren deed de kans op een electieve keizersnede stijgen bij primiparae, voornamelijk omwille van niet-­‐obstetrische redenen. Bij meerbarende vrouwen deed een verleden van fysiek geweld de kans op een spoed keizersnede stijgen. Interventies Over een periode van anderhalf jaar vonden we een significante daling van de prevalentie van partnergeweld (als slachtoffer) met 31,4% en een significante stijging van de psychosociale gezondheid (5,4/140), zowel in de interventie als in de controle groep. Meer dan een vijfde van de vrouwen zocht formele hulp en 70,5% zocht informele hulp. Een derde van de vrouwen nam ten minste één veiligheidsmaatregel en wanneer er partnergeweld (als slachtoffer) gerapporteerd werd, werd er significant meer veiligheidsgedrag gesteld in vergelijking met de vrouwen die geen partnergeweld rapporteerden. De vragenlijst en het interview werden als matig tot heel behulpzaam ervaren door meer dan een derde van de vrouwen en dit was significant groter dan de mate waarin de verwijskaart als behulpzaam werd ervaren. We konden geen van de bovenstaande bevindingen aan het uitdelen van de verwijskaart linken. Hoewel de behulpzaamheid van de verwijskaart groter was in de IG, was het net niet statistisch significant. Over het algemeen vonden we dat vragen naar partnergeweld een impact had op onze respondenten, we kunnen onze bevindingen echter niet verklaren door het overhandigen van de verwijskaart. 25
Conclusie en aanbevelingen De resultaten in dit onderzoek tonen aan dat een substantieel deel van de zwangere vrouwen een verleden heeft van misbruik en/of geweld. Psychisch partnergeweld blijkt het meest frequent gerapporteerd te worden. De prevalentiecijfers van partnergeweld die uit onze studies naar voor kwamen, liggen iets lager dan wat andere Westerse studies rapporteren en fysiek partnergeweld en psychisch misbruik door de partner zijn beduidend lager tijdens de zwangerschap. Met deze resultaten in het achterhoofd roepen wij op tot een grondig methodologisch en wetenschappelijk debat over de definities van partnergeweld en een bijhorende meer genuanceerde terminologie die rekening houdt met de complexe context en wederkerigheid die bijzonder relevant is in de perinatale periode. Het is eveneens noodzakelijk om het grote publiek rond gewelddadig of grensoverschrijdend gedrag in partnerrelaties te sensibiliseren. Sensibiliseringscampagnes die positieve en niet-­‐gewelddadige communicatie vanaf de vroege kindertijd promoten, kunnen substantieel bijdragen om de normalisering van geweld te bannen en partnergeweld zoveel mogelijk te elimineren. Ons onderzoek toonde aan dat partnergeweld en psychosociale gezondheid sterk met elkaar verweven zijn. We zijn ervan overtuigd dat meer onderzoek nodig is om het inzicht in de veelheid van factoren die een rol spelen in de complexe interactie tussen partnergeweld en psychosociale gezondheid verder uit te diepen. Gelinkt aan de belangrijke rol van psychosociale gezondheid die onze studie demonstreerde, zouden we ons graag aansluiten bij het toenemende aantal auteurs die pleiten voor de integratie van partnergeweld in een bredere psychosociale screening als een standaardonderdeel van prenatale zorg. We toonden eveneens aan dat de correlatie tussen een verleden van misbruik/geweld en de manier van bevallen beperkt is. Verder longitudinaal en grootschalig onderzoek is echter nodig om de complexiteit aan betrokken factoren in kaart te brengen en de impact van misbruik/geweld op outcome van de bevalling verder te belichten. Onze interventiestudie illustreerde dat zelfs het detecteren van de lichte vormen van wederzijds misbruik/geweld als helpend kan ervaren worden in de strijd tegen partnergeweld, hoewel de combinatie van het identificeren met simpelweg het verstrekken van een verwijskaart waarschijnlijk niet de ideale manier is om dat doel te bereiken. 26
Vragen stellen naar geweld heeft een impact die we niet kunnen ontkennen, om hier op een adequate manier gevolg aan te geven zal het betrekken van zorg-­‐ of hulpverleners vermoedelijk zinvoller zijn dan een lijst met contactgegevens te overhandigen. Toekomstige interventies zouden meer multifactorieel moeten zijn en verschillende elementen zoals psychosociale gezondheid, middelenmisbruik, sociale steun, culturele opvattingen etc. simultaan in rekening brengen, verschillende types van geweld onderscheiden (intiem terrorisme vs. wederzijds geweld), controleren voor het effect van de meting zelf en een interventie ontwerpen op maat van de specifieke noden van koppels die partnergeweld ervaren. 27
28
Chapter 1: Background In this chapter we provide a general framework to situate the topic of this research. First, we explain the current definitions and concepts starting with more general aspects such as interpersonal violence, intimate partner violence (IPV) and continue with more specific aspects such as pregnancy-­‐
associated violence. Subsequently, we give an overview of lifetime and pregnancy-­‐associated prevalence rates and comment on the evolution of IPV around the time of pregnancy. Then, we describe risk factors and consequences of IPV and its relation to the pregnancy-­‐period. Further, we summarize the most influential IPV theories that provide insight into the causal pathways and dynamics of IPV associated with pregnancy. Finally, we elaborated on the challenges of addressing IPV through screening and interventions and the role of perinatal care in this matter. 1.
Definitions and concepts 1.1.
Definition of interpersonal violence The World Health Organisation defines violence as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation”(Krug, Mercy, Dahlberg, & Zwi, 2002a) . Violence can be divided into the following categories (cf. figure 1): • self-­‐directed violence • interpersonal violence • collective violence This categorization differentiates between violence a person inflicts upon himself or herself, violence inflicted by another individual or by a small group of individuals, and violence inflicted by larger groups such as states, organized political groups, militia groups and terrorist organizations. 29
Figure 1: Violence typology (Krug et al., 2002a) Interpersonal violence refers to violence between individuals, and is subdivided into family and intimate partner violence and community violence. The former category includes child maltreatment; intimate partner violence; and elder abuse, while the latter is broken down into acquaintance and stranger violence and includes youth violence; assault by strangers; violence related to property crimes; and violence in workplaces and other institutions (Krug, Mercy, Dahlberg, & Zwi, 2002b). Interpersonal violence exists in many forms and is often a combination of physical, psychological, sexual and/or socio-­‐economic violence. It can occur in all types of informal and formal relations as well as in contexts and settings surpassing personal relationships. Interpersonal violence can be perpetrated by individuals as well as induced and condoned by institutions and states. Determinants of interpersonal violence are situated at the personal, interpersonal, organizational and societal level. While certain determinants are more structural (as migration, poverty, low socio-­‐economic status, sexual identity and gender orientation, cultural practices and norms…) others are life-­‐cycle driven, enhancing the risks of victimization as well as perpetration for example in pregnancy and childbirth, early childhood, adolescence, young adulthood, ageing and in crisis situations when people are increasingly dependent on others (Krug et al., 2002a). 30
1.2.
Definition of intimate partner violence IPV is defined as any behaviour within a present or former intimate relationship that leads to physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviour patterns (Heise, Ellsberg, & Gottmoeller, 2002; Garcia-­‐
Moreno, Guedes, & Knerr, 2012). An intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner) is a person with whom one has a close personal relationship that may be characterized by the partners’ emotional connectedness, regular contact, ongoing physical contact and sexual behaviour, identity as a couple, and familiarity and knowledge about each other’s lives. The relationship need not involve all of these dimensions. IPV can occur among heterosexual or same-­‐sex couples and does not require sexual intimacy. IPV can vary in frequency and severity. It occurs on a continuum, ranging from one hit that may or may not impact the victim to chronic, severe battering (Breiding, Basile, Smith, & Mahendra, 2015). The Centers for Disease Control and Prevention (CDC) (Breiding et al., 2015) distinguish four main types of intimate partner violence: • Physical violence is the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes, but is not limited to, scratching; pushing; shoving; throwing; grabbing; biting; choking; shaking; aggressive hair pulling; slapping; punching; hitting; burning; use of a weapon; and use of restraints or one's body, size, or strength against another person. Physical violence also includes coercing other people to commit any of the above acts; • Sexual violence is divided into five categories. Any of these acts constitute sexual violence, whether attempted or completed. Additionally all of these acts occur without the victim’s consent, including cases in which the victim is unable to consent due to being too intoxicated (e.g., incapacitation, lack of consciousness, or lack of awareness) through their voluntary or involuntary use of alcohol or drugs; • Rape or penetration of victim – This includes completed or attempted, forced or alcohol/drug-­‐facilitated unwanted vaginal, oral, or anal insertion. Forced penetration occurs through the perpetrator’s use of physical force against the victim or threats to physically harm the victim; 31
Victim was made to penetrate someone else – This includes completed or attempted, forced or alcohol/drug-­‐facilitated incidents when the victim was made to sexually penetrate a perpetrator or someone else without the victim’s consent; • Non-­‐physically pressured unwanted penetration – This includes incidents in which the victim was pressured verbally or through intimidation or misuse of authority to consent or acquiesce to being penetrated; • Unwanted sexual contact – This includes intentional touching of the victim or making the victim touch the perpetrator, either directly or through the clothing, on the genitalia, anus, groin, breast, inner thigh, or buttocks without the victim’s consent; • Non-­‐contact unwanted sexual experiences – This includes unwanted sexual events that are not of a physical nature that occur without the victim’s consent. Examples include unwanted exposure to sexual situations (e.g., pornography); verbal or behavioural sexual harassment; threats of sexual violence to accomplish some other end; and /or unwanted filming, taking or disseminating photographs of a sexual nature of another person. Stalking is a pattern of repeated, unwanted, attention and contact that causes fear or concern for one’s own safety or the safety of someone else (e.g., family member or friend). Some examples include repeated, unwanted phone calls, emails, or texts; leaving cards, letters, flowers, or other items when the victim does not want them; watching or following from a distance; spying; approaching or showing up in places when the victim does not want to see them; sneaking into the victim’s home or car; damaging the victim’s personal property; harming or threatening the victim’s pet; and making threats to physically harm the victim; Psychological aggression is the use of verbal and non-­‐verbal communication with the intent to harm another person mentally or emotionally, and/or to exert control over another person. Psychological aggression can include expressive aggression (e.g., name-­‐calling, humiliating); coercive control (e.g., limiting access to transportation, money, friends, and family; excessive monitoring of whereabouts); threats of physical or sexual violence; control of •
•
•
32
reproductive or sexual health (e.g., refusal to use birth control; coerced pregnancy termination); exploitation of victim’s vulnerability (e.g., immigration status, disability); exploitation of perpetrator’s vulnerability; and presenting false information to the victim with the intent of making them doubt their own memory or perception (e.g., mind games). Other terms that have been used to refer to IPV are: domestic violence, family violence, spouse/partner abuse/assault, battering, violence against women, wife beating, gender based violence, etc. A multitude of definitions and terminology are currently being used interchangeably and the inconsistent use of terms referring to different types of (partner) violence is a large impediment. For example the term ‘domestic violence’ is used in many countries to refer to partner violence but the term can also encompass child or elder abuse, or abuse by any member of a household (Garcia-­‐Moreno et al., 2012). The lack of a consistent definition limits the ability to: gauge the magnitude of the problem, adequately measure risk and protective factors, identify those groups at highest risk who might benefit from focused intervention or increased services, monitor changes in the incidence and prevalence over time which, in turn, limits our ability to monitor the effectiveness of prevention and intervention activities and compare the problem across regions and nations (Breiding et al., 2015). To avoid confusion with regard to the terminology used, we use the term IPV to refer to IPV-­‐victimisation. When we are referring to perpetration it will be specified explicitly. 1.3.
Pregnancy-­‐associated IPV Pregnancy and childbirth are major milestones in the lives of many couples and their families. It is an important turning point where roles and relationships are being redefined on different levels. The transition to parenthood brings joy but also new challenges to couple relationships (Fisher et al., 2012; Kan & Feinberg, 2010). Pregnancy may be a stressful time because of changes in physical, emotional, social and economic needs. This period is associated with increased demands on individual capacities, the intimate partner relationship and household economic resources, and a reduction in leisure time and opportunities to socialise, which can exert 33
adverse effects on emotional wellbeing. Research (Silva, Ludermir, Araujo, & Valongueiro, 2011a; Hellmuth, Gordon, Stuart, & Moore, 2013) demonstrates that individual and dyadic coping strategies tend to decrease under stress, leading to an increased risk of physical and psychological aggression. Factors such as low socio-­‐economic status (SES) may also exacerbate stress, especially during pregnancy (Doss, Rhoades, Stanley, & Markman, 2009). Whereas expectant couples may be able to cope with the stress that commonly arises during this time without using violence, low SES pregnant women may be particularly vulnerable to IPV victimization/perpetration as a result of being exposed to the confluence of these factors (Curry, Perrin, & Wall, 1998; Kaslow & Thompson, 2008a). This vulnerable period, however, is not limited to the time between conception and birth. Researchers have clearly demonstrated that risk factors for IPV associated with pregnancy encompass the time frame of one year before conception until one year after childbirth (Saltzman, Johnson, Gilbert, & Goodwin, 2003; Martin et al., 2004; Taillieu & Brownridge, 2010a; Jasinski, 2004; Charles & Perreira, 2007). Therefore, we conceptualise IPV as pregnancy-­‐associated IPV or IPV associated with pregnancy, or IPV in the perinatal period which refers to violence occurring up to one year before, during and one year after pregnancy (Sharps, Laughon, & Giangrande, 2007). Obviously, pregnant women can also be confronted with other types of violence than partner violence (e.g. child abuse, assault by a stranger, honour related violence etc.). Within the frame of this research, we chose to focus on partner violence for several reasons. First of all IPV is the most prevalent form of violence and therefore relevant to a large part of the population. Second, pregnant women are more likely to be in a relationship compared to a non-­‐
pregnant population and therefore more at risk of experiencing IPV (Taillieu & Brownridge, 2010a). In addition, the reproductive age group (15-­‐49 years) has also been identified as a high-­‐risk group for IPV (Shamu, Abrahams, Temmerman, Musekiwa, & Zarowsky, 2011). 34
2.
Prevalence 2.1.
Lifetime prevalence Knowing the prevalence of IPV is an important first step in helping to inform the development and implementation of interventions to prevent and treat sequelae (Devries et al., 2010a). Over the last decades, research has increasingly shown that IPV is a worldwide and prevalent problem. Recent global prevalence figures indicate that about 1 in 3 women worldwide have experienced either physical and/or sexual intimate partner violence or non-­‐
partner sexual violence in their lifetime. Most of this violence is intimate partner violence. Worldwide, almost one third of women who have been in a relationship report that they have experienced some form of physical and/or sexual violence by their intimate partner. Regarding Europe, 25.4% of women and girls experience physical and/or sexual violence by their partner during their lifetime (WHO, 2014). 2.2.
Pregnancy-­‐associated prevalence Over the past 30 years, over hundred studies have been published in the Western world on pregnancy-­‐associated violence (James et al., 2013; Straus et al., 2011). Recently, more evidence has been emerging from low and middle-­‐income countries (Shamu et al., 2011). Prevalence rates in African and Latin American countries are mainly situated at the high end of the continuum and the European and Asian countries are positioned at the lower end (Devries et al., 2010a). Despite this considerable amount of research, sound estimates of the prevalence of abuse and violence during the childbearing period are difficult to obtain (Daoud et al., 2012). One of the first authors that published a comprehensive review of prevalence rates of pregnancy related violence were Gazmararian and colleagues (Gazmararian et al., 1996). Despite the fact that this article is almost 20 years old, it is still actively cited. Gazmararian et al. (Gazmararian et al., 1996) found that rates of IPV varied considerably between studies, and reported a range of physical partner violence from 0.9 to 20.1%. More recent papers have published estimates of IPV around the time of pregnancy that vary between 3 and 30% (Devries et al., 2010a). Although estimates within regions and countries are highly variable, the majority of studies show prevalence rates ranging from 3.9% to 8.7% (Devries et al., 2010a). This large variation in prevalence rates is caused by a myriad of study design features and 35
methodological challenges (cf. infra), making comparison across studies and nations a true challenge. We would also like to note that most studies only measured physical and/or sexual partner violence. Psychological or emotional abuse is often not included due to the current lack of agreement on standard measures and threshold at which acts can be considered being emotional/psychological abuse/violence (WHO, 2014). A recent systematic review (Taillieu & Brownridge, 2010a) of prevalence studies of violence during pregnancy, reported 0.9 -­‐ 30% physical violence, 1 – 3.9% sexual violence and 1.5 – 36% psychological abuse during pregnancy. In another meta-­‐analysis, James et al. (James, Brody, & Hamilton, 2013) calculated a mean reported prevalence rate of partner violence among pregnant women of 19.8% over 92 studies, reporting 28.4% emotional abuse, 13.8% physical abuse, and 8.0%, sexual abuse during pregnancy. In Belgium, 10 years ago, Roelens and colleagues (Roelens, Verstraelen, Van Egmond K., & Temmerman, 2008a) surveyed 537 pregnant women attending antenatal care in five large hospitals in East-­‐Flanders. Women were asked to complete the questionnaire at home and to return it anonymously by mail to the principal investigator. They found that 26.7% of the women reported lifetime physical and/or sexual violence, 22.3% reported physical violence and 11.2% reported sexual violence with more than half of these women indicating being raped. 2.4% reported experiencing physical and/or sexual partner violence 12 months preceding pregnancy and of 2.2% physical and/or sexual partner violence during pregnancy. For more than half (53.8%) of women experiencing partner violence during pregnancy, IPV did already occur before pregnancy. Jeanjot and colleagues (Jeanjot, Barlow, & Rozenberg, 2008) reported similar results based on a structured interview of 200 women during early post-­‐partum in a university hospital in Brussels. This study indicated that 22% of the women experienced domestic violence during their lifetime and 11% experienced it during pregnancy. In more than half of the cases, the (ex)partner was indicated as the perpetrator. Pieters and colleagues (Pieters, Italiano, Offermans, & Hellemans, 2010) did a large-­‐scale prevalence-­‐study on violence in Belgium interviewing 2,014 men and women by telephone and found that 7.1% of the respondents experienced partner violence while being pregnant. The variation in prevalence rates is influenced by the considerable differences in definitions (e.g. physical and/or sexual and/or psychological violence/abuse, domestic violence vs. IPV), study populations (e.g. small health-­‐care based samples vs. population-­‐based samples), the mode of 36
inquiry (e.g. face-­‐to-­‐face interview vs. self-­‐administered questionnaire), type of questions (e.g. general questions vs. specific behaviour) and the timing of inquiry (e.g. single measurement early in pregnancy vs. multiple measurements throughout the whole pregnancy). In other words, myriad study design features have influenced the prevalence rates reported, making comparison across studies a true challenge (Taillieu & Brownridge, 2010a; Saltzman et al., 2003; Daoud et al., 2012; Brownridge et al., 2011; Roelens et al., 2008a). Higher prevalence rates have been associated with more inclusive definitions of abuse, more than a single item asking about abuse experiences, specific behavioural questions instead of general questions, multiple inquiries and face-­‐to-­‐face interviews. More information and details on prevalence rates found in this research, can be found in papers 1, 2 and 3. 2.3.
Evolution of pregnancy-­‐associated IPV Pregnancy may be a stressful time because of changes in physical, emotional, social and economic needs. This period is associated with increased demands on individual capacities, the intimate partner relationship and household economic resources, and a reduction in leisure time and opportunities to socialize, which can exert adverse effects on emotional wellbeing (Fisher et al., 2012; Wisner, Chambers, & Sit, 2006). Research (Silva, Ludermir, Araujo, & Valongueiro, 2011b; Hellmuth et al., 2013) demonstrates that individual and dyadic coping strategies tend to decrease under stress, leading to an increased risk of physical and psychological aggression. Factors such as low SES and the multitude of factors involved may also exacerbate stress, especially during pregnancy (Doss et al., 2009). Whereas most expectant couples may be able to cope with the stress that commonly arises during this time without using violence (Kaslow & Thompson, 2008b; Curry et al., 1998), getting a clear view on the mechanisms involved in couples that do use violence, would be a great step forward in addressing the problem. However, the precise mechanisms and determinants that influence the interaction between IPV and pregnancy, are not well-­‐known. Three different patterns of IPV around the time of pregnancy have been identified in the literature: (1) IPV starting up (no violence/abuse before pregnancy, but violence/abuse during pregnancy), (2) IPV continuing (violence/abuse both before and during pregnancy, either remaining unchanged or increasing/decreasing), and (3) IPV ceasing (violence/abuse before pregnancy, but no violence/abuse during pregnancy). 37
The first pattern, the initiation of violence during pregnancy, appears to be the least cited pattern of violence against pregnant women. However, a substantial proportion of women (between 3.8% and 40.0%) experience violence for the first time during pregnancy (Taillieu & Brownridge, 2010a). Increased levels of arguments within couples caused by stress and changes in life due to pregnancy, can trigger violence during pregnancy and the postpartum period (Martin et al., 2004; Silva et al., 2011b). Jealousy and mistrust regarding paternity, ambivalent feelings (unwanted, mistimed) toward the pregnancy, resentment toward the unborn, increased financial pressure, increased ties and dependence between the couple, decreased physical and emotional availability, decreased sexual availability and activity, sleepless nights and changes in family dynamics may provoke greater conflicts within couples and the use of violence as a resource to resolve these conflicts (Kramer et al., 2009; Huth-­‐Bocks, Levendosky, Theran, & Bogat, 2004a; Jasinski, 2004; Burch & Gallup, 2004). The second pattern, or the pattern of violence persistence, is the most common pattern of pregnancy-­‐related IPV. One of the strongest predictors of pregnancy violence is a history of pre-­‐pregnancy violence (Taillieu & Brownridge, 2010a). Between 60% and 96% of women who are abused during pregnancy also report being abused in the past, suggesting that in pregnancy violence represents a continuation pre-­‐existing violence for most pregnant victims (Roelens, Verstraelen, Van Egmond K., & Temmerman, 2008b; Taillieu & Brownridge, 2010a). However, changes in type and frequency of violence during pregnancy, have been reported (Bacchus, Mezey, & Bewley, 2004; Guo, Wu, Qu, & Yan, 2004b; Martin et al., 2004; Sagrestano, Carroll, Rodriguez, & Nuwayhid, 2004). Studies including some form of emotional abuse in their violence measure (Renker & Tonkin, 2006; Janssen et al., 2003) are more likely to report that abuse continues into pregnancy, which could be indicative of changing abuse patterns during pregnancy. There is some evidence suggesting that the type of violence experienced may change at pregnancy onset. For example, Martin et al. (2004) reported that pregnancy was associated with increased psychological and sexual abuse for women experiencing pre-­‐pregnancy violence compared to women without a similar history. 38
Several researchers have demonstrated that for the third pattern, violence cessation, the prevalence of violence during pregnancy is consistently lower than violence occurring before pregnancy, both in developed (Heaman, 2005; Datner, Wiebe, Brensinger, & Nelson, 2007; Johnson, Haider, Ellis, Hay, & Lindow, 2003; Charles & Perreira, 2007; Saltzman et al., 2003; Curry et al., 1998; Bacchus, Mezey, Bewley, & Haworth, 2004; Bohn, Tebben, & Campbell, 2004; Covington, Justason, & Wright, 2001; Cox et al., 2004a; Dunn & Oths, 2004; Gazmararian et al., 1996; Janssen et al., 2003; McFarlane, Parker, & Soeken, 1996a; Renker & Tonkin, 2006; Yost, Bloom, McIntire, & Leveno, 2005) and less developed nations (Perales et al., 2009; Guo, Wu, Qu, & Yan, 2004a; Diaz-­‐Olavarrieta et al., 2007; Farid, Saleem, Karim, & Hatcher, 2008; Nasir & Hyder, 2003; Thananowan & Heidrich, 2008). Taillieu (Taillieu & Brownridge, 2010a) found that 31 to 69% of the women indicate that IPV stopped during pregnancy, suggesting that pregnancy may be a protective factor for some women. There is not much literature that explores the reasons for violence cessation during pregnancy. However, but one could hypothesize that pregnancy changes the social status of a woman and that it increases social control and respect for the woman (Bagcioglu, Vural, Karababa, Aksin, & Selek, 2014). In Western societies a pregnant woman is seen as a receptacle for the valuable vulnerable unborn child (Tuerkenheimer, 2006). Partners may realize that physical and sexual (not necessarily psychological) violence can harm the baby and therefore use less (physical) violence. Another hypothesis is that women feel more vulnerable during pregnancy and actually use more tactics to avoid violent escalations. Furthermore, the pregnancy period is a time that is focused on the future, creating a common goal for both partners. Although, IPV can stop during pregnancy, it is often resumed during postpartum. Even though there is some literature on the evolution of IPV around the time of pregnancy, these patterns remain an important pathway to research because little is understood about how partner violence may change throughout a woman’s pregnancy, what factors contribute to the varying patterns, and why pregnancy appears to be a protective period for some women while it is a period of increased risk for others(Macy, Martin, Kupper, Casanueva, & Guo, 2007; Silva et al., 2011a; Taillieu & Brownridge, 2010a). More information and data on the evolution of pregnancy-­‐associated IPV is available in paper 2. 39
3.
Risk factors It is more and more accepted that a single risk factor cannot explain why some individuals behave violently toward each other and why others don’t (Michau, Horn, Bank, Dutt, & Zimmerman, 2015). IPV is the result of the complex interplay of individual, relationship, social, cultural and environmental factors. Determining and understanding how these factors are related to IPV, is an important step to inform screening an intervention efforts at mitigating IPV and its negative consequences (Krug, 2002; Zink, Elder, Jacobson, & Klostermann, 2004). A number of determinants have been investigated as they relate to a woman's risk of experiencing IPV during pregnancy. Although an understanding of what places certain women at risk for experiencing IPV during pregnancy is an important step in this direction, these risk markers need to be incorporated into larger frameworks in order to provide a more comprehensive understanding of this specific form of violence. The socio-­‐ecological model (Bronfenbrenner, 1979) is a framework that has been widely used to grasp and conceptualize the multifaceted nature of violence. This model consists of 4 levels: Individual The first level identifies biological and personal history factors that increase the likelihood of becoming a victim or perpetrator of violence. Some of these factors are for example age, education, income, substance use, or history of abuse. Relationship The second level examines close relationships that may increase the risk of experiencing violence. A person's closest social circle-­‐peers, partners and family members-­‐influences their behaviour and contributes to their range of experience. Community The third level explores the settings, such as schools, workplaces, and neighbourhoods, in which social relationships occur and seeks to identify the characteristics of these settings that are associated with becoming victims or perpetrators of violence. 40
Societal The fourth level looks at the broad societal factors that help create a climate in which violence is encouraged or inhibited. These factors include social and cultural norms. Other large societal factors include the health, economic, educational and social policies that help to maintain economic or social inequalities between groups in society (Center for Disease Control and Prevention, 2013). Researchers have only recently begun to look for individual and community factors that might affect the occurrence of partner violence. Although violence is found to exist in most places, there are some pre-­‐industrial societies where partner violence is virtually absent (Counts D.A., Brown J., & Campbell J., 1992; Levinson D., 2016). These societies stand as testament to the fact that social relations can be free of violence and that IPV is avoidable under particular conditions. Our present understanding of factors affecting the prevalence of partner violence is based largely on studies conducted in the Western world. In general, the current research base is highly skewed towards investigating individual factors rather than community or societal risk factors. Indeed, while there is an emerging consensus that an interplay of personal, situational, social and cultural factors combine to cause abuse, there is still only limited information on which factors are the most important and how they interact (Krug, 2002). Moreover, knowledge on risk factors for perpetrating violence (by pregnant women) is even more limited. In the underneath chapter we will provide an overview of the most important risk factors with regard to IPV and pregnancy. This information should, however, be viewed as both incomplete and highly tentative. Several important factors may be missing because no studies have examined their significance, while other factors may prove simply to be correlates of partner violence. Although numerable studies have attempted to identify specific risk factors related to IPV during the pregnancy period, the findings are mixed and the impact of risk factors on IPV remains unclear. With discrepancy in research findings, it is difficult to judge the strength of these risk factors. We will not make any statements on causality, since the vast majority of the studies examining risk factors are cross-­‐sectional in nature, based on clinical samples and executed in Western settings. Moreover, due to the large amount of confounding and mediating factors involved, determining precise 41
causal pathways within the dynamics of IPV is currently virtually impossible. To our knowledge, only one study (James et al., 2013) investigated the risk factors of IPV associated with pregnancy and performed a meta-­‐analysis. The main results of this study are included in the paragraphs underneath. 3.1.
Individual risk factors 3.1.1. Age A number of studies have shown that there is a relationship between young age and increased risk of IPV during pregnancy (Macy et al., 2007; Dufort, Gumpert, & Stenbacka, 2013; Finnbogadottir, Dykes, & Wann-­‐Hansson, 2014; James et al., 2013; Janssen, Heaman, Urquia, O'Campo, & Thiessen, 2012; Shamu et al., 2011; Thananowan & Heidrich, 2008; Swahnberg et al., 2004; Coker, Sanderson, & Dong, 2004a; Stith, Rosen, & McCollum, 2003; Saltzman et al., 2003; Bohn et al., 2004; Dunn & Oths, 2004; Heaman, 2005; Janssen et al., 2003; Radestad, Rubertsson, Ebeling, & Hildingsson, 2004). Although the relationship between age and an increased risk of pregnancy has been repeatedly documented, the association presumably results from confounding by socio-­‐economic status (Van Parys, Deschepper, Michielsen, Temmerman, & Verstraelen, 2014; Bohn et al., 2004; Dunn & Oths, 2004; Janssen et al., 2003; Muhajarine & D'Arcy, 1999; Brownridge et al., 2011; Taillieu & Brownridge, 2010a). 3.1.2. Civil/marital status Several studies have demonstrated that being single is associated with an increased risk for experiencing violence during pregnancy (Saltzman et al., 2003; Janssen et al., 2003; Macy et al., 2007; James et al., 2013; Janssen et al., 2012; Shamu et al., 2011; Thananowan & Heidrich, 2008; Macy et al., 2007; Swahnberg et al., 2004; Coker, Sanderson, & Dong, 2004b; Stith et al., 2003; Saltzman et al., 2003; Charles & Perreira, 2007; Dunn & Oths, 2004; Lipsky, Holt, Easterling, & Critchlow, 2005; Martin et al., 2004; Muhajarine & D'Arcy, 1999). A recent meta-­‐analysis of 92 studies (James et al., 2013) found an effect size of 1.73 for being single; in other words, women who were unmarried possessed 73% greater odds of being abused during pregnancy than married women (95% CI 0.86–2.58). Women may be at greater risk when they separate or divorce while pregnant (Saltzman et al., 2003). However, some of these studies found that the association was no longer significant when controlling for other socio-­‐demographic variables (Dunn & Oths, 2004; 42
Muhajarine & D'Arcy, 1999). The post-­‐separation period may be particularly important because research has suggested that abused pregnant women who are at the greatest risk for homicide may be more likely to leave their partners once they become pregnant compared to pregnant women with lower risk of homicide assessments (Decker, Martin, & Moracco, 2004; Brownridge et al., 2011; Taillieu & Brownridge, 2010a). 3.1.3. Education The findings concerning the relationship between education and the risk for violence during pregnancy are inconsistent. A number of researchers found that women with less than 12 years of education were more likely to experience violence during pregnancy (Macy et al., 2007; Shamu et al., 2011; Finnbogadottir et al., 2014; James et al., 2013; Dufort et al., 2013; Janssen et al., 2012; Thananowan & Heidrich, 2008; Swahnberg et al., 2004; Coker et al., 2004b; Stith et al., 2003; Saltzman et al., 2003). The meta-­‐analysis of James and colleagues (James et al., 2013) showed that pregnant women with a lower level of education were almost twice as likely to be abused as women possessing higher levels (ES = 1.92, 95% CI 0.072–0.312).Other studies have found that this association disappears in adjusted models (Dunn & Oths, 2004; Muhajarine & D'Arcy, 1999). Additionally, several studies report no significant difference in the risk for pregnancy violence based on varying degrees of educational attainment (Brownridge et al., 2011; Taillieu & Brownridge, 2010a; Diaz-­‐Olavarrieta et al., 2007; Perales et al., 2009; Fanslow, Silva, Whitehead, & Robinson, 2008a). Although there is conflicting evidence on education as a risk factor for IPV in the perinatal period, the majority of the studies seems to indicate that low levels of education is a risk factor for IPV. 3.1.4. Employment A number of studies have investigated the association between women’s employment status and the risk for violence during pregnancy, with some studies finding unemployment to be associated with an increased risk of violence (Thananowan & Heidrich, 2008; Janssen et al., 2012; James et al., 2013; Shamu et al., 2011; Bohn et al., 2004; Dunn & Oths, 2004; Janssen et al., 2003; Muhajarine & D'Arcy, 1999; Radestad et al., 2004; Saltzman et al., 2003) and others finding no association between employment status and risk for violence (Martin et al., 2004; Bohn et al., 2004; Dunn & Oths, 2004). Again, when confounding factors where entered into the models, the correlation often disappeared. Moreover, most studies did not investigate the 43
relationship between the male partner’s employment status and the risk for violence during pregnancy (Dunn & Oths, 2004; Bohn et al., 2004). In two studies that did investigate this relationship, male unemployed status emerged as a significant predictor for perpetrating violence against pregnant women (Brownridge et al., 2011; Taillieu & Brownridge, 2010a; Martin et al., 2004). 3.1.5. Income We identified contradicting findings in literature regarding the association between low income and violence during pregnancy. Some authors report that women with low incomes are more likely to experience violence during pregnancy (Dunn & Oths, 2004; Thananowan & Heidrich, 2008; Janssen et al., 2012; James et al., 2013; Dufort et al., 2013; Shamu et al., 2011; Bohn et al., 2004; Janssen et al., 2003) or as household income increased, the risk of having ever experienced violence during pregnancy decreased (Fanslow, Silva, Whitehead, & Robinson, 2008b). Other authors did not find a relationship between low income and risk to IPV or the relationship disappeared when confounding factors were added to the analysis (Dunn & Oths, 2004). Pregnancy is associated with increased financial pressures and may increase a woman's financial dependency on her partner (Pallitto, Campbell, & O'Campo, 2005; Bacchus, Mezey, & Bewley, 2006; Sales & Murphy, 2000a). Financial control by restricting access to money is a means to maintain control in a relationship (Pallitto et al., 2005) and this type of control has been reported by a number of women who have been abused during pregnancy (Bacchus et al., 2006; Pulido, 2001; Sales & Murphy, 2000a). Socio-­‐economic status (SES), often measured as a combination of education, income and occupation, is a determinant that is often linked to IPV (American Psychological Association, 2016). A number of studies have used proxy measures such as Medicaid recipients or other public health care benefits to assess the relationship between low SES and IPV. These studies suggest that low SES is associated with increased risk for pregnancy violence (Perales et al., 2009; Saltzman et al., 2003; Lipsky et al., 2005; Brownridge et al., 2011; Taillieu & Brownridge, 2010a). As the meta-­‐analysis of James et al. (James et al., 2013) illustrates, women of low socioeconomic status were at 66% increased risk [Effect Size (ES)= 1.66, 95%CI 5 0.58–2.74] 44
3.1.6. Substance abuse A considerable number of cross-­‐sectional studies have documented a relationship between women's alcohol and/or drug use and the risk for experiencing pregnancy violence (Janssen et al., 2003; Tzilos, Grekin, Beatty, Chase, & Ondersma, 2010; James et al., 2013; Gentry & Bailey, 2014; Alhusen, Lucea, Bullock, & Sharps, 2013; Holden, McKenzie, Pruitt, Aaron, & Hall, 2012; Shamu et al., 2011; Bailey, 2010a; Bailey & Daugherty, 2007; Datner et al., 2007; Wallace, Burns, Gilmour, & Hutchinson, 2007; Lipsky et al., 2005; Pallitto et al., 2005), while fewer studies have investigated how substance abuse by the male partner relates to violent behaviour. Some authors have found that pregnant women with a partner with a drinking and/or drug problem (Muhajarine & D'Arcy, 1999; Diaz-­‐Olavarrieta et al., 2007; Hellmuth et al., 2013; Charles & Perreira, 2007; McFarlane, Parker, & Soeken, 1996b) had a higher risk to experience violence. James et al. (James et al., 2013) demonstrated that pregnant women whose partners abused alcohol possessed 73% greater odds of being abused than pregnant women whose partners did not abuse alcohol (ES= 1.73); however, the stability of this effect is questionable (95% CI 20.03–3.78). In a small qualitative study of victims of violence during pregnancy, many of the respondents reported being assaulted while their partners were intoxicated and that the violence escalated when their partners were drunk (Bacchus et al., 2006). However, it is important to note that violence was not confined only to periods of intoxication, and all of the women also reported experiencing violence when their partner was sober. In other words, substance abuse is often perceived as a causal factor for IPV, while using illicit drugs or alcohol does not necessarily leads to IPV. It is clear that people under the influence of substances are more easily inclined to use violence, since it lowers the threshold and reduces restraints. Simultaneously, people experiencing IPV often use more substances as a strategy to cope with the associated stress of living in violent/abusive relations (Brownridge et al., 2011; Taillieu & Brownridge, 2010a). 3.1.7. Lifetime abuse A meta-­‐analysis on risk factors for domestic violence during pregnancy pointed out that abuse before pregnancy is the strongest risk factor for predicting violence during pregnancy. Pregnant women whose partners previously abused them were found to have four times greater odds of being 45
abused during pregnancy than women with no history of abuse (James et al., 2013). Furthermore, not only previous violent behaviour from a partner or ex-­‐
partner is a strong risk factor for IPV. As explained in the social learning theory chapter, violence in families is often transmitted across generations. Children who witness or experience violence are more likely to perpetrate or fall victim to violence as adults compared to non-­‐exposed children (Whitfield, Anda, Dube, & Felitti, 2003; Widom, Czaja, & Dutton, 2014; Chan et al., 2012; Taylor, Lee, Guterman, & Rice, 2010; Casanueva & Martin, 2007; Mezey, Bacchus, Bewley, & White, 2005; Brownridge, 2006a; Dube et al., 2003). Although it is clear that lifetime abuse is a strong predictor (Stewart, MacMillan, & Wathen, 2013) and violence in the family of origin has an impact on rates of adult perpetration and victimization, this relationship has not been fully explored as it relates specifically to the risk of violence during pregnancy (Brownridge et al., 2011; Taillieu & Brownridge, 2010a). 3.1.8. Ethnicity As with most other risk factors, the findings regarding the relationship between ethnicity and IPV during pregnancy are contradicting. Some studies report a relationship between minority status (Hispanic, Black, African-­‐
American, Native American compared to white women) and an increased risk for pregnancy violence (James et al., 2013; Janssen et al., 2012; Shamu et al., 2011; Charles & Perreira, 2007; Fanslow et al., 2008b; Robinson & Spilsbury, 2008; Janssen et al., 2003; Lipsky et al., 2005; Saltzman et al., 2003; Muhajarine & D'Arcy, 1999) and others find no association between the risk for pregnancy violence and ethnicity or report that white women experience more severe forms of violence compared to minority women (Bohn et al., 2004; Jasinski, 2001; Campbell & Campbell, 1996). Thus, the association between ethnicity and violence during pregnancy remains unclear in extant research. However, there has been some evidence to suggest that the increased prevalence rates of pregnancy violence reported by minority women may be associated with socioeconomic disadvantage, which may be a more accurate indicator of risk, rather than ethnicity per se (Lipsky et al., 2005; Brownridge et al., 2011; Taillieu & Brownridge, 2010a). 46
3.1.9. Rural/Urban Residence The potential relationship between rural/urban residence and the risk for violence during pregnancy has not been fully explored. Women living in rural areas (and aboriginal women living in isolated rural communities) may be at increased risk for violence (Janssen et al., 2003; Muhajarine & D'Arcy, 1999; Noel & Yam, 1992), other authors found no differences in the risk for violence related to residential area (Radestad et al., 2004). However, most of these studies did not assess the risk of violence during pregnancy specifically (Brownridge et al., 2011; Taillieu & Brownridge, 2010a). 3.1.10. Housing problems There is some indication that women experiencing housing problems (moving more than 2 times/year, no permanent living arrangement, homelessness) is related to violence during pregnancy (Datner et al., 2007; Saltzman et al., 2003; Brownridge et al., 2011; Taillieu & Brownridge, 2010a). 3.1.11. Pregnancy-­‐related determinants a. Pregnancy intention and termination Following on the link between pregnancy intention and IPV, a growing body of literature demonstrates a clear association between IPV and pregnancy termination or abortion, which is indicative of unintended/unplanned pregnancies (Chibber, Biggs, Roberts, & Foster, 2014; Stockl et al., 2012; Ely & Otis, 2011; Silverman et al., 2010; Whitehead & Fanslow, 2005). A number of studies have found that unintended/unplanned pregnancy is associated with the experience of violence during pregnancy and vice versa (Goodwin, Gazmararian, Johnson, Gilbert, & Saltzman, 2000; Charles & Perreira, 2007; Ismayilova & El-­‐Bassel, 2014; Stockl et al., 2012; Han & Stewart, 2014a; Pallitto et al., 2013a; Edin & Nilsson, 2013; Rahman, Nakamura, Seino, & Kizuki, 2012; Silverman, Decker, Reed, & Raj, 2006; Cripe et al., 2010; Fanslow, Silva, Robinson, & Whitehead, 2008; Gao, Paterson, Carter, & Iusitini, 2008; Perales et al., 2009; Saltzman et al., 2003; Thananowan & Heidrich, 2008). Population-­‐based studies on PRAMS (Pregnancy Risk Assessment Monitoring System) data in the USA have indicated that women reporting unintended pregnancies were approximately 2.5 times more likely to experience violence during pregnancy compared to women with intended pregnancies (Taillieu & Brownridge, 2010a). The meta-­‐
analysis from James and colleagues (James et al., 2013) reported that women who did not intend or want their pregnancy possessed 66% greater odds of 47
being abused than women who had planned their pregnancy (ES= 1.66, 95% CI 20.75–4.07). A recent WHO-­‐study (Pallitto et al., 2013b) demonstrated that women with a history of IPV had significantly higher odds of unintended pregnancy and of abortion across a variety of nations. Pooled estimates showed increased odds of unintended pregnancy and abortion, even after adjusting for confounding factors. Particularly, women abused during pregnancy have been shown to be more likely to have had multiple (three or more) abortions compared to non-­‐abused pregnant women (Janssen et al., 2003; Nguyen et al., 2012). Leung et al. (Leung, Leung, Chan, & Ho, 2002) found that abortion-­‐seekers tended to experience more severe abuse than other gynaecological patients. In addition, more than a fourth of the women seeking abortion admitted that their decision to terminate had been influenced by their histories of abuse (Leung et al., 2002). b. Parity There is some indication that violence during pregnancy is associated with the number of pregnancies or children within the family. Some studies found that multiparous women are more likely to experience violence during pregnancy compared to those pregnant with their first child (Fanslow et al., 2008; Onoh et al., 2013; Palmetto, Davidson, Breitbart, & Rickert, 2013; Salazar, Hogberg, Valladares, & Ohman, 2012; Rickert, Wiemann, Harrykissoon, Berenson, & Kolb, 2002). On the other hand, being a first-­‐time parent is also shown to be a risk factor (Goodwin et al., 2000). In addition, a number of studies reported no significant difference in parity among abused and non-­‐abused pregnant women (Charles & Perreira, 2007; Diaz-­‐Olavarrieta et al., 2007; Dunn & Oths, 2004; Taillieu & Brownridge, 2010a). 3.2.
Relationship and interpersonal risk factors Many women who are abused during pregnancy have reported that their partners attempt to socially isolate them from family, friends, and other social support systems and they were jealous of other close relationships (Sales & Murphy, 2000a; Bacchus et al., 2006; Pulido, 2001; Brownridge et al., 2011; Taillieu & Brownridge, 2010a). Conversely, having a social support network has clearly been associated with a decreased risk of violence during pregnancy and has been identified as a protective factor (Farid et al., 2008; James et al., 2013; Loeffen, Lo Fo Wong, Wester, Laurant, & Lagro-­‐Janssen, 2011; Taft et al., 2011). Informal and formal social support have been shown 48
to improve women’s (mental) health and ability to seek help from formal sources (Taft et al., 2011; Liang, Goodman, Tummala-­‐Narra, & Weintraub, 2005). As stated at the beginning of this chapter and reflected in the abovementioned extent of individual risk factors, the current evidence base of risk factors on interpersonal, relational, community or societal risk factors is limited (Krug, 2002) and research to increase our understanding of contextual and couple-­‐level factors with IPV among pregnant women is needed (Li et al., 2010a). When studying IPV, it is important to examine the violent behaviours that may occur within relationships, as well as feelings about and interpretations of the experienced violence. In order to understand IPV fully, the inclusion of women’s and men’s perceptions of vulnerability with respect to their relationships with their intimate partners is crucial. Moreover, since relationships are dynamic and change over time, it is valuable to study all these aspects over the course of the relationship with attention paid to important life changes that occur, such as the onset of pregnancy (Goldstein & Martin, 2004a). There is not a lot literature available on relationship risk factors of IPV specifically related to the pregnancy-­‐period. However, there is fair amount of research on IPV with regard to the treatment partner relationship problems. Couples can be considered as complex systems in which individuals have continued interactions over time; the interactions are affected by learning and feedback (Finkenauer et al., 2015). IPV can be understood from a dynamic developmental systems perspective in which couple aggression is conceptualized as an interactional pattern that is responsive to the conjoint developmental characteristics and behaviours of each partner, as well as contextual factors and relationship influences and processes (Capaldi, Knoble, Shortt, & Kim, 2012; Capaldi & Langhinrichsen-­‐Rohling, 2012). The studies that explored relationship and interpersonal characteristics have linked IPV to: poor conflict management skills or conflict resolution behaviours, (increased) marital discord or conflict, dissatisfaction in the relationship, hostility, anger, jealousy, male dominance in the family and traditional sex-­‐
role identity, career and life stress, high levels of stress and conflict in the family, (Jasinski, 2001; Jasinski, 2004; Taillieu & Brownridge, 2010a; Palmetto et al., 2013; Krug, 2002; Anderson, 2010; WHO, 2010a; Jaspaert, 2015). Areas of psychopathology that have received attention as risk factors for IPV, particularly in developmental studies conducted in the past decade, include 49
the externalizing and internalizing domains. From this work, conduct problems or antisocial behaviour has emerged consistently as a substantial risk factor for later IPV involvement for men and women who perpetrate IPV and are frequently found to be a mediator for earlier risk factors such as harsh parental treatment. Personality disorders such as controlling, antisocial, dysphoric/borderline personalities, impulsivity and poor emotional regulation have also found to be risk factors for IPV (Jasinski, 2001; Jasinski, 2004; Taillieu & Brownridge, 2010a; Palmetto et al., 2013; Krug, 2002; Anderson, 2010). In contrast, in the internalizing domain where fewer studies were identified, the findings for depressive symptoms indicate that they are associated with IPV perpetration and victimization, but that this association is not robust in multivariate analyses. A particularly interesting indication here was that depressive symptoms may be a stronger risk factor for IPV perpetration for women than for men. The association between depressive symptoms and IPV for women is usually viewed as due to a causal association from the latter to the former. However, these findings indicate that depressive symptoms may be a risk factor, perhaps because of the effects of symptoms such as irritability and negative affect. Associations between depressive symptoms and IPV may be reciprocal. Further study is needed to increase understanding of this association (Capaldi 2012). 3.3.
Societal, cultural and community risk factors Cultural and social norms are rules or expectations of behaviour within a specific cultural or social group. Often unspoken, these norms offer social standards of appropriate and inappropriate behaviour, governing what is (and is not) acceptable and coordinating our interactions with others. A variety of external and internal pressures maintain these cultural and social norms. Cultural and social norms are highly influential in shaping individual behaviour, including the use of violence. Norms can protect against violence, but they can also support and encourage the use of it. For instance, cultural acceptance of violence, either as a normal method of resolving conflict or as a usual part of rearing a child, is a risk factor for all types of interpersonal violence. Cultural and social norms also vary widely; so, behaviour acceptable to one social group, gang or culture may not be tolerated in another. This might help explain why some countries have high levels of violence and others have low levels (WHO, 2014). 50
In Western societies, pregnancy and childbirth are associated with positive emotions and with motherhood. It is often presented as a ‘pink period’, with nothing but happiness. In reality, this period is seldom only positive for women and their families (Geller, 2004). There is a great societal pressure on women regardless of their SES, ethnic status and religion, to view motherhood as their primary (positive) adult role. Given the idealisation of and the societal pressure on childbearing and motherhood, the very notion that a woman could be subjected to or use violence during pregnancy is shocking (Tuerkenheimer, 2006). Laws and policies provide clear representations of cultural and social norms on violence (around the time of pregnancy) that either tolerate of discourage the behaviour. Legislation that makes violent behaviour an offence sends a message to society that it is not acceptable. While nearly all countries have laws in place that criminalize most forms of homicide, only some countries have laws on IPV (WHO, 2010b). Even when laws are at place, the criminal justice system seldom intervenes to address this violence and they have been impermeable to the realities of pregnancy violence (Tuerkenheimer, 2006). The status of women among different cultures, along with the status afforded to the mother-­‐role, may play a role in the degree of acceptance and/or tolerance of pregnancy violence within a specific culture (Taillieu 2010). Although cultural attitudes about pregnancy would seem to be relevant to abuse during pregnancy, they have not been measured in most research (Campbell, Garcia-­‐Moreno, & Sharps, 2004). Some researchers have identified neighbourhood as an important risk factor for IPV. Significant neighbourhood influences include low per capita income, high unemployment rate, resource deprivation, and concentrated disadvantage (Li et al., 2010b; Frye & O'Campo, 2011). Neighbourhood’s ethnic heterogeneity, overcrowding, hopelessness, poverty and low collective efficacy are highly predictive of neighbourhood violence that in turn could increase IPV (Daoud, O'Campo, Urquia, & Heaman, 2012; Krug, 2002). It has also been argued, that partner violence is more common in places where war or other conflicts or social upheavals are taking place or have recently taken place. Where violence has become commonplace and individuals have easy access to weapons, interpersonal relations are frequently disrupted (Krug, 2002). 51
Socio-­‐cultural factors such as male domination and decision-­‐making autonomy, male honour and aggression, patriarchy, gender inequality, male control over family resources, economic inequalities, limited female access to divorce, accepted traditional norms permitting men to inflict punishment on their wife/partner, are all factors that increase the likelihood of IPV (Anderson, 2010; Antai & Adaji, 2012; Krug, 2002). Some studies show the risk of men’s physical and emotional abusive behaviour was greater when female partners had higher income or occupational status than their male partners (Kaukinen, Meyer, & Akers, 2013; Atkinson, Greenstein, & Lang, 2005; Melzer, 2002). These findings support the theoretical argument that violence is a means by which men perform or demonstrate masculinity, as men’s IPV perpetration was higher in contexts in which masculine identity was threatened inducing a sense of inadequacy for having failed to live up to their culturally expected role of breadwinners (Antai & Adaji, 2012; Anderson, 2010). On the contrary, relationships that embrace egalitarian decision-­‐
making and equal division of power often report low levels of conflict, control and abuse (Kaukinen, 2004). Thus, women with greater decision-­‐making power (linked to education, earnings) may be perceived as defying societal gender roles and challenging their partner’s masculinity as provider. As a result, they become vulnerable to their partner’s control tactics such as abuse (Antai & Adaji, 2012). How a community responds to partner violence may affect the overall levels of abuse in that community. Counts, Brown & Campbell (Counts D.A. et al., 1992) found that societies with the lowest levels of partner violence were those that had community sanctions against partner violence and those where abused women had access to sanctuary, either in the form of shelters or family support. The community sanctions, could take the form either of formal legal sanctions or the moral pressure to intervene if a woman was beaten. This study suggests that IPV will be highest in societies where the status of women is in a state of transition. Where women have a very low status, violence is not ‘‘needed’’ to enforce male authority. On the other hand, where women have a high status, they will probably have achieved sufficient power collectively to change traditional gender roles. Partner violence is thus usually highest at the point where women begin to assume non-­‐traditional roles or enter the workforce. 52
3.4.
Conclusion IPV is the result of a complex interplay of individual, relationship, social and cultural factors. Determining and understanding how these factors relate to (intimate partner) violence and each other specifically in the childbearing period, is important to provide a more comprehensive understanding of this specific form of violence. In general, the current research base is highly skewed towards investigating individual factors rather than community or societal risk factors. Indeed, there is still only limited information on which factors are decisive and the pathways on how they interact. We believe that large-­‐scale trials studying several risk factors simultaneously, especially at the interpersonal and societal levels, could increase insight and help clarify conflicting evidence regarding risk factors for pregnancy-­‐related IPV . The following figure presents an overview of some risk factors that have been shown to be related to IPV. 53
Figure 2: Overview risk factors 54
4.
Consequences of IPV Researchers from high income countries and increasingly from low and middle income countries (Shamu et al., 2011) have reached a consensus that IPV (during the perinatal period), has a detrimental impact on the health and well-­‐being of mother and child (Espinosa & Osborne, 2002; Macy et al., 2007; Rodrigues, Rocha, & Barros, 2008; Cripe et al., 2010; Devries et al., 2010a; Daoud et al., 2012; Han & Stewart, 2014b; Nunes et al., 2010; Coker et al., 2004b; Bacchus et al., 2004; Bailey & Daugherty, 2007; Chambliss, 2008; Sharps et al., 2007; Hegarty et al., 2010; McCarraher, Bailey, & Martin, 2005; Miller et al., 2011; Rodrigues et al., 2008; Roelens et al., 2008a; Salazar, Valladares, Ohman, & Hogberg, 2009a; Taft et al., 2011; Taillieu & Brownridge, 2010a; Tilley & Brackley, 2004; Jasinski, 2004; McFarlane, Soeken, & Wiist, 2000). The consequences of violence can be acute or chronic in nature and can result in direct or indirect effects. Injuries such as cuts, scratches, bruises, sprains, welts, factures, internal bleeding, spinal cord damage, head trauma are direct consequences that are evident results of violence. Indirect consequences are less obvious and can be mediated by the following mechanisms: (1) elevated physical and psychological stress levels (cf. chapter on stress theory), (2) isolation and inadequate access to antenatal care, (3) negative maternal coping behaviours, such as cigarette smoking, alcohol use, and illicit drug use, and (4) inadequate maternal nutrition. These indirect links associated with abuse during pregnancy may work through different pathways to result in adverse pregnancy outcomes and are illustrated in the underneath figure 3. Stress may exacerbate pre-­‐existing conditions such as chronic hypertension or depression, or it may lead to pregnancy complications such as pregnancy-­‐induced hypertension or preterm labour (Coker et al., 2004b). 55
Figure 3: impact of abuse during pregnancy on pregnancy outcomes (Coker et al., 2004b) More information on causal pathways and consequences of violence and it’s interaction with pregnancy can be found in the chapter on theoretical frameworks. The underneath overview of physical, obstetrical, foetal/neonatal and psychological consequences of IPV does not aim to be exhaustive but provides a synthesis of the consequences that were studied in cross-­‐sectional as well as in (randomised) controlled trials. 4.1.
Physical health consequences Physical consequences that have been linked to of IPV are: acute sprains and strains, contusions, abrasions and other direct results of trauma, degenerative joint disease, low back pain, trauma-­‐related joint disorders, cervical pain, pelvic pain, menstrual disorders, vaginitis/vulvitits/cervicitis, sexually transmitted infections (STI’s), acute respiratory tract infection, urinary tract infections, gastroesophageal reflux disease, chest pain, abdominal pain, high 56
cortisol levels (Bonomi et al., 2009; Han & Stewart, 2014b; Coker et al., 2004b). One of the most extreme consequences that has been linked to IPV, is death through homicide or suicide (Stockl et al., 2013; Samandari et al., 2011; Cheng & Horon, 2010). The number-­‐one risk factor for intimate partner homicide, whether a male or a female is the victim, is prior domestic violence (Campbell, Glass, Sharps, Laughon, & Bloom, 2007). Studies within the past two decades have shown that homicide is a leading cause of pregnancy associated death, defined as a death from any cause occurring during pregnancy or within 1 year of pregnancy delivery or pregnancy termination regardless of the site or duration of the pregnancy (Cheng & Horon, 2010). McFarlane (McFarlane, Campbell, Sharps, & Watson, 2002) reported that, after adjusting for age, ethnicity, education, and relationship status, the risk of becoming an attempted/completed homicide victim was three-­‐fold higher for women abused during pregnancy. Compared with women not abused during pregnancy, controls and attempted/completed homicide victims abused during pregnancy reported significantly higher levels of violence. 4.1.1. Obstetrical and reproductive consequences Partner violence during the perinatal period has been associated with an increased risk of following obstetrical complications: low birth weight, preterm labour and/or delivery, intra-­‐uterine growth retardation, severe nausea/vomiting, miscarriage, uterine rupture, premature rupture of membranes, late foetal loss, abortion, unintended/unwanted pregnancy, abnormal vaginal blood loss, anaemia, abruptio placentae, hypertension, pre-­‐
eclampsia, gestational diabetes, low gestational weight gain, etc. (Jasinski, 2004; Macy et al., 2007; Roelens et al., 2008a; Daoud et al., 2012; Shah & Shah, 2010; Han & Stewart, 2014b; Watson & Taft, 2013; Sharps et al., 2007; Cha & Masho, 2014a; El, Gilbert, Xing, & Smith, 2005; Boy & Salihu, 2004; Han & Stewart, 2014b; Devries et al., 2010a; Coker et al., 2004a; Bacchus et al., 2004; Bailey & Daugherty, 2007; Chambliss, 2008; Cripe et al., 2010; Gomez-­‐
Beloz, Williams, Sanchez, & Lam, 2007; Hegarty et al., 2010; McCarraher et al., 2005; Sanchez et al., 2008; Miller et al., 2011; Rodrigues et al., 2008; Salazar, Valladares, Ohman, & Hogberg, 2009b; Taft et al., 2011; Taillieu & Brownridge, 2010a; Tilley & Brackley, 2004; Espinosa & Osborne, 2002; McFarlane et al., 2000). As mentioned above, IPV has shown to increase the risk for complications during pregnancy and may thereby increase interventions during delivery. 57
Abuse related stress may increase the production of stress hormones (adrenaline, noradrenaline & cortisol) which may affect uterine activity and cause slow progress during labour and delivery. Slow progress in turn may lead to interventions and, for some, to instrumental birth. However, few studies examined the association between abuse and mode of delivery (Schei B, 2014). Although Nerum and colleagues (Nerum et al., 2010; Nerum, Halvorsen, Straume, Sorlie, & Oian, 2013) found a major increase in risk of CS for women who have been subjected to rape in adulthood, the findings are inconclusive since. Factors such as fear of childbirth followed by a CS on maternal request may be strongly correlated with the association between abuse history (as a child and as an adult) and operative delivery (Schei B, 2014; Lukasse, Vangen, Oian, & Schei, 2010). Research also suggest that IPV negatively affects the utilization of antenatal care, some authors found that women experiencing IPV had a higher utilization of care (Taillieu & Brownridge, 2010a; Moraes, Arana, & Reichenheim, 2010; Bloom, Curry, & Durham, 2007; Plichta, 2007), while others report more inadequate antenatal care. Violence/abuse during pregnancy has been associated with late entry into antenatal care (Devries et al., 2010a; Thananowan & Heidrich, 2008; Pallitto et al., 2005; Perales et al., 2009; Bailey & Daugherty, 2007; Bohn, 2002; Lipsky, Holt, Easterling, & Critchlow, 2003), which may impact the detection of maternal morbidity and developmental health of the unborn child. There is also some indication that women experiencing violence during pregnancy are less likely to have received adequate antenatal care in terms of recommended amount of consultations and clinical tests (Han & Stewart, 2014b; Cha & Masho, 2014b; Rahman et al., 2012; Goo & Harlow, 2012; Bailey, 2010a; Lipsky et al., 2005). There is a little evidence that women experiencing abuse/violence, use less contraception, which may be indicative of a lack of control over the own fertility. This specific form of IPV is also being referred as reproductive coercion. Indeed, there is some indication that male partners may prevent the use of birth control in abusive relationships (Campbell, 2002; Chambliss, 2008; Pallitto & O'Campo, 2005; Taillieu & Brownridge, 2010a). 58
4.1.2. Foetal or neonatal consequences With regard to the foetus/neonate, following consequences have been reported: prematurity/low birth weight, small for gestational age, developmental problems (cognitive, motorial, learning disability, behavioural disturbances), child abuse and/or neglect, mortality (Shah & Shah, 2010; Daoud et al., 2012; Han & Stewart, 2014b; Bailey, 2010b; Boy & Salihu, 2004). There is some evidence that an elevated cortisol level, can affect the child’s brain development and can lead to conduct disorders, increasing the risk of having stress-­‐related psychiatric disorders in later life (Mejdoubi et al., 2013a). 4.2.
Psychological or mental health consequences Many people experiencing IPV report that the physical violence is not the most damaging: it is the relentless psychological abuse that leaves the person with long-­‐lasting adverse effects (Campbell 2002; WHO 2014). The association between IPV and the physical consequences of this behaviour is well-­‐
established. Yet, evidence of the impact of IPV on the mental or psychological health of women (and their families) is only starting to emerge. Reporting IPV, is associated with increased risk of anxiety disorders, eating disorders, sleeping disorders, anxiety/panic attacks, nervousness, concentration problems, sexual dysfunctions, fear of intimacy, loss of self-­‐esteem, psychosomatic complaints or disorders (e.g. unexplained headaches, abdominal pain), pre-­‐ and postnatal depression, trauma symptoms (such as sleeping problems, flashbacks, panic attacks) post-­‐traumatic stress syndrome, postpartum psychosis, (attempted) suicide (Mechanic, Weaver, & Resick, 2008; Janssen et al., 2012; Saito, Creedy, Cooke, & Chaboyer, 2012; Chambliss, 2008; Bacchus et al., 2004; Shamu et al., 2011; Cripe et al., 2010; Rose, Bhandari, Marcantonio, Bullock, & Sharps, 2010; Johnson et al., 2003; Taft et al., 2011; Campbell, 2001; Bohn et al., 2004; Silverman et al., 2006; Bailey, 2010a; Rodrigues et al., 2008; Coker et al., 2004b; Dunn & Oths, 2004). Furthermore, IPV is strongly linked with harmful health behaviours such as using tobacco, alcohol or illicit drugs, (calming) medication, poor maternal nutrition, and high-­‐risk sexual behaviour (Taft et al., 2011; Daoud et al., 2012; Krug et al., 2002a; Chambliss, 2008; Bacchus et al., 2004; Cripe et al., 2010; Rose et al., 2010; Johnson et al., 2003; Taft et al., 2009; Campbell, 2001; Bailey, 2010a; Rodrigues et al., 2008; Coker et al., 2004b; Dunn & Oths, 2004; Janssen et al., 2012; Janssen et al., 2003; Sharps, Campbell, Baty, Walker, & 59
Bair-­‐Merritt, 2008; Petersen, Gazmararian, & Andersen, 2001; Mechanic et al., 2008; Shamu et al., 2011) Indeed, women (and men) living in violent relationships use more substances to cope with the stress. Research that reports on the consequences of IPV is sometimes criticised for the potential mediating effect of substance abuse on the negative (physical) health consequences of IPV. However, more and more studies show that even when the analysis is adjusted for these factors, the correlation between IPV and the abovementioned consequences (mostly) remains significant (Shah & Shah, 2010; Bair-­‐Merritt et al., 2010). Research also suggest that IPV affects the utilization of antenatal care, some authors found that women experiencing IPV had a higher utilization of care (Bloom et al., 2007; Cha & Masho, 2014b; Taillieu & Brownridge, 2010a; Moraes et al., 2010; Plichta, 2007) while others report more inadequate antenatal care (Bohn, 2002; Christiaens, Verhaeghe, & Bracke, 2008; Pallitto et al., 2005; Bohn et al., 2004; Cha & Masho, 2014b; Devries et al., 2010b; Thananowan & Heidrich, 2008; McFarlane, Groff, O'Brien, & Watson, 2006a; McFarlane, Parker, Soeken, & Bullock, 1992a; Bailey & Daugherty, 2007; Lipsky et al., 2003). 4.3.
Health consequences of IPV perpetration We would like to note that although the link between IPV victimization and negative outcomes is well-­‐established, emerging evidence shows that there is also an association between (pregnant) women’s perpetration of aggressive behaviour and mental, emotional, physical health, and parenting abilities during pregnancy and postpartum (Shneyderman & Kiely, 2013; Hellmuth et al., 2013; Tzilos et al., 2010). However, a very limited number of studies have addressed the matter of IPV perpetration during pregnancy and more large-­‐
scale studies with a strong design need strengthen the evidence base. 4.4.
Economic consequences As far as we know, no specific research has been done on the economic impact of IPV in the perinatal period. However, there is some data available on the economic impact of IPV in general, which is being presented in the paragraphs underneath. Since the perinatal period is generally associated with an increase in costs (increase in health care use, purchase of baby material, decreased income due to maternity leave etc.), it is not unthinkable that these general cost approximations will be an underestimation. 60
The consequences of IPV extend beyond the health and happiness of individuals, but affect the well-­‐being of entire communities and nations (WHO, 2014). A cohort study of Australian women aged 18–44 years estimated that IPV was responsible for 7.9% of the overall burden of disease, which was larger than other risk factors traditionally included in burden-­‐of-­‐
disease studies such as blood pressure, tobacco, and obesity (Manzolli, Nunes, Schmidt, & Ferri, 2012; Vos et al., 2006). The health impact and loss of life caused by IPV generate a significant economic burden for the people directly involved but also for society, including the direct costs of medical and non-­‐medical services, the indirect costs associated with lost workplace and household productivity, criminal justice, housing and the long-­‐term impact on human pain and suffering (Roldos & Corso, 2013; EIGE, 2014). Based on a UK case study the EIGE (European Institute for Gender Equality) estimated that the cost of intimate partner violence against women is 13 732 068 214€ and of intimate partner violence against women and men is 15 374 525 253€. Extrapolated for each European Member State the cost of intimate partner violence to the EU was 122 177 800 785€, of which 109 125 574 091€ was because of intimate partner violence against women. The spending on specialised services to mitigate the harms and prevent the repetition of the violence is 3 % of the cost of intimate partner violence against women. Specialist services, can be beneficial to women and the cost of these services is very small relative to the cost to economy and society. The loss to the economy, through lost output as a result of injuries, is around 12 %. Services, especially criminal justice, make up around 30 % of the cost of the violence. Just under half the cost is a result of the public estimation of the value placed on the physical and emotional impact that the violence causes (EIGE, 2014). 61
5. Theoretical frameworks for IPV associated with pregnancy Research on violence between intimate partners is a fairly ‘young’ research area and is, like any other scientific field, influenced by its underlying paradigm(s). The phenomenon emerged as a recognizable issue in the mid-­‐
1970s (Straus M.A., 1980) and in that time empirical knowledge of this social, psychological, and legal phenomenon was very limited. Under the impulse of the women’s movement, advocates started to organize shelters to provide safety and assistance for abused women in the second half of the 1970s. Simultaneously, clinical information started to emerge that described patterns of severe physical and sexual abuse. The victims were described as “battered women,” and the male perpetrators were labelled “batterers” (Walker L.E., 1979). This early and important recognition and conceptualization of intimate partner violence has guided policy, law, education, and interventions to date. The term “domestic violence” was adopted by women’s advocates and feminists to emphasize the risks women faced within their own family and household, and over time the term became synonymous with battering. Since the early 1980s, family sociologists also studied violence occurring in families and between intimate partners. Typically, they used large nationally representative samples, and this information diverged significantly from shelter, hospital, and police data with respect to incidence, perpetrators, severity, and context. In particular, large-­‐scale studies seemed to indicate that women were as violent as men in intimate relationships (Archer, 2000). Domestic violence advocates and service providers largely ignored or strongly rejected these studies because they were so at odds with their experiences in the shelters, hospitals, and courts. Advocates also feared that what they viewed as misinformation (that women were as violent as men) would dilute society’s focus on and funding of services for abused women (Pleck, 1979). Thus, until recently, the two groups most concerned with intimate partner violence, feminist activists and family sociologists, have rarely intersected, and misunderstanding and acrimonious debate have interfered with a more constructive and unified approach to what remains a serious societal problem for intimate partners and their children. Up until now, the study of violence associated with pregnancy has remained relatively atheoretical. Theory development has been confined to are a few general perspectives that have been applied to research on violence around the time of pregnancy (Taillieu & Brownridge, 2010a). Unfortunately, general IPV theories often fail to capture the complexity of the problem (Bell & 62
Naugle, 2008a) and only address parts of the interaction with pregnancy-­‐
related aspects. However, these theories or parts of these theories can provide an interesting framework to interpret the results obtained in our research. In the underneath chapters, we give an brief overview of the most influential theoretical frameworks relevant to IPV and pregnancy. The following table provides an overview of the most important theoretical aspects on the etiology of violence and it’s relation to pregnancy. 63
Table 1: Overview theoretical frameworks for IPV associated with pregnancy Theory Summary of IPV conceptualization and interaction with pregnancy Feminist IPV is the intentional use of violence by men to control perspective and oppress women in patriarchal societies. Pregnancy is seen as a period of increased vulnerability for the women and of augmented power of the men. Family sociology IPV is not a unitary phenomenon and roughly two types perspective of violence can be differentiated: 1) situational couple violence is a gender symmetric form of communication that escalates into violence, 2) intimate terrorism is a gender asymmetric form where the perpetrator uses violence to take general control over his partner. In most cases, prevalence rates of IPV perpetration and victimisation associated with pregnancy are similar for both men and women. Evolutionary Human investment in raising a child is large. Men are psychology concerned with the continuation of their gene pool and there would be zero return in terms of genetic representation if the child is not his own. The use of IPV is largely motivated by ‘paternal uncertainty’ and abusive male partners tend to be more sexually jealous and possessive of their partners. Stress theory Pregnancy and childbirth are stressful life events. Individual and dyadic coping strategies tend to decrease under stress leading to an increased risk of violence. Physiological changes during pregnancy attenuate psychological responding to stress and develop a higher concern for the safety and conflicts with experiencing IPV. Social learning Violent behaviour is learned through modelling that theory conflict is resolved by means of violence or abusive behaviour. IPV is influenced by being rewarded and/or punished for these actions. Violence during pregnancy may represent a continuation of a pattern of violence experienced throughout life. 64
Attachment theory Infants develop a relationship with a primary caregiver and this leads to internal working models which guide relationships. The impact of partner violence on working models may be particularly salient during pregnancy, as women are forming and reorganizing representations of significant others, themselves as care givers, and their infants. The concept of ‘double binding’ refers to the conflicting psychosocial processes of binding-­‐in to the unborn child and the abusive intimate partner that women experience as they engage in the developmental tasks associated with becoming a mother while living in abusive relationship. 5.1.
Feminist theory The feminist model is one of the oldest and most well-­‐known theories concerning IPV and seeks to understand violent relationships by examining the sociocultural and gendered context in which these relationships develop. Many supporters of this theory view sexism and female inequality within patriarchal societies as the main causes of IPV (Lenton, 1995; Walker, 1984; Dobash R.E. & Dobash R.P., 1977). Power inequity and the intentional use of violence to control and oppress women, are key elements in this perspective. Gender roles defined by society and taught to individuals during childhood are thought to place men in positions of power over women (Dobash R.E. & Dobash R.P., 1977; Mihalic & Elliott, 1997a). These socially-­‐defined gender roles lead to victimization of women and perpetration of violence by men (Walker, 1984). Proponents of the feminist theory suggest that various tactics, including physical violence, may be used by men to control and exert their dominance over women and their families (Dobash R.E. & Dobash R.P., 1977; Pence E., 1993). Consequently, some have argued that interventions should focus primarily on addressing men's domineering behaviours and patriarchal beliefs (McMahon M. & Pence E., 1996) Support for the feminist theory stems from descriptive, correlational research examining the relationship between men's endorsements of patriarchal values and their respective rates of physical violence against their partners. Results from some of these studies indicate 65
that families are at a greater risk for experiencing IPV when husbands hold traditional sex-­‐role attitudes and when there are greater discrepancies between the husbands' and wives' acceptance of patriarchal values (Bell & Naugle, 2008b; Leonard & Senchak, 1996). Pregnancy may symbolize a time when the woman assumes more control over her own body and may represent a degree of independence from her male partner; violence against the pregnant partner may represent a male partner’s attempt to reassert control (Bacchus et al., 2006). During pregnancy, the power of the abusive partner over the woman increases due to the augmented vulnerability of the pregnant woman. The threat of hurting or losing a desired child as a consequence of violence can be very powerful weapon (Tuerkenheimer, 2006). Abusers tend to hold more conventional sex role attitudes, and pregnancy-­‐related factors (such as reduced mobility, increased tiredness, preoccupation with pregnancy, blocked free access to a woman’s body, and a lack of emotional availability) may interfere with a woman’s ability to perform her traditional role as homemaker/ caretaker (Pallitto & O'Campo, 2005; Bacchus et al., 2006; Jasinski, 2004), which may lead to an increased risk of violence. According to the resource theory, the more resources (social, personal, and economic) a person can command, the more power he or she can potentially call on. The individual who is rich in terms of these resources has less need to use force in an open manner. In contrast, a person with little education, low job prestige and income, or poor interpersonal skills may use violence to compensate for a real or perceived lack of resources and to maintain dominance (Hyde-­‐Nolan M.E. & Juliano T., 2011). Pregnancy is also associated with increased financial pressures and may increase a woman’s financial dependency on her male partner (Bacchus et al., 2006; Pallitto et al., 2005; Sales & Murphy, 2000b). Financial control by restricting access to money is a means to maintain control in a relationship (Pallitto & O'Campo, 2005), and this type of control has been reported by a number of women who have been abused during pregnancy (Brownridge et al., 2011). 66
5.2.
Family sociology theory As cited above, since the 1980s a growing body of empirical research demonstrates that IPV is not a unitary phenomenon and that several types of violence can be differentiated with respect to partner dynamics, context and consequences (Kelly J.B. & Johnson M.P., 2008). One of the leading authors in this field (Michael P. Johnson) has developed a theoretical framework that distinguishes 3 types of IPV: 1) situational couple violence 2) intimate terrorism and 3) violent resistance (Johnson M.P., 2008). In situational couple or mutual violence, the violence is embedded in a pattern of conflict that turn into arguments that escalate into verbal aggression and ultimately into physical violence. It is not embedded in a relation-­‐wide pattern of power, coercion and control. For most couples this type of violence involves minor forms of violence (e.g. pushing, shoving, …), has a low frequency of occurrence, and they deal with it themselves. For other couples it can be extremely serious and become chronic as arguments escalate regularly over time and consequences can be very serious. The interpersonal dynamic in mutual violence is one of conflict that escalates to violence where either or both partners can be violent. Fear is not a characteristic of women and men in situational couple or mutual violence. This type of violence is the most common type of violence, is gender symmetric and is most often reported by large-­‐scale survey research using community or national representative samples. In violence that can be labelled as intimate terrorism, the perpetrator uses violence to take general control over his or her partner; while the partner does not. The violent behaviour is only one tactic in a general pattern of power and control, which includes violent and non-­‐violent means. In heterosexual relationships, this asymmetric type of violence is primarily perpetrated by men. It is likely to escalate over time, less likely to be mutual and more likely to result in injuries to women and draw attention from neighbours, police and health caregivers. Intimate terrorism is the type of violence that is often shown in films/media (e.g. malicious man that pushes wife down the stairs) and found in data obtained primarily from police reports, women’s shelters, court-­‐mandated treatment programs and emergency rooms. As a result of the efforts of the women’s movement in the 1980’s, this type of violence is often the type of violence that jumps to the mind when referred to domestic violence. In violence resistance the violence takes place as an immediate reaction to an assault (from the intimate terrorist) and that is intended primarily to protect 67
oneself or others from injury (‘self-­‐defence’). This type of violence is primarily perpetrated by women and often starts as soon as the intimate terrorism starts. In heterosexual relationships most women find out quickly that responding with violence is ineffective because of the size and strength of the male partner and may even make things worse. This typology offers a clear framework and can be used to address the problem in the field and interpret research result. However, humans and their circumstances are inherently messy and there are always individuals/couples that not fit into the major identified types (Kelly J.B. & Johnson M.P., 2008). Within the context of childbirth, pregnant women’s use of violence is virtually ignored (Taillieu & Brownridge, 2010a; Charles & Perreira, 2007; Martin et al., 2004). This is closely linked to the cultural conception of the ‘vulnerable pregnant woman’ that deserves sympathy and protection (by law), and a pregnant woman using violent tactics, violates our notion of acceptable feminine behaviour. Despite extensive literature documenting the prevalence and negative effects of IPV victimization in a perinatal population, literature examining women’s IPV perpetration in this population is scant (Sullivan, Meese, Swan, Mazure, & Snow, 2005; Tzilos et al., 2010; Hines & Douglas, 2012a; Swan, Gambone, Caldwell, Sullivan, & Snow, 2008; Coker et al., 2002; Swan & Snow, 2006a). Nonetheless, the limited amount of studies on this topic indicate that the prevalence of IPV perpetration during pregnancy and postpartum is similar to the prevalence of their IPV victimization and women’s use of IPV is a significant health threat during pregnancy. Women’s IPV perpetration has detrimental health effects for men and women across populations (Hines & Douglas, 2012b; Swan et al., 2008) and increases women’s risk for substance abuse, depression, and IPV victimization (Hellmuth et al., 2013; Tzilos et al., 2010; Coker et al., 2002; Swan & Snow, 2006b; Sullivan et al., 2005). Hence, reducing female IPV perpetration is likely to benefit child health and public health (Bair-­‐Merritt et al., 2010; McDonald, Jouriles, Tart, & Minze, 2009). 68
5.3.
Evolutionary psychology The evolutionary psychology theory offers an interesting viewpoint to the understanding of the use of violence during the perinatal period. According to this theory, men dispose of a lot reproductive potential (amount of spermatozoa) and are therefore driven to spread their genes. Women have less reproductive potential (one egg every month for a limited period in time) and consequently invest more in the genetic selection of their partner(s). Strong genes are externalised by strong and competitive behaviour (e.g. sports, career), which are inherently associated with aggressive behaviour in order to be able to protect women and children. Over time, humans have evolved toward monogamous and bi-­‐parental care to increase the chances of survival of their offspring. The human investment in raising a child is large and if the child is not his own, there would be zero return in terms of genetic representation. Men are concerned with the continuation of their gene pool and violence is largely motivated by ‘paternal uncertainty’. Unless a man constantly monitors his partner, or isolates her from other men (e.g. chaperoning, veiling, feet-­‐binding in China, harems, …), there is always a possibility, because of rape or infidelity, that the children she bears are not his (Burch & Gallup, 2004). Paternal uncertainty and accusations of infidelity have been associated with an increased risk of violence among pregnant women (Bacchus et al., 2006; Chambliss, 2008; Pallitto et al., 2005). Research indicates that abusive male partners tend to be more sexually jealous and possessive of their partners compared to non-­‐abusive men (Chambliss, 2008; Bacchus et al., 2006; Burch & Gallup, 2004; Decker et al., 2004). Violence is seen as a paternal assurance technique used to combat paternal uncertainty and increase the chance that the kids he’s raising are its own. In a comparison of violent and non-­‐violent pregnant couples, women who were abused during pregnancy were more likely to be carrying a child that was not her current partner's biological child (Martin et al., 2004), which may be related to paternity issues. Pregnant women are often preoccupied with the physical symptoms and body changes associated with pregnancy as well as with the health of the unborn child (Noel & Yam, 1992; Pulido & Gupta, 2002), which may translate into an increased risk of violence from an emotionally insecure and dependent male partner (Bacchus et al., 2006; Noel & Yam, 1992). Further, male partner resentment towards the unborn child may surface as a response to doubts surrounding paternity. 69
In a qualitative study investigating factors contributing to pregnancy violence, a third of the women abused during pregnancy cited jealousy or anger over the unborn child as the precipitating cause of the violence they experienced (Taillieu & Brownridge, 2010a). 5.4.
Stress theory Within this theory, pregnancy and childbirth are framed as stressful life events (Geller, 2004). Normative transmissions associated with the entrance into and/or exit from a social role may be associated with stress and pregnancy represents a significant transition period (Jasinski, 2001). Most expectant couples are able to cope with the stress that commonly arises during this time without using violence, yet individual and dyadic coping strategies tend to decrease under stress leading to an increased risk of violence. Moreover, childbearing couples with a lot of additional and/or pre-­‐
existing strains, such as low socio-­‐economic status, may be particularly vulnerable to IPV (Hellmuth et al., 2013). The increased risk of violence may also be a result of the cumulative effect of multiple stressors (e.g. financial problems, housing difficulties, young age, being single). Pregnancy as a result of domestic violence, rape, incest, is a situation where a multitude of stressors co-­‐exist and can result in extreme feelings of distress (Geller, 2004). In a test of the hypothesis of the cumulative effect of multiple stressors using longitudinal data from the National Survey of Families and Households, Jasinski (Jasinski, 2001) found that certain pregnancy-­‐related factors (hypothesized to be associated with increased stress) contributed to differing patterns of violence. Specifically, the birth of a first child was associated with the cessation of pre-­‐existing violence whereas persistent violence was associated with mistimed pregnancies. The mother's age at birth of the first child was not significantly associated with any violence category (violence initiation, violence cessation, or persistent violence). These findings suggest that certain pregnancy-­‐related factors may be associated with different trajectories of violence. However, it remains unclear whether these pregnancy-­‐related factors are, in fact, associated with increased stress, as couple stress was not directly measured in the analyses (Taillieu & Brownridge, 2010a). 70
It is well established that the timing of stress is important because of critical periods of development in the foetus. However, timing of stress could also be important because maternal responses to stressful events may differ depending upon when the events occur during the gestational period. Physiological responses to stressors decrease as pregnancy advances. Responding of both the hypothalamic–pituitary–adrenal and sympathetic–
adrenal–medullary systems are progressively dampened during pregnancy. Such changes in the physiological stress response may be associated with attenuated psychological responding. For example, Glynn et al. (Glynn, Wadhwa, Dunkel-­‐Schetter, Chicz-­‐DeMet, & Sandman, 2001) found that appraisals of the emotional impact of a major earthquake were related to the time of gestation at which the earthquake occurred. Those who experienced the earthquake early in pregnancy rated it as more stressful than those who experienced it late in pregnancy (Glynn, Schetter, Wadhwa, & Sandman, 2004a; Glynn et al., 2001). Thus, data suggest that emotional responding does change as pregnancy advances. Life events that are experienced later in pregnancy are perceived as less stressful than those that occur earlier. There are both peripheral and central physiological changes during pregnancy that could account for the altered emotional responding. Pregnancy is associated with progressive changes in the endocrine, immune and cardiovascular systems and these peripheral changes affect responding to exogenous stressors. For example, blood pressure, heart rate and catecholamine responses to stress are reduced during pregnancy. It is likely that these peripheral changes have implications for central processes as well (Glynn, Schetter, Wadhwa, & Sandman, 2004b; Woods, Melville, Guo, Fan, & Gavin, 2010). The high levels of oestrogen/progesterone and the complex interaction between the different physiological processes generates higher sensitivity and emotionality. Consequently, this creates a tendency to feel more fragile and develop a higher concern for the own safety and the safety of the baby. This pregnancy-­‐
induced (increased) need for a safe haven is obviously conflicting with experiencing IPV (Libbus et al., 2006; Lothian, 2008). The chronic experience of stress, which is often applicable to IPV, has been shown to impair the regulation of the hypothalamic– pituitary–adrenal axis, that keeps the body’s response to stress in check. Stress, depression and anxiety are associated with high levels of catecholamines, which are associated with a reducing the placental blood flow and the supply of essential nutrients and oxygen to the baby (Weinstock, 71
2008). Furthermore, an association between maternal anxiety in pregnancy and an increased uterine artery resistance has been demonstrated. Women exposed to high levels of cortisol are more susceptible to a number of pregnancy complications such as preterm birth and low birth weight (Wisborg, Barklin, Hedegaard, & Henriksen, 2008; Kramer et al., 2009). 5.5.
Social learning theory The social learning theory (Bandura A., 1973) states that (social) behaviour is primarily learned by observing and imitating/modelling actions of others and this behaviour is influenced by being rewarded and/or punished for these actions. This theory has potential as a partial explanation for partner violence around the time of pregnancy, although it has not been explicitly tested (Palmetto et al., 2013; Taillieu & Brownridge, 2010a). Violence in the family is often transmitted across generations, as children learn through modelling that conflict is resolved by means of violence or abusive behaviour and this contributes to the normalization of aggressive behaviour within this particular environment. Children who witness or experience violence are therefore more likely to perpetrate or fall victim to violence as adults compared to non-­‐exposed children (Brownridge, 2006b; Whitfield et al., 2003). However, not all children that have witnessed IPV or were part of the abuse, show violent behaviour or fall victim to abuse later in life. Whether or not violence continues into adulthood is thought to be dependent on the consequences associated with early episodes of violence in peer and dating relationships (Riggs, Caulfield, & Street, 2000). IPV is believed to be maintained if it serves a purpose or has been appropriately reinforced (Mihalic & Elliott, 1997b). Thus, positive outcomes following partner abuse may increase a person's expectations that future violence will result in similar outcomes, and consequently result in continued use of aggression (Riggs D.S. & O'leary K.D., 1989). Social learning theorists emphasize that direct reinforcement of violent behaviour is not required to maintain that behaviour. Instead, simply witnessing either positive or negative consequences of violent behaviour may be sufficient in determining whether or not an individual will engage in future violent episodes (Riggs D.S. & O'leary K.D., 1989; Bell, Harford, McCarroll, & Senier, 2004). Furthermore, researchers have found a strong correlation between IPV and child abuse, both types of violence often coexist (Chambliss, 2008; Burch & Gallup, 2004; Campbell, 2002; Casanueva & Martin, 2007; Pulido & Gupta, 72
2002; Pulido, 2001; Taylor et al., 2010). In an investigation of convicted spouse abusers, Burch and Gallup (Burch & Gallup, 2004) found that witnessing IPV in the family of origin correlated with being physically punished (r=.267, p<0.001), being physically abused (r=.363, p<0.001) and being sexually abused (r=.157, p<0.05) in childhood. Furthermore, the frequency and severity of current partner abuse were correlated with the physical punishment of children in the home. Taylor and colleagues (Taylor et al., 2010) showed that IPV in adulthood, including minor and nonphysical aggression between parents, increases the odds of using corporal punishment towards their children. The presence of bilateral IPV essentially doubled the odds that one or both parents would use corporal punishment, even after controlling for potential confounders such as parenting stress, depression, and alcohol or other drug use. Casanueva and Martin (Casanueva & Martin, 2007) found that women physically abused during pregnancy had three times the odds of having increased Child Abuse Potential Inventory (CAPI) scores compared to non-­‐abused pregnant women. Sales and Murphy (Sales & Murphy, 2000a) reported that many of the drug-­‐addicted women who experienced violence during pregnancy had histories of child abuse. Violence during pregnancy may represent a continuation of a pattern of violence experienced by these women throughout their lives. Díaz-­‐Olavarrieta et al. (Diaz-­‐Olavarrieta et al., 2007) reported that 25 of the 99 women in their sample who had experienced violence during pregnancy had also reported abuse during every life period for which they were asked (childhood, adult life, past year, and pregnancy). It is clear that violence in the family of origin has an impact on rates of adult perpetration and victimization, however, this relationship has not been fully explored as it relates specifically to the risk of violence during pregnancy. 5.6.
Attachment theory The attachment theory was originally developed by Bolwby (Bolwby J., 1969). The most important tenet of this theory is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Infants become attached to individuals who are sensitive and responsive in social interactions with them, and who remain consistent caregivers for some months during the period from about six months to two years of age. Caregivers' responses lead to the development of patterns of attachment; these, in turn, lead to internal working models which 73
will guide the individual's perceptions, emotions, thoughts and expectations in later relationships. Based on Bolwlby’s work, several child-­‐caregiver attachment patterns have been identified: secure, anxious, avoidant, ambivalent/resistant and disorganised patterns. In the late 1980s the attachment theory was extended to adult romantic relationship. Roughly corresponding to the infant attachment styles, four styles of attachment have been identified in adults: secure, anxious-­‐
preoccupied, dismissive-­‐avoidant and fearful-­‐avoidant. Securely attached adults tend to have positive views of themselves, their partners and their relationships. They feel comfortable with intimacy and independence, balancing the two. Anxious-­‐preoccupied adults seek high levels of intimacy, approval and responsiveness from partners, becoming overly dependent. They tend to be less trusting, have less positive views about themselves and their partners, and may exhibit high levels of emotional expressiveness, worry and impulsiveness in their relationships. Dismissive-­‐avoidant adults desire a high level of independence, often appearing to avoid attachment altogether. They view themselves as self-­‐sufficient, invulnerable to attachment feelings and not needing close relationships. They tend to suppress their feelings, dealing with rejection by distancing themselves from partners of whom they often have a poor opinion. Fearful-­‐avoidant adults have mixed feelings about close relationships, both desiring and feeling uncomfortable with emotional closeness. They tend to mistrust their partners and view themselves as unworthy. Like dismissive-­‐avoidant adults, fearful-­‐avoidant adults tend to seek less intimacy, suppressing their feelings (Hazan & Shaver, 1990; Hazan & Shaver, 1987; Bartholomew & Horowitz, 1991). There is a growing body of literature supporting the association between traumatic experiences and problematic attachment in adulthood (Huth-­‐Bocks, Levendosky, Theran, & Bogat, 2004b). In trauma theory, the psychological damage done by violence comes from the way an individual interprets and is affected by the experience of trauma more than the actual type and frequency of the violent experience as such. This finding is being confirmed by Samelius et al. (Samelius, Wijma, Wingren, & Wijma, 2007). They found that women acknowledging their experiences as being abusive or violent often have more somatic complaints. In other words, whether a woman perceives her experience as abuse/violence, seems to be decisive for the development of somatization in these women. 74
Couples that are victimized by their partners are put in an especially vulnerable situation as the person to whom they “might ordinarily turn for safety and protection is precisely the source of danger”(Herman, 1992). The more one is exposed to this danger, the more sensitive one is to the threat of more violence. People who are exposed to violence repeatedly over time are susceptible to a significant psychological reaction to such traumatic events (Goldstein & Martin, 2004b). The experience of trauma can lead to a number of cognitive and affective symptoms including: intrusive thoughts, feelings and images, restricted affect, avoidance of cues associated with the trauma, dissociative symptoms, and hyperarousal or hypervigilance, all of which may reflect an incomplete process of mental reorganization following a trauma (LyonsRuth & Block, 1996). These symptoms are often more complex, diffuse, and long standing in victims of chronic trauma. In addition, repeated trauma that occurs in the context of relationships can severely affect a victim’s capacity for relatedness (Herman, 1992). Interestingly, most of the research in this area thus far has defined trauma as childhood abuse or loss, with almost no data on relational trauma experienced in adulthood, such as domestic violence. Clearly, domestic violence is a traumatizing experience that often is chronic and repetitive and has a myriad of negative consequences. Recently, literature is emerging that suggests that attachment theory has much to offer in understanding domestic violence (Lyons-­‐Ruth, Bronfman, & Parsons, 1999a). For example, domestic violence occurs in the context of a significant attachment relationship (i.e., with her partner), likely influencing the capacity for relatedness and his/her internal working models of self and other. This may be the case even if the person has had adequate attachment relationships in the past. Because the current, violent relationship often is perceived as threatening, it is probable that the attachment system is in a relatively constant state of activation (Solomon J. & George C., 1999). In addition, because domestic violence often is ongoing, this type of trauma may be inherently unresolved. Moreover, experiences of domestic violence may trigger or reactivate past traumas, re-­‐
evoking fear and helplessness. Because of both past and current traumas, one would expect that people experiencing partner violence would be more likely to show insecure attachment representations similar to those in studies examining adult outcomes of childhood abuse. However, emerging evidence indicates that victims of domestic violence rather show a spectrum of problematic attachment styles (Lyons-­‐Ruth, Bronfman, & Parsons, 1999b). 75
Domestic violence is a relatively common, and often chronic, experience in women’s lives, including during pregnancy. Based on the literature examining childhood trauma, violence, and adults’ states of mind with respect to attachment, it is highly likely that women’s working models of self and others are affected by domestic violence. The impact of partner violence on working models may be particularly salient during pregnancy, as women are forming and reorganizing representations of significant others, themselves as care givers, and their infants. In fact, it seems possible that the pregnancy as such and the growing, moving foetus may be perceived as threatening at times and/or may re-­‐evoke aspects of the trauma associated with experiencing violence by a partner. A similar idea has been noted by other researchers who have suggested, for example, that even harmless acts by an infant (e.g. kicking of foetus is perceived as ‘baby beating me up from the inside’) may trigger the attachment system and dysregulated feelings if the acts resonate with the parent’s experience of trauma (Huth-­‐Bocks et al., 2004a). 5.6.1. Double binding A theory that builds on the attachment theory is the concept of “double binding”. This construct is composed of two internal opposing concepts encountered by pregnant women in abusive relationships: on the one hand ‘becoming a mother’ and on the other hand ‘being in an abusive relationship’ (Lutz, Curry, Robrecht, Libbus, & Bullock, 2006). The term ‘becoming a mother’ is used to describe the multiple biological, psychological, social and transitional changes a woman experiences during pregnancy. Rubin (Rubin R., 1984) described the cognitive work that pregnant women perform in the process of becoming a mother. This theory includes four maternal tasks: 1) seeking and ensuring safe passage for mother and infant, 2) securing and ensuring acceptance of the pregnancy and the new family member by significant others, 3) binding-­‐in to the child, 4) giving of oneself to the dependent valued child. Binding-­‐in to the pregnancy is the process that the woman undergoes as she realizes that she will become a mother; it is characterised by ensuring safe passage for herself and the unborn child. Part of seeking safe passage for the child is the task of promoting social acceptance of the child, beginning with the acceptance by its father. Consequently the quality of the mother’s relationship with the father of the baby influences all of her maternal tasks, but most significantly whether and how she accepts and supports the pregnancy. Incorporated into the father’s acceptance of the baby is the maternal dream of having an ideal 76
loving supportive home and family and becoming a good mother. This ideal becomes a goal for the pregnant woman even with the wide variations in existing family structure and complex social conditions. The appearance of a welcoming, stable and loving environment may conceal partner abuse and project optimism about the family’s future, a future that is in reality threatened. This process of binding-­‐in involves trying to maintain the appearance of a secure and good relationship. Little is known on how the context of abuse affects women’s achievement of developmental tasks and on how a woman becomes a mother while making decisions about her relationship that jeopardizes the safety of the family unit (Lutz et al., 2006). Based on Landenburger’s process theory (Landenburger, 1989), women in abusive relationships experience a second type of binding. This process of binding refers to the period where the woman realizes that there is something wrong with the relationship, but believes that the abusive behaviour can be fixed and she can construct a loving relationship. Wishing for the loving relationship, she overlooks warning signs, works on the relationship and wonders what it is about her that provokes the abuse. The good in the relationship is valued and is used as a mechanism for blocking out the abuse. Particularly during pregnancy (Campbell & Campbell, 1996), people want to make the relationship work and they believe that things will get better once the baby is born, although some women have also expressed a feeling of being trapped now that they are pregnant (Lutz, 2005a). The double binding concept refers to the simultaneous and often conflicting psychological and social processes of binding-­‐in to the unborn child and the abusive intimate partner that women experience as they engage in the developmental tasks associated with becoming a mother while living in abusive relationship. The tasks of ensuring safe passage for herself and the baby, securing and ensuring acceptance of the pregnancy by the baby’s father and significant others are inextricably linked with the reality of the abuse. Binding-­‐in to the partner by working harder on the relationship, ignoring warning signs, and hoping that things will get better may be a way of coping with this internal conflict. A consequence of double binding is the sense of living in two separate worlds. One life is public, reflecting the pregnancy, the other private, reflecting the abuse. The public life represents the external idealized view of the woman’s life, pregnancy and family. The private life represents the reality of abuse that the woman comes to realize but not wish 77
to publicly acknowledge. Wishing to end the violence and not the relationship is particularly true for pregnant women. Becoming a mother presumes a positive and supportive partner relationship, yet the abuse coexists and presents competitive behavioural demands and social expectations for women. Despite the abuse, the childbearing cycle strengthens the bonds to the partner and the commitment to the family. The attachment process towards the foetus includes meeting the basic needs of the baby (e.g. housing, baby supplies) and protecting the foetus from abuse. In this perspective women can respond very different to the abuse. For some woman the pregnancy and safeguarding the child can be a catalyst to leave the relationship (Patzel, 2001), other women can seek ways to reduce the violence or modify their own response to violence (and for example do not fight back anymore) (Lutz, 2005a). 5.7.
Conclusion Health care practices, psychosocial services and its organisation do not take place in a normative vacuum. Moreover, they embody the beliefs and biases of the society that created it. In Belgium, mainstream practices concerning pregnancy and childbirth have a strong bio-­‐medical focus, which corresponds to the ‘medical model’. This model reflects the Western society’s core value system, which is strongly oriented toward science, high technology, economic profit, and patriarchally governed institutions (Davis-­‐Floyd, 2001). Belgian psychosocial services and practices are also strongly embedded in the Western norms and value system, but are difficult to grasp in one general model or paradigm. Although these values and norms clearly influence the current scientific practice on topics such as IPV and pregnancy, the ideological paradigms are seldom made explicit. As a consequence, it creates an illusion of sound scientific neutrality that reflects the ‘truth’ or at least an approximation of it. The feminist paradigm still has a strong influence on contemporary research. This is for example reflected in the fact that most studies only measure victimisation in women and seldom address perpetrative behaviour. More specifically within the context of childbirth, pregnant women’s use of violence is virtually ignored (Taillieu & Brownridge, 2010a; Charles & Perreira, 2007; Martin et al., 2004). This is closely linked to the cultural conception of the ‘vulnerable pregnant woman’ that deserves sympathy and protection and a pregnant woman using violent tactics, violates our notion of acceptable feminine behaviour. Despite extensive literature documenting the prevalence and negative effects of IPV victimization in a 78
perinatal population, literature examining women’s IPV perpetration in this population is scant (Tzilos et al., 2010). At the same time, the feminist paradigm still has a role to fulfil since there remains a lot of gender-­‐inequality in several domains. However, the feminist paradigm does not always comply with gender-­‐balanced research premises. Therefore, it is useful to introduce other viewpoints such as the family sociology paradigm to the discussion to add some counterweight. In this paradigm IPV is conceptualized as a phenomenon in which both sexes contribute mutually. The impact of this fairly new paradigm on societal debate can be illustrated with the recent social experiments posted on YouTube (OCK TV, 2016). These clips show a heterosexual couple that is having an argument in the street where the man becomes verbally and physically aggressive. Almost immediately, people in the streets respond clearly disapproving. The same situation is simulated where the woman becomes similarly verbally and physically aggressive. In this situation the public doesn’t interfere and giggles about the situation. The confrontation of millions of YouTube viewers with this unequal social response on equally violent or abusive behaviour breathes new life into the debate on the gender aspects of violence and will probably feed the academic debate as well. The public opinion is an important and influential factor in the research fields involved in pregnancy-­‐associated IPV. However, the societal debate on these sensitive matters is often polarized and lacks nuance which is more embedded in scientific publications and debate. If one wants to address the problem of IPV, it is essential to have a nuanced view on the causes or triggers of violent behaviour. Why do some couples use violent or abusive tactics and why others don’t? How do the individual, relational, cultural and societal factors interact and how does this affect behaviour? In what way does pregnancy influence an abusive/violent intimate relationship and how does abusive/violent communication interfere with pregnancy? If we have a clear view on causes, triggers and interaction between these aspects, it enable us to contribute to finding (it allows us to create) methods that could help couples to avoid violent or abusive behaviour. The theoretical frameworks presented in the preceding chapter all try to answer some of the above questions asked. Unfortunately however, there currently is no theory that provides an integrated framework for (pregnancy-­‐
associated) IPV. This type of theoretical framework to guide research on IPV is sorely needed (Swan & Snow, 2006a). Concretely, new IPV theories should 79
move beyond the individual level and be more comprehensive in nature differentiating types and patterns of violence, taking into consideration the perspectives of both victims and perpetrators and integrating views from multiple academic disciplines, including psychology, sociology, and criminal justice (Rhatigan, Moore, & Street, 2005). Additionally, these theories should be more idiographic in nature, accounting for the significant heterogeneity of IPV and the interaction with the specifics of pregnancy and childbirth identified within the literature. New theoretical perspectives should also address the multi-­‐layered context and proximal events associated with IPV episodes (Bogat, Levendosky, & von, 2005; Hamberger, 2005; O'Leary & Slep, 2006) taking into account the influence of socio-­‐cultural rules and beliefs associated with IPV and pregnancy (Bell & Naugle, 2008b). It would allow us to develop a more complete understanding of the complexity of the problem based within its context and offer a steppingstone to the development of interventions which have a genuine chance of improving perinatal care, maternal and child health and well-­‐being. 80
6. Interventions in perinatal care Women in their reproductive years and especially during pregnancy, use medical services more frequently than at any other point in life (Gazmararian et al., 2000) and most health professionals believe that IPV is a health care issue. Therefore, health care services play a central role in the care for women experiencing IPV, but the content and quality of health care professionals’ responses has been a focus of concern since the 1970s (Taft et al., 2009). Over the last few decades there has been a concerted effort by women’s organisations and justice sector to respond to the needs of women experiencing violence. In contrast, the response of health services has been rather slow (Taft et al., 2009). Most researchers and caregivers agree that perinatal care is an ideal ‘window of opportunity’ to address IPV, for it is often the only moment in the lives of many couples when there is regular contact with health care providers, creating ideal conditions to build a trusting relationship (McFarlane, Groff, O'Brien, & Watson, 2006b; Devries et al., 2010a). Nevertheless, a lot remains unclear about how to deal with IPV in the perinatal care context and which interventions should be adopted. Despite greater recognition of IPV as a major public health problem with many negative health and well-­‐being consequences, much less effort has been given to developing effective preventive strategies and interventions aimed at reducing IPV and/or its consequences (Bailey, 2010a; Jack et al., 2012). Hence, the development and evaluation of violence response interventions and policies in the health care sector and institutions is what is currently called for (WHO, 2014). A number of systematic reviews (Wathen & MacMillan, 2003; Feder et al., 2009; Nelson, Bougatsos, & Blazina, 2012; Ramsay et al., 2009b; Sadowski & Casteel, 2010) have concluded that the evidence supporting specific interventions for abused women is weak, especially interventions provided in (perinatal) health care settings. The limited evidence available indicates that providing psychological and social support, advocacy, and appropriate referrals to social and legal resources can potentially help women reduce their risk of violence and its consequences, and improve birth outcomes (Ludermir, Lewis, Valongueiro, de Araujo, & Araya, 2010; Han & Stewart, 2014b; Kiely, El-­‐Mohandes, El-­‐Khorazaty, & Gantz, 2010). McFarlane and colleagues (McFarlane et al., 2006a) found that in a non-­‐pregnant population in the USA, disclosure of abuse, such as what potentially happens during abuse assessment, was associated with the same reduction in violence and increase in safety behaviours as an intensive nurse case management 81
intervention. According to the authors, simple assessment for abuse and offering of referrals has the potential to interrupt and prevent recurrence of IPV and associated trauma. This remarkable finding incited us to explore the potential effect of similar intervention in a Belgian perinatal health care setting (cf. paper 6). 6.1.
Screening / routine inquiry The first step in addressing the problem of IPV is identification. Research has demonstrated that women refrain from spontaneous disclosure of IPV, especially during pregnancy (O'Campo, Kirst, Tsamis, Chambers, & Ahmad, 2011; Keeling & Mason, 2011; Rubertsson, Hildingsson, & Radestad, 2010; O'Doherty et al., 2015). The reasons why women refrain from telling anyone about intimate partner violence may be shame, embarrassment, a perceived rush to be seen/treated, fear of retaliation, negative consequences for their children, and a perceived requirement to end the relationship (Hathaway, Willis, & Zimmer, 2002; Fugate, Landis, Riordan, Naureckas, & Engel, 2005; Du Mont, Forte, Cohen, Hyman, & Romans, 2005; Lutz, 2005a; Lutz, 2005b). The normalisation process of IPV implies social isolation, control by the partner, and denial of the severity of the situation. In addition, economic dependence and the fact that the abusive partner maybe the only source of social and emotional support may make women hesitant to (spontaneously) disclose violence (Rubertsson et al., 2010; Yoshihama, 2002). Since most women do not spontaneously disclose IPV to their (perinatal) health care provider(s), it has been advocated that routine screening offers a solution to identify women at risk and could lead to interventions that reduce violence and improve health outcomes (Nelson et al., 2012; Taft et al., 2009). Generally, most women are in favour of universal screening, although this varies with abuse status and age (Feder et al., 2009). However, within the field of domestic/family violence the immediate and longer term value of screening remains controversial. There is a range of understanding about screening for IPV, a problematic concept when traditional screening criteria are applied (Hegarty, 2005). It is important to distinguish between universal screening (the application of a standardised question to all symptom-­‐free women according to a procedure that does not vary from place to place), selective screening (where high-­‐risk groups, such as pregnant women or those seeking pregnancy terminations are screened), routine enquiry (when all women are asked but the method or question varies according to the 82
healthcare professional or the woman’s situation), and case-­‐finding (asking questions if certain indicators are present) (O'Doherty et al., 2015). Ten years ago, the US and Canadian Task Forces on Preventive Health Care concluded that there was insufficient evidence to recommend for or against routine screening for IPV in pregnant or non-­‐pregnant women (Wathen & MacMillan, 2003; Nelson et al., 2012). They concluded there was no evidence indicating that women experienced better outcomes from post-­‐screening interventions nor indicating a potential negative impact (Ramsay et al., 2009a; Wathen & MacMillan, 2003). Despite the US Preventive Services Task Force Recommendation, most major medical organizations (including the American Medical Association, the American Academy of Paediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynaecologists, and the American College of Emergency Physicians) recommend routine IPV screening as a part of standard patient care. Due to the evidence on the magnitude and detrimental consequences of IPV, a lot of professional associations and governments opted to recommended screening and did not wait for a broad scientific consensus on the safety and effectiveness of screening. However, recent evidence demonstrates a growing consensus about the safety and effectiveness of routine enquiry within health care settings (Spangaro, Zwi, Poulos, & Man, 2010; O'Reilly, Beale, & Gillies, 2010; Bailey, 2010a; Nelson et al., 2012; Hegarty et al., 2013; O'Campo et al., 2011). Moreover, there is currently a clear evidence based consensus to recommend IPV screening for women during childbearing age as a safe and effective practise and provide or refer women who screen positive to intervention services (Moyer, 2013; 2012; WHO, 2014; O'Doherty et al., 2015). ACOG (Amercian College of Obstetricians and Gynaecologists) states that obstetricians-­‐gynaecologists should screen all women for IPV at periodic intervals, including during obstetric care (at the first perinatal visit, at least once per trimester and at the postpartum check-­‐up), offer ongoing support and review available prevention and referral options. Research has demonstrated that screening more than once during pregnancy, of which minimum once during the third trimester (≥ 27 weeks), increases disclosure rates (Gazmararian et al., 1996). Over the past 10 years, a wide variety of IPV screening tools have been developed and tested. Rabin (Rabin, Jennings, Campbell, & Bair-­‐Merritt, 2009) reported in her systematic review that the most studied IPV screening tools were the Hurt, Insult, Threaten, and Scream (HITS), the Woman Abuse 83
Screening Tool/-­‐Short Form (WAST/WAST-­‐SF), the Partner Violence Screen (PVS), and the Abuse Assessment Screen (AAS). The HITS and WAST(SF) were originally developed for family physicians, the PVS was developed as a brief instrument for the emergency department and the AAS was created to detect abuse perpetrated against pregnant women. According to Rabin, no single IPV screening tool had well-­‐established psychometric properties. Even the most common tools were evaluated in only a small number of studies. Sensitivities and specificities varied widely within and between screening tools. Therefore, health care providers need to determine the optimal balance between brevity and comprehensiveness relevant to their own setting and population, further testing and validation are critically needed (Rabin et al., 2009). It is, however, very unlikely that one single question will address the range of women’s experiences of IPV (O'Doherty et al., 2015). Screening instruments can be used in written form on paper, by means of a (audio-­‐assisted) computer or face-­‐to-­‐face. Research has demonstrated that some women prefer face to face inquiry whilst others prefer paper based tools (MacMillan et al., 2006). Some authors showed that patients are more likely to disclose sensitive and illegal behaviours on computer-­‐based surveys than on paper questionnaires or personal interviews (Rhodes et al., 2006). There is no clear consensus about which screening method is the ‘best method’, since there is evidence that all methods are effective in detecting IPV to a greater or lesser degree (Chang et al., 2012; Ahmad et al., 2009). Nonetheless, the isolated use of screening instruments is not enough to provide qualitative and responsible care related to IPV. Studies showed that routine IPV screening in health settings was most effective in multiple-­‐
component programs that included initial and ongoing staff training, evidence-­‐based guidelines, effective screening protocols, safe documentation, institutional support, and immediate onsite or offsite referral pathways (O'Campo et al., 2011; Baird, Salmon, & White, 2013). To encourage women to disclose abuse when accessing the health care system during the pregnancy/childbirth continuum, a conducive environment is necessary. Although, some research has suggested that women are more likely to disclose to their family doctor in primary health care, than in Emergency Departments (Roelens et al., 2008a) others have showed that the type of health care provider does not play a role. However, the context in which the questions are asked seem to be important (Nelson et al., 2012; Coker et al., 2012; O'Campo et al., 2011). 84
The provision of a safe and confidential arena, being sensitive, empathic, non-­‐
judgmental and caring, are key factors (Feder et al., 2009; Keeling & Mason, 2011). Despite the prevalent nature, the negative impact of abuse, and the multitude of recommendations to screen, there has been, and continues to be some reluctance amongst professionals to enquire about, or respond to IPV. This reluctance has been attributed to a number of barriers on the part of the health care providers, including the fear of ‘opening Pandora’s box’. A lack of awareness or attentiveness for IPV, practitioners own biases regarding who is ‘at risk’, perceived lack of time and knowledge on how to approach the subject, discomfort with the subject, fear of offending woman, lack of knowledge and training about how to respond to (non)disclosure or where to refer the women, frustration with patient’s denial, a belief that the women will not leave the abusive relationship, language and cultural obstacles, and the presence of the partner are frequently cited barriers (O'Reilly et al., 2010; Bohn et al., 2004; Taft et al., 2009; Baird et al., 2013; Salmon, Murphy, Baird, & Price, 2006; Bacchus et al., 2006; Zink et al., 2004; Roelens et al., 2008b; Jeanjot et al., 2008). In contrast to the multitude of provider-­‐related barriers, many women want their health care provider to (routinely) ask about IPV or even wait for their providers to finally ask about it after having given many hints that were not picked up. Screening by health care providers is generally acceptable to women under conditions that they are assured of their trust, confidentiality and support, that the questions are asked in a comfortable manner and that the context is perceived as private and safe (O'Reilly et al., 2010; Nelson et al., 2012). Moreover, Roelens and colleagues (Roelens et al., 2008a) found that in general women had a neutral or positive attitude toward routine screening for IPV by the family physician or obstetrician-­‐gynaecologist, and this was unrelated to whether they experienced IPV or not. While some literature demonstrates that screening alone is insufficient to mitigate women’s IPV experiences during pregnancy (MacMillan et al., 2009), other researchers have showed that inquiring for IPV may be one of the most powerful interventions, whether IPV is disclosed or not (Chang et al., 2012; McFarlane et al., 2006b). Asking questions sends a message of awareness and openness toward the subject and might stimulate women to find help sooner or later. Detection of IPV in healthcare settings remains critical to connect women with necessary intervention resources they may not otherwise gain access to, whether is it part of routine care or not. 85
Due to the interrelatedness of IPV and psychosocial/mental health, negative health behaviour and other risk factors (cf. supra), more and more authors argue to perform an broad antenatal psychosocial risk assessment, including IPV (Coker et al., 2012; Kiely, Gantz, El-­‐Khorazaty, & El-­‐Mohandes, 2013; Harrison, Godecker, & Sidebottom, 2011). 6.2.
Interventions Evidence shows strong relationships between violence and potentially modifiable factors such as concentrated poverty, income and gender inequality, the harmful use of alcohol, and the absence of safe, stable, and nurturing relationships between intimate partners, children and parents. Scientific research shows that strategies addressing the underlying causes of violence can be effective in preventing violence (WHO, 2010a). More specifically for health care providers, several options are available in the management of pregnant women experiencing IPV. A first type of interventions are interventions directed at the women themselves. Health care providers (with training in this area) may be able to provide limited counselling in the form of a brief intervention or motivational interviewing. However, lack of time and experience precludes this option in the vast majority of cases. Other more commonly employed options are referrals to safe environments such as shelters, referrals to counselling or other community based resources, and the provision of resource information. Another set of intervention options is referral of the perpetrator to a perpetrator treatment program. The practicality of this approach is somewhat limited, however, if the provider has no contact with the abuser or the abuser is unwilling to seek help. However, along these lines, people can be encouraged to file legal charges or seek a protective order (Bailey, 2010a). Overall, there is a global consensus that health-­‐care professionals should know how to identify patients experiencing intimate partner violence and provide first-­‐line supportive care that includes empathetic listening, ongoing psychosocial support, and referral to other services (Garcia-­‐Moreno et al., 2015). As stated at the beginning of this chapter, studies evaluating interventions for IPV during the perinatal period are scarce. Moreover, the overall quality of the studies is limited and does not produce strong evidence that certain interventions are effective and should be adopted in practise (Jahanfar, Janssen, Howard, & Dowswell, 2013). 86
The evidence of IPV interventions outside the context of pregnancy remains similarly insufficient and inconclusive (Bailey, 2010a; Nelson et al., 2012; Ramsay et al., 2009b; Wathen & MacMillan, 2003; Ludermir et al., 2010). Nonetheless, four studies on home visitation programs (Olds et al., 2004; Bair-­‐
Merritt et al., 2010; Mejdoubi et al., 2013b; Taft et al., 2011) and one multifaceted counselling intervention (Kiely et al., 2010) show promising results and reported a significant decrease in physical, sexual and/or psychological partner violence (odds ratios from 0.38 to 0.92) (Tiwari et al., 2005a; Kiely et al., 2010; Cripe et al., 2010; Mejdoubi et al., 2013b; Zlotnick, Capezza, & Parker, 2011; Taft et al., 2011; Bair-­‐Merritt et al., 2010; Curry, Durham, Bullock, Bloom, & Davis, 2006; Humphreys, Tsoh, Kohn, & Gerbert, 2011; Olds et al., 2004). However, although the home visitation program from Olds et al. (Olds et al., 2004) noted a significant decrease in physical IPV for the nurse-­‐visited women, this was not found for the paraprofessional-­‐visited women. The authors attributed this finding to an increased emphasis among the nurses on partner violence, but it remains unclear if this was really the case. The Dutch equivalent of the home visitation program from Olds (Mejdoubi et al., 2013b), compared a nurse home visitation program to usual care and reported significantly less IPV and perpetration in the intervention group until 24 months after birth in a sample of high-­‐risk young pregnant women. With regard to the secondary outcomes, Olds (Olds et al., 2004) reported significantly better mental health, fewer subsequent miscarriages and low birth weight newborns in the paraprofessional-­‐visited but not in the nurse-­‐
visited women. The different impact of nurses and paraprofessionals raises questions about the mechanisms through which the interventions affected the outcomes. Two other studies evaluating home visitation programs for IPV during the perinatal period (Taft et al., 2011; Bair-­‐Merritt et al., 2010) found limited evidence for improved mental health, less postnatal depression, improved quality of life (QOL), fewer subsequent miscarriages, and less low birth weight/prematurity. None of the studies reported any evidence of a negative or harmful effect of the interventions. Evidence from five studies evaluating different types of supportive counselling (Humphreys et al., 2011; Zlotnick et al., 2011; Cripe et al., 2010; Curry et al., 2006; Tiwari et al., 2005b), show that only two (Kiely et al., 2010; Tiwari et al., 2005a) found a statistically significant effect of the intervention on IPV. First, the high-­‐quality study by Kiely et al. (Kiely et al., 2010) found that their 87
cognitive behavioural intervention significantly reduced recurrent episodes of IPV (except for sexual IPV). Second, Tiwari et al. (Tiwari et al., 2005a) reported significantly less psychological and minor physical (except for sexual IPV) violence in the intervention group. Sexual partner violence seems to be a form of violence that is difficult to influence. The other four studies (Humphreys et al., 2011; Zlotnick et al., 2011; Cripe et al., 2010; Curry et al., 2006) did not find a significant difference in IPV between the intervention and control groups. Concerning secondary outcomes, Kiely et al. (Kiely et al., 2010) observed significantly fewer very preterm neonates and an increased mean gestational age in the intervention group. Tiwari et al. (Tiwari et al., 2005a) reported significantly fewer women with postnatal depression and improved QOL in the intervention group. None of the studies reported any evidence of a negative or harmful effect of interventions, although only one study (Humphreys et al., 2011) mentioned assessing potential harms caused by intervention. More details on the studies evaluating interventions for IPV during the perinatal period can be found in paper 5 and 6. In conclusion, strong evidence of effective interventions for IPV during the perinatal period is lacking. Nonetheless, home visitation programs and some multifaceted counselling interventions produced promising results. Intervening in a single risk factor seems to be unsuccessful because other risk factors may persist as barriers to the desired change. Current evidence indicates that comprehensive IPV interventions addressing several risk factors (e.g. depression, smoking, social support, etc.) simultaneously, have the highest chances for success. However, large-­‐scale, high-­‐quality research is essential to provide further evidence about the effect of these interventions and clarify which (Kaukinen et al., 2013) interventions should be adopted in the perinatal care context. 6.3.
Help-­‐seeking behaviour 6.3.1. Model of help-­‐seeking and change Although it has been noted that the availability, quality and quantity of different (formal) services for IPV has improved past several decades, research reveals an underutilisation of resources providing assistance for IPV (Kaukinen et al., 2013). A number of studies have reported a reluctance to access existing (formal and informal) support networks (Liang et al., 2005). In an effort to understand the mechanisms involved in help-­‐seeking behaviour, 88
Liang and colleagues outlined a theoretical framework (Overstreet & Quinn, 2013). Their recursive model suggests that those who experience IPV must recognize and define the abusive situation as intolerable, decide to seek help, and select a supportive source of help. As illustrated in the figure 4, each stage of the help-­‐seeking process in Liang’s model is influenced by individual, interpersonal, and sociocultural factors (Overstreet & Quinn, 2013). This model is a stage model, meaning that based on a cost-­‐benefit analysis of the situation, people progress from more private attempts to deal with the abuse, to informal support-­‐seeking, and as violence worsens to more formal/public help-­‐seeking. According to Liang (Liang et al., 2005), the process of help-­‐seeking should not be assumed as a universally positive experience, as it can be a source of danger, conflict, rejection and criticism. Figure 4: Model of help-­‐seeking and change (Liang et al., 2005) 89
6.3.2. Stages of change model The abovementioned model of help-­‐seeking and change (Liang et al., 2005) is closely linked to the ‘stages of changed or readiness to change’ model of Prochaska (Prochaska, Diclemente, & Norcross, 1992a). More specifically the definition of the situation as abusive and the decision to seek help could benefit from including certain aspects of the precontemplation phase and the process of becoming aware of the problem. Although, Liang and colleagues, do not specifically include or refer to the Prochaska model, we think it offers an interesting viewpoint and practical tool in addressing IPV . The ‘Stages of change in the modification of problem behaviours’ of Prochaska & DeClimente (Prochaska et al., 1992a) is a transtheoretical model involving motivational interview techniques, and describes a process through which many individuals may go while considering major life changes, modifying a problem behaviour, or acquiring a positive behaviour. It focuses on decision making and involves emotions, cognitions, and behaviour. The model has been applied to health behaviour changes related to smoking, drugs, gambling, exercise adoption, and dietary modification and has been recently been applied to IPV. Change is not seen as dichotomous event but as process that is experienced in stages. Consequently, measuring the impact of an intervention or change, should not be done through a linear measure. Change is complex and concurrently includes levels of self, relationship, family and community (Dienemann, Campbell, Landenburger, & Curry, 2002). There are 5 stages of change: precontemplation (not aware or minimising the problem), contemplation (acknowledging the problem and considering possible changes), preparation (making plans), action (following through with plans), and maintenance (keeping the new action as a part of daily activity). In attempting to make a change, a person cycles through the stages, often moving back and forth between the different stages (Zink et al., 2004; Kramer et al., 2009). Returning to a previous stage is an integral part of the change process and is rather the norm than the exception. Returning to a previous stage is seen as positive because it creates additional opportunities to learn how to change. For example, a pregnant woman returning to an abusive relationship may, on the surface, appear to have made an ill-­‐considered decision. In some instances this decision may, however, allow the woman additional time to defuse a tense situation or prepare for a safer change (Frasier, Slatt, Kowlowitz, & Glowa, 2001). 90
The stages of change model focuses on individual change, whereas with women experiencing IPV, changes would be occurring within and to the relationship with another person. Making changes in a violent relationship often involves the safety and wellbeing of the woman and her child(ren). A decision to alter or leave the relationship needs careful planning and can be risky, since violence often escalates during and after separation. Women experiencing IPV wish for the end of violence, not always for the end of the relationship. This is particularly true for pregnant women. It is crucial for providers to understand the context of the woman’s behavioural responses to IPV in the perinatal phase and stages of readiness for any sort of change. Becoming a mother often presumes that there is a positive, supportive relationship with one’s partner, yet abuse often coexists and presents competing behavioural demands and social expectations for women. Behaviours of pregnant women experiencing IPV, challenge our traditional notions of how expectant or new mothers should behave. Despite the abuse, the childbearing cycle strengthens the bonds to the intimate partner and commitment to family and imbues women with new hopes and dreams for the idealized family, all normal components of maternal-­‐role acquisition (cf. double binding). Women often hope that the pregnancy will end the abuse. All relationships, including the abusive relationship, have its good and bad moments. The social importance of the father and/or partner and the “normal” family compounded with “not wanting to be alone” during the pregnancy reinforces women’s decisions not to leave the relationship (Kramer et al., 2009). The underneath table 2 gives an overview of effective interventions for IPV adapted to the specific stages of change. 91
Table 2: Overview effective interventions matched with stages of change (Frasier et al., 2001). 92
6.3.3. Determinants in help-­‐seeking behaviour Several factors have been linked to help-­‐seeking behaviour. Unlike other social relationships, relationships between intimate partners include a wide range of contacts, including eating, sleeping, co-­‐parenting, playing, working, making large and small decisions, and sexual activity. The fluid, liberal, and intimate nature of these interactions may make subtle violations and abuses difficult to detect and harder still to understand or define. Moreover, because the actual nature, severity, and presence of violence in an intimate relationship may be constantly shifting, with abusers alternating between violence and loving contrition, acknowledging the relationship as abusive may be difficult and confusing (Liang et al., 2005). Fanslow and Robinson (Fanslow & Robinson, 2010) identified 63.4% of abused women did not seek help from formal services due to their perception of the violence to be “normal or not serious.” This perception of “normality” has resulted in women enduring violence without any help (Lucea et al., 2013a). The type, extent and severity of the IPV have been associated with help-­‐
seeking behaviour. Loke et al. (Loke, Wan, & Hayter, 2012)reported that the women in their study would not have sought help if they had not perceived a threat to their safety. This is consistent with reports that most women tend to put up with IPV until they perceive danger (Ellsberg, Winkvist, Pena, & Stenlund, 2001). When the abuse is less severe, women are more likely to endure the pain of violence, withdrawing from the argument or scene. When the violence became or was perceived as more severe, involving the use of deadly objects or the fear for one’s life, the women would call for help. This suggests that victims do not receive the necessary services until they are in danger (Loke et al., 2012). In contrast, Dufort (Dufort et al., 2013) found that non help-­‐seekers had similar experiences of severe IPV as help-­‐seekers. Concerning the type of violence, Duterte (Duterte et al., 2008) found that women experiencing sexual IPV were more likely to seek medical and legal services and women experiencing physical IPV were 3 times more likely to seek legal services than women who experienced psychological IPV alone. Other research has shown that higher levels of psychological abuse are significantly correlated with use of informal resources (Goodkind, Sullivan, & Bybee, 2004). Women who experienced severe physical abuse from an intimate with acts of coercive control and verbal abuse were more likely to have told someone about the violence when compared with women who experienced moderate physical violence or women who experienced sexual abuse alone (Ansara & Hindin, 2010; Fanslow & Robinson, 2010). 93
A variety of victim demographics, including age, education, socioeconomic, and marital status have been associated with the nature and extent of victims’ help-­‐seeking behaviours by past research (Kaukinen et al., 2013). Education is one of the most consistent predictors of help-­‐seeking and likely shapes women’s knowledge of the role of these support sources in providing avenues to ending violent relationships. Women with a higher education than their partners, are less likely to tolerate IPV and are therefore more likely to access relevant support sources in their decisions to end a violent intimate relationship. Women’s employment also increases the odds they will seek help from family and friends, whereas unemployed women, who are dependent on their employed partner, are less able to end or leave the relationship with the partner they economically depend upon. In contrast, women with high incomes might be less likely to seek formal help and expose their experiences to others, keeping it a private matter, for fear of consequences to their employment and economic standing. These women may be more able to address partner violence without tapping support services given their access to financial assets. As far as the type of help that is being sought, informal sources of help and social support, including family and friends, continue to be the primary source women turn to in dealing with the aftermath of violence in their intimate relationship. More formalised sources, including law enforcement, medical services and specialize IPV services, remain underused (Kaukinen et al., 2013). Several population-­‐based studies have shown that 58% to 80% of abused women opted to disclose information about the abuse and sought support at least once from any informal resource while up to 64% of women reported use of formal services (Lucea et al., 2013a). Social support from family, friends, and co-­‐workers are common informal resources (Coker, Derrick, Lumpkin, Aldrich, & Oldendick, 2000), while health professionals (47.2%) and the police (34.2%) are commonly used formal resources (Ansara & Hindin, 2010). General social support research has identified an association between support (mainly from informal sources) and mental health functioning. For instance, many studies have demonstrated that the size of one’s informal social network, as well as the level of perceived supportiveness of its members, predicts psychological health. This literature suggests that those with close relationships that provide both psychological and material resources are in better psychological health than those with fewer informal supports. 94
This is significant with regard to IPV in particular, considering that informal social support has been identified as a key protective factor that is associated with fewer mental health problems among battered women (Liang et al., 2005). 95
7. Conclusion Over the past 30 years, a considerable number of studies have been published in the Western world on pregnancy-­‐associated violence (James et al., 2013; Straus et al., 2011). However, myriad study design features and methodological challenges resulted in a wide variation in prevalence rates reported, making comparison across studies and nations a true challenge. Despite this substantial amount of research, sound estimates of the prevalence of violence/abuse during the childbearing period are difficult to obtain (Daoud et al., 2012). Particularly, prevalence rates on psychological violence are currently lacking. In order to address this gap, we will assess the prevalence of physical, emotional, and/or sexual violence experienced as a child and/or as an adult (objective 1 and 2) and will make a comparison of prevalence rates found in six European countries (objective 1). Even though there is some literature on the evolution of IPV around the time of pregnancy, little is understood about how partner violence may change throughout a woman’s pregnancy and what factors contribute to the varying patterns. Therefore, we will explore in a Flemish/Belgian population if IPV is starting up, continuing or ceasing (objective 2) during pregnancy. The association between IPV and the physical consequences of this behaviour is quite well-­‐established and there is a large consensus that it has a detrimental impact on the health and well-­‐being of mother and child. Yet, evidence of the impact of IPV on the mental or psychological health of women (and their families) is only starting to emerge. Hence, we will explore whether IPV 12 months before and/or during pregnancy is associated with psychosocial health in Flanders, Belgium (objective 3). As far as the impact of IPV on obstetric outcome, the vast majority of studies have focused on preterm birth and low birth weight and there is relatively strong evidence that shows a correlation between both. However, there is still only a limited amount of information on which factors are decisive and on the pathways how they interact. Furthermore, findings on the impact of abuse history on mode of delivery are inconclusive. Some have found major increase in risk of CS for women who have been subjected to rape in adulthood, others have stated that factors such as fear of childbirth may be strongly correlated with the association between abuse history and operative delivery. 96
In order to get more clarity in this matter, we will explore whether a history of abuse/violence is associated with operative delivery and if the association varies according to the type of abuse/violence reported as a child or an adult in six European countries (objective 4). Most researchers and caregivers agree that perinatal care is an ideal ‘window of opportunity’ to address IPV (McFarlane et al., 2006b; Devries et al., 2010a). Nevertheless, a lot remains unclear about how to deal with IPV in the perinatal care context and which interventions should be adopted. Studies evaluating interventions for IPV during the perinatal period are scarce. Moreover, the overall quality of the studies is limited and does not produce strong evidence that certain interventions are effective and should be adopted in practise (Jahanfar et al., 2013). The evidence of IPV interventions outside the context of pregnancy remains similarly insufficient and inconclusive (Bailey, 2010a; Nelson et al., 2012; Ramsay et al., 2009b; Wathen & MacMillan, 2003; Ludermir et al., 2010). Despite greater recognition of IPV as a major public health problem with many negative health and well-­‐being consequences, much less effort has been given to developing effective preventive strategies and interventions aimed at reducing IPV and/or its consequences (Bailey, 2010a; Jack et al., 2012). Hence, the development and evaluation of violence response interventions and policies in the health care sector and institutions is what is currently called for (WHO, 2014). In an effort address this call, we will first provide a systematic literature overview of the existing evidence on effectiveness of pregnancy-­‐associated IPV interventions (objective 5). Second, we will explore the suggestion made by McFarlane et al. (2006) that the simple assessment for abuse and offering of referrals has the potential to interrupt and prevent recurrence of IPV and associated trauma. Therefore, we will investigate the effect of identifying IPV and handing out a referral card, on the evolution of IPV, psychosocial health, help-­‐seeking and safety behaviour during and after pregnancy in Flanders, Belgium (objective 6). 97
98
Chapter 2: Methodology 1. General objective The general objective is to assess the prevalence, determinants and associated obstetric outcomes of IPV before, during and after pregnancy and to investigate the effect of an intervention for pregnancy-­‐associated IPV. 2.
Specific objectives Prevalence Objective 1: To assess the prevalence of physical, emotional, and/or sexual violence experienced as a child and/or as an adult in six European countries (BIDENS-­‐study). Objective 2: To assess the prevalence of physical, psychological and sexual partner violence 12 months before and/or during pregnancy and to provide insight into the evolution of IPV in Flanders, Belgium (MOM-­‐study). Associated factors Objective 3: To explore whether IPV 12 months before and/or during pregnancy is associated with psychosocial health in Flanders, Belgium (MOM-­‐
study). Objective 4: To explore whether a history of abuse/violence was associated with operative delivery and if the association varied according to the type of abuse/violence reported as a child or an adult in six European countries (BIDENS-­‐study). Interventions Objective 5: To provide a systematic literature overview of the existing evidence on effectiveness of pregnancy-­‐associated IPV interventions. Objective 6: To investigate the effect of identifying IPV and handing out a referral card, on the evolution of IPV, psychosocial health, help-­‐seeking and safety behaviour during and after pregnancy in Flanders, Belgium (MOM-­‐
study). 99
3. Methodology BIDENS-­‐study The BIDENS-­‐study is a longitudinal cohort study of women attending antenatal care in six European countries: Belgium, Iceland, Denmark, Estonia, Sweden and Norway (coordinating centre). Between one and seven urban antenatal care sites were involved in data collection in each country end recruitment took place between March 2008 and August 2010. All women required sufficient language skills to participate in the study. In Belgium, women who could not to be separated from their accompanying person were not recruited and women less than 18 years of age were excluded due to local ethical requirements. A total of 7200 consenting women, subsequently completed a written questionnaire and allowed the extraction of data on their delivery from their medical file. Due to country specific organization as well as the requirements of local ethical committees, minor variations in the recruitment procedure occurred. In Belgium, we recruited in 3 hospitals (UZ Gent, Jan Yperman in Ieper and OLV van Lourdes in Waregem). The women were approached by the midwife or secretary when attending antenatal care. Women were asked to complete the questionnaire in the privacy of a separate room and handed the filled in questionnaire in a sealed envelope to the midwife or secretary. Assistance from the social services was available if deemed necessary. More details about the recruitment sites and procedures in each country are provided in paper 1 and 4. The BIDENS-­‐questionnaire consisted of 68 items on socio-­‐economic background (age, civil/marital status, mother tongue, education, occupation, economic stress), life-­‐style (smoking, alcohol, medication), general and mental health (depression, post-­‐traumatic stress), emotional/physical/sexual violence/abuse as a child or as an adult, degree of suffering related to the violence/abuse, negative life events, fear of childbirth and obstetric history (planned/unplanned pregnancy, method and experience of previous deliveries, and preference of mode of delivery). A complete version of the questionnaire was developed in English and is available in annex 1. More details about the measures and how they were analysed are available in paper 1 and 4. Birth outcome data was collected from hospital records and recorded on the outcome sheet prepared for the study. Data for following variables was recorded: gestational age at delivery, mode of delivery, induction of labour, epidural anaesthesia, elective or acute C-­‐section, indication for operative 100
delivery, counselling for fear of labour, baby born alive, baby’s birth weight, baby’s gender, baby’s Apgar score at 5 min. after birth, baby admitted to neonatal intensive care unit. Filled in questionnaires and outcome sheets from the partaking countries were systematically sent to the data-­‐handling centre in Tromsø (Norway) where all necessary procedures for scanning in all data were set up. A cleaned electronic SPSS file including data from every country was made available to all researchers. The data was anonymised prior to analysis. Additional methodological details on the BIDENS-­‐study are available in paper 1 and 4. 4.
Methodology MOM-­‐study 1
The MOM -­‐study is a Belgian multi-­‐centre study that consists of two phases. The first phase is a cross-­‐sectional prevalence study and the second phase a single-­‐blind RCT. In brief, the prevalence study (based on a written questionnaire) aims to determine the prevalence of physical, sexual violence & psychological abuse and psychosocial health in a pregnant population. The RCT (based on two telephone interviews: one 10-­‐12 months and one 16-­‐18 months after the receipt of a referral card at the 6-­‐week postpartum consultation) aims to assess the impact of an intervention (identifying IPV and handing out a referral card), on the evolution of IPV, psychosocial health, help-­‐seeking and safety behaviour within a Belgian perinatal population. The research included in this thesis only addresses the results of the first interviews (10-­‐12 months). A detailed study protocol is available in annex 2. The underneath figure 5 provides a timeline containing an overview of the different research activities in both phases of the MOM-­‐study. 1
The acronym of the study refers to the Dutch phrase “Moeilijke momenten en gevoelens”(~ difficult moments and feelings) and “onder het mom van, masker” (~under the guise /veil of…), and also the short word ‘mom’/’mum’ that refers to mother. 101
Figure 5: Timeline MOM-­‐study 4.1.
Setting and context of Belgian perinatal health care Generally, the Belgian health care system is is based on the medical model (Christiaens et al., 2008). It is considered to be highly accessible in terms of availability, physical accessibility and affordability and by high rates of health care utilisation with women choosing their own health care provider(s). Belgian obstetricians-­‐gynaecologists not only account for gynaecologic and obstetric pathology, but also act as the primary care physicians to the general female population, e.g. in providing primary obstetric care and in offering preventive women's health medicine (Roelens et al., 2008b; Roelens, Verstraelen, Van Egmond K., & Temmerman, 2006). Hence, the majority of the care is hospital-­‐based. There is no clear distinction between primary, secondary and tertiary levels of care. Most of the time the different levels, private as well as public, are being used in a parallel way, inside as well as outside the hospital context (Hemminki & Blondel, 2001). Belgian maternity care is organized around the concept of risk, and not around ‘normality’. More than 98% of all women get antenatal care from the obstetrician-­‐gynaecologist who also supervises the subsequent delivery. Hence, most pregnant women have continuity of specialist care throughout pregnancy and childbirth, unless women choose otherwise or the obstetrician is unavailable (e.g. vacation) at the time of birth. A minority of women, is being cared for by a (team of) midwi(f)ve(s) during pregnancy and childbirth, whether in the context of a homebirth (1%) or not (Christiaens et al., 2008; Beeckman, Louckx, Masuy-­‐Stroobant, Downe, & Putman, 2011). Screening or systematic inquiry for IPV is not part of routine perinatal care. 102
4.2.
Prevalence study We conducted a multi-­‐centre cross-­‐sectional study in Flanders, the Northern part of Belgium and recruited in 11 antenatal care clinics, in order to obtain a balanced sample of the general obstetric population. The convenience sample of hospitals was geographically spread across Flanders, and included a mix of rural and urban settings, as well as small and large hospitals that provide services to socio-­‐economically and ethnically diverse populations. From June 2010 until October 2012, consecutive women seeking antenatal care were invited to participate if they were at least 18 years old and able to fill in a Dutch, French or English questionnaire. The study was limited to one questionnaire per woman and we did not impose limits on the gestational age. The midwife or secretary introduced the study as a survey on difficult moments and feelings during pregnancy and briefly explained the procedure. Consenting women were handed a questionnaire, including an informed-­‐
consent form, which was filled in in a separate room (if available) without any accompanying person present. If the woman was unable to fill in the informed consent form and questionnaire in private, she was excluded from the study for safety reasons. The overall response rate was 76.7% in this phase of the study, a detailed overview of the study sample collection is available in paper 2. The study was approved by the Ethics Committee of Ghent University which acted as central ethical comity and local ethical clearance from all 11 participating hospitals was obtained (Belgian registration number 67020108164). The sample size calculation for first phase of the study (prevalence) was based on the calculations for the RCT (cf. infra). The self-­‐administered questionnaire (see annex 3) consisted of four main parts: - socio-­‐demographics: age, gestational age, civil status and education; - psychosocial health: Abbreviated Psychosocial Scale (APS) (Goldenberg et al., 1997); - physical and sexual violence: Abuse Assessment Screen (AAS) (McFarlane, Parker, Soeken, & Bullock, 1992b); - psychological abuse: WHO-­‐questionnaire multi-­‐country study on violence (Garcia-­‐Moreno, Heise, Jansen, Ellsberg, & Watts, 2005b); - satisfaction with care: Patient Satisfaction Scale (Plichta, Duncan, & Plichta, 1996). 103
The questionnaire was available in Dutch, French and English and was based on a rigorous translation and back translation of the original instruments. More details on the measures and how they were analysed are available in paper 2. The questionnaires were scanned and processed using the software Remark Office OMR version 7 and exported to SPSS version 21. The data file was rigorously checked by two researchers for data entry errors. To check the quality of the scanning process, a random sample of 100 questionnaires was controlled by hand, yielding an error rate of 1%. Additional methodological details on the MOM-­‐study are available in paper 2, 3 and 6. 4.3.
Intervention study 4.3.1. Setting and study population We conducted a multi-­‐centre single-­‐blind Randomized Controlled Trial (RCT) in Flanders, the Northern part of Belgium. From June 2010 to October 2012, women seeking antenatal care in 11 antenatal care clinics were consecutively invited to participate in the study if they were pregnant, at least 18 years old and able to fill in a Dutch, French or English questionnaire. We did not impose limits on gestational age. The midwife or receptionist introduced the study as a study on difficult moments and feelings during pregnancy and briefly explained the procedure. Women that orally consented to participate were handed an informed consent form and a questionnaire, which were both filled in in a separate room (if available) without the presence of any accompanying person. If the woman was unable to fill in the informed consent form and questionnaire in private, she was then excluded from the study for safety reasons. On the first page of the questionnaire women received an invitation to participate in the intervention phase of the study. Those willing to participate wrote their contact details down and were informed that eligible respondents would be interviewed twice by telephone and receive a gift voucher as compensation. The selection of eligible participants for randomization was based on IPV disclosure and willingness to participate in the intervention study. As a consequence, the IPV prevalence rate at follow-­‐up should have been 100%. However, 5 women were just below the victimisation threshold handled (see below) but slipped through the net of randomization, however thus were excluded from the final analysis. 104
The study was approved by the Ethics Committee of Ghent University (the central review board) and by the local ethical committees of all 11 participating hospitals (Belgian registration number 67020108164). The trial was registered with the U.S. National Institutes of Health ClinicalTrials.gov registry under identifier NCT01158690). (https://clinicaltrials.gov/ct2/show/NCT01158690?term=van+parys&rank=1) 4.3.2. Allocation concealment / randomization As soon as the baseline assessment was filled in, the contact details and the related data of eligible respondents were systematically entered into an Access database. Case numbers were randomly assigned to the IG (intervention group) and CG (control group) by a computer generated list. The identification key was created and safely stored by a researcher not directly involved in the study. At the postpartum consultation (+/-­‐ 6 weeks after delivery), the participants were handed a numbered opaque envelope. The lay-­‐out and format of the envelopes of both groups were identical, so neither the health care providers nor the researchers could see or feel the difference. Since the envelope contained a referral card for the IG and a “thank you” card for the CG, it was not possible to blind the participants as a consequence of the design of this RCT. Nevertheless, we made a number of deliberate efforts to minimise the possibility of contamination between the two groups. First, the midwives/receptionists involved in the recruitment were not involved in the design of the study and had no knowledge of the hypotheses. Information about the study given to the clinical staff and receptionists was kept to a strict minimum. Second, women were allowed a separate available room where they filled in the questionnaire and waiting time at the clinic was minimised so that the intervention and control group women had little time or opportunity to meet each other. Moreover, the receptionists/midwives/doctors delivered the anonymous intervention or control envelopes to the women individually at postpartum check-­‐up. Finally, the women’s allocation was not recorded anywhere, except in the secured identification key. In total 2,587pregnant women were invited to participate and 2,338 were excluded of which 693 were ineligible for the first phase of the study, while 1620 did not meet the inclusion criteria for the second phase and 25 were lost before randomization. A total of 249 women were randomized, 129 allocated 105
to the IG and 120 to the CG. At this stage, an additional 25 women were lost, and 10.9% in the IG and in the CG this was 9.2% did not receive the envelope due to the lack of a postpartum consultation or the oblivion of the midwife/receptionist. At the first follow-­‐up interview (10-­‐12 months after receipt of the envelope), 12.2% was lost to follow up in the IG and 10.1% was lost in the CG, resulting in a final sample size of 101 in the IG and 98 in the CG. More details are available in the flow diagram in paper 6. 4.3.3. Sample size Since IPV was the only main outcome measure with hard data available, the sample size was powered to test a reduction in the prevalence of IPV. Calculations were based on the most recent prevalence estimate of IPV in a Belgian pregnant population, which reported 3.4% physical and/or sexual partner violence in the year before and/or during pregnancy (Roelens et al., 2008b). Since we measured IPV several times (Gazmararian et al., 1996) and also included psychological abuse, we expected to detect a prevalence that exceeded the most recent prevalence rate with 5%, equalling an total estimate of 8.4%. Based on other RCTs with a similar study design, we considered an IPV decrease of 30% relative to the 100% baseline prevalence in the IG clinically relevant, and we also hypothesised a 10% spontaneous or unexplained decrease of IPV in the CG (McFarlane et al., 2006a; Barlow et al., 2013; Loeffen et al., 2011). Assuming 30% loss to follow-­‐up of and an alpha significance level of 0.05, at least 89 participants had to be included in each group (total N=178) in order to detect a difference of 0.2 with 80% power. This means that a total sample of 2,119 women was needed to retain the required number of women in both groups. 4.3.4. Intervention In brief, our study-­‐intervention consisted of three parts: a questionnaire, a referral/thank-­‐you card (see annex 4), and two interviews. Eligible women were handed an envelope by the midwife or receptionist at their 6-­‐week postpartum consultation. The envelope of the IG contained: an information letter, a bank card-­‐sized referral card containing the contact details of services providing assistance for IPV on one side and tips to increase safety behaviour on the other side, and a gift voucher. The resources and safety tips were selected in close collaboration with other researchers and expert care 106
workers active in the field of IPV. The envelope of the CG contained: an information letter, a bank card-­‐sized thank-­‐you card, and a gift voucher. The participants were interviewed 10 to 12 months and 16 to 18 months after receipt of the envelope. The optimum period for the outcome measurement for this type of intervention has not been established. While some interventions may produce immediate positive effects, other effects may not be evident for some time. Therefore, we decided to time the first outcome measurement in a short term (within 12 months) and the second measurement in a medium term (from 12 to 24 months), as defined by Ramsey et al (Ramsay et al., 2009b). The information about IPV and resources for IPV provided to the health care professionals and receptionists in the participating hospitals was kept to a strict minimum, since the study aimed to measure the effect of the intervention in an unbiased manner with least intention to encourage help from the professionals in this stage. Furthermore, to our knowledge, only one in 11 participating hospitals displayed a sensitization poster and some folders concerning IPV. This led us to the assumption that the impact of parallel interventions on our respondents was minimal. The rationale behind the design of this intervention lies in the conclusion of McFarlane and colleagues (McFarlane et al., 2006a) that in a non-­‐pregnant US population, the disclosure of abuse was associated with the same reduction in violence and increase in safety behaviours as an intensive nurse case management intervention. The authors argued that the simple assessment of abuse and provision of referrals have the potential to interrupt and prevent recurrence of IPV and associated trauma. As explained before, the current Belgian perinatal health care system is based on the medical model and obstetricians-­‐gynaecologists provide primary obstetric care to 98% of the women. There is no clear policy on how to handle IPV within perinatal care and screening or systematic inquiry for IPV is not part of routine perinatal care. Belgian perinatal health care workers report a lot of barriers (Roelens et al., 2006; Jeanjot et al., 2008) in addressing IPV, therefore we designed an intervention that does not ask a lot of time or commitment and is feasible to implement on a large scale. Moreover, the referral card is commonly used as the control-­‐intervention most RCT and as far as we know no other study has explored the impact of this card compared to routine antenatal care. 107
4.3.5. Measures The interview (see annex 5) consisted of: - socio-­‐demographics: age and mother tongue; - IPV: both victimisation and perpetration, measured through the short form of the revised Conflict Tactics Scale (CTS2S) (Straus, 2004); - psychosocial health: Abbreviated Psychosocial Scale (APS) (Goldenberg et al., 1997); - help-­‐seeking behaviour: Community Agencies Use Questionnaire (McFarlane et al., 2006a); - readiness to change (Hegarty, O'Doherty, Gunn, Pierce, & Taft, 2008); - safety behaviour: Safety Promoting Behaviour Checklist’ (McFarlane et al., 2006b); - perceived helpfulness of the intervention (questionnaire/referral card/interview). The main outcome measures of this intervention study were: IPV, psychosocial health, (in)formal help-­‐seeking behaviour and safety behaviour. Readiness to change was included as a mediating variable for help-­‐seeking behaviour. More details on the measures and how they were analysed are available in paper 6. 5. Methodology systematic literature review We did a systematic literature review to gain insight into the existing evidence on effectiveness of pregnancy-­‐associated IPV interventions. The PRISMA guidelines were used as a framework for this review (Moher, Liberati, Tetzlaff, & Altman, 2009). The systematic review was based on an extensive search in the electronic databases PubMed, Web of Science, CINAHL, and the Cochrane Library. The search was limited to peer-­‐reviewed articles reporting results from RCTs published in English from 2000 to 2013. The searches were systematically updated during the writing process, the last update taking place in March 2013. We started our search in PubMed and applied the same strategy in Web of Science, CINAHL and the Cochrane Library. Reference lists of retrieved articles were checked and relevant articles were added by hand search. 108
The database search was executed by two reviewers independently, findings were discussed and differences resolved. We retrieved 412 potentially relevant articles based on keywords and limits set, 15 additional articles were identified through hand search. After title and abstract evaluation of 358 articles, 17 articles were eligible for more detailed evaluation. After full text evaluation another eight were excluded, leaving nine studies submitted to critical appraisal and included in the systematic review. After full text evaluation, the risk of bias and the quality of the selected studies was assessed based on ‘‘The Cochrane Collaboration’s tool for assessing risk of bias’’ (Higgings, 2013). The two reviewers independently assessed risk of bias for each study and classified every study as low, high or unclear risk of bias. More details on inclusion/exclusion criteria and a detailed overview of the search strategy are available in paper 5. Using a specially designed data extraction form, the two reviewers independently extracted information from the selected papers. Data items compromised country, setting, sample size & participants, sampling methods, measuring tools, description of the intervention and control group(s), outcomes, and follow-­‐up period. Authors were contacted if additional information was required. 6. Ethical aspects Due to the sensitive and complex nature of the subject of our research, a lot of time and energy was invested in the ethical aspects of both the BIDENS and the MOM-­‐the study. Conducting research on IPV during the pregnancy and postpartum period inevitably involved issues of safety, confidentiality and interviewer skills and training. Research conducted without sensitivity and attention to these matters could be distressing and put respondents, health staff and researchers at risk. All research on IPV needs to prioritize safety, and foresee protocols to protect the safety of all participants and to ensure that the research is conducted in an ethical and appropriately sensitive manner. Hence, the design and execution of the study was in accordance with the WHO ethical and safety recommendation for research on domestic violence against women (WHO, 2001). The key ethical and safety principles that guided our research are summarized in the box underneath. 109
a. The safety of respondents and the research team is paramount, and should guide all project decisions; b. Prevalence studies need to be methodologically sound and to build upon current research experience about how to minimize the under-­‐reporting of violence; c. Protecting confidentiality is essential to ensure both respondents’ safety and data quality; d. All research team members should be carefully selected and receive specialized training and on-­‐going support; e. The study design must include actions aimed at reducing any possible distress caused to the participants by the research; f. Fieldworkers should be trained to refer women requesting assistance to available local services and sources of support. Where few resources exist, it may be necessary for the study to create short-­‐term support mechanisms; g. Researchers and donors have an ethical obligation to help ensure that their findings are properly interpreted and used to advance policy and intervention development; h. Violence questions should only be incorporated into surveys designed for other purposes when ethical and methodological requirements can be met. For the BIDENS –study, formal approvals of local ethical committees and data protection agencies were obtained at all sites. In Belgium: The Ethical Committee of Ghent University acted as the central ethical committee for the study; U(Z) Gent, 22012008/ B67020072813, date of approval: 1st February 2008 (see annex 6), Waregem hospital date added: 21st October 2008. In Iceland: The scientific board approved the study (24.06.2008-­‐ VSN-­‐
b2008030024/03-­‐15) according to Icelandic regulations, date: 24th June 2008. In Denmark, even though ethical approval for non-­‐invasive studies is not required, the study was presented to the Research Ethics Committee of the Capital Region, who found no objections to the study (H-­‐A-­‐2008-­‐002), date: 11th February 2008. Permission was obtained from the Danish Data Protection Agency (J.nr. 2007-­‐ 41-­‐1663). In Estonia, ethical permission was 110
given by the Ethics Review Committee on Human Research of the University of Tartu, Estonia; 190/M-­‐29, 192/-­‐22, 196/X-­‐2, date: 17th December 2007, East-­‐Tallinn Central Hospital added: 19th January 2009, Russian language and prolonged period added: 22nd February 2010, East-­‐Viru Central Hospital added: 26th April 2010. In Norway, the Regional Committee for Medical Research Ethics in North approved the study (72/2006), date: 29th August 2007; and the Data Inspectorate (NSD) (15214/3/) also approved the study, date: 19th December 2007. In Sweden, the study was approved by the Regional Ethical Committee in Stockholm (2006/354-­‐31/1), date: 14th June 2006. For the MOM-­‐study ethical approval (see annex 7, EC 2010/093, Belgian th
registration number B67020108164) was obtained on March 8 , 2010 from the ethical committee of the Ghent University (Hospital), which acted as central ethical committee. Since this was a multicentre study, local ethical approval from all participating hospitals was also obtained (Ethisch Comité Middelheim Ziekenhuis Netwerk Antwerpen, Ethisch Comité Universitair Ziekenhuis Antwerpen, Ethisch Comité Onze Lieve Vrouw Ziekenhuis Aalst, Ethisch Comité Gasthuis Zusters Ziekenhuis St Augustinus Antwerpen, Ethisch Comité Algemeen Ziekenhuis Sint Jan Brugge, Ethisch Comité Algemeen Ziekenhuis Jan Palfijn Gent, Ethisch Comité Onze Lieve Vrouw van Lourdes Ziekenhuis Waregem, Ethisch Comité Universitair Ziekenhuis Gent, Ethisch Comité Algemeen Ziekenhuis Groeninge Kortrijk, Ethisch Comité Virga Jesse Ziekenhuis Hasselt, Ethisch Comité Ziekenhuis Oost-­‐Limburg Genk). In consultation with all ethical committees involved in both studies, following measures were taken into account. All communication about the study did not mention the words ‘violence or abuse’, the study was presented as a study on difficult moments and feelings in pregnant women. The questionnaires were filled in on the spot at the clinic in privacy and were not taken home. Participation in both studies was only possible if the woman could be separated from accompanying persons (except for children below 2 years old). All measures were taken to ensure that women could get additional support (from social services) if this was deemed necessary by the respondent or the clinic staff. The information letter clearly indicated that the aim of the study was not to provide support or guidance. If women needed additional support (after filling in the questionnaire), they were referred to a 24/24h telephone hotline (tele-­‐onthaal). Respondents were also informed 111
that anonymity would be lifted when the researcher estimates that the safety-­‐risks of (further) participation were too big. Hence, the treating health staff was informed about the IPV and the risks involved and are responsible to provide the required assistance. At the end of the interviews, the researcher clearly mentions that referral cards are made available to all women (including the women that were randomised in the control group and did not receive the referral card) in the toilets at the antenatal clinic where they filled in the questionnaire. We obtained ethical approval to include minors in this study on the condition that a psychologist was involved before filling in the questionnaire to evaluate the maturity of the minor and co-­‐signed the informed consent (instead of a parent or guardian which could be involved in the violence). Furthermore, the interviews with minors had to take place at the antenatal clinic in the presence of a psychologist. Due to logistical and financial consequences of these conditions, we opted not to include minors in both studies. 112
Chapter 3: Results The general objective is to assess the prevalence, determinants and associated obstetric outcomes of IPV before, during and after pregnancy and to investigate the effect of an intervention for pregnancy-­‐associated IPV. In order to meet the general objective, we formulated several specific objectives which are all addressed in the six papers included in this dissertation. We here divide them into 3 sections. First, we assessed the prevalence of physical, emotional, and/or sexual violence experienced as a child and/or as an adult in six European countries (paper 1), and assessed the prevalence of physical, psychological and sexual partner violence 12 months before and/or during pregnancy and provided insight into the evolution of IPV in Flanders, Belgium (paper 2). Second, we assessed whether the following factors were associated: IPV 12 months before and/or during pregnancy & psychosocial health (paper 3) and a history of abuse & operative delivery and (paper 4). Third, we focussed on the effectiveness of IPV interventions, by means of a systematic literature review (paper 5) and an RCT that investigated the effect of identifying IPV and handing out a referral card, on the evolution of IPV, psychosocial health, help-­‐seeking and safety behaviour during and after pregnancy in Flanders, Belgium (paper 6). Concerning paper 1 and 4, funding was obtained by the principle investigator (prof dr Berit Schei), the PhD-­‐candidate was actively involved in the design of the study, applied for ethical approval in Belgium, organised and coordinated the Belgian participation in the study and acquired the Belgian data. She was involved in the analysis and contributed to drafting the articles. Regarding papers 2, 3, 5 and 6, the PhD-­‐candidate acquired the funding, conceived the study, applied for ethical approval, organised and coordinated study recruitment, acquired the data, performed the analysis, drafted and finalised the manuscripts. Overview papers: Paper 1: Lukasse M, Schroll, AM, Ryding EL, Campbell J, Karro H, Kristjansdottir H, Laanpere M, Steingrimsdottir T, Tabor A, Temmerman M, Van Parys AS, Wangel AM, Schei B (2014). Prevalence of emotional, physical and sexual abuse among pregnant 113
women in six European countries. Acta Obstet Gynecol Scand; 93:669– 677 Paper 2: Van Parys AS, Deschepper E, Michielsen K, Temmerman M, Verstraelen (2014). Prevalence and evolution of intimate partner violence before and during pregnancy: a cross-­‐sectional study. BMC Pregnancy and Childbirth, 14:294 Paper 3: Van Parys AS, Deschepper E, Michielsen K, Galle A, Roelens K, Temmerman M, Verstraelen (2015). Intimate partner violence and psychosocial health, a cross-­‐sectional study in a pregnant population. BMC Pregnancy and Childbirth (2015) 15:278 Paper 4: Schei B, Lukasse M, Ryding EL, Campbell J, Karro H, Kristjansdottir H, Laanpere M, Schroll AM, Tabor A, Temmerman M, Van Parys AS, Wangel AM, Steingrimsdottir T (2014). A History of Abuse and Operative Delivery – Results from a European Multi-­‐
Country Cohort Study. PLoS ONE 9(1): e87579. Paper 5: Van Parys AS, Verhamme A, Temmerman M, Verstraelen H (2014). Intimate Partner Violence and Pregnancy: A Systematic Review of Interventions. PLoSONE 9(1): e85084 Paper 6: Van Parys AS, Deschepper E, Roelens K, Temmerman M, Verstraelen (2016). Impact of a Referral Card Based Intervention on Intimate Partner Violence, Psychosocial Health, Help-­‐Seeking and Safety Behaviour during Pregnancy and Postpartum, a Randomised Controlled Trial. Submitted to BMC Pregnancy and Childbirth on June st
1 , 2016 114
Paper 1: Prevalence of emotional, physical and sexual abuse among pregnant women in six European countries The objective of this paper was to assess the prevalence of physical, emotional, and/or sexual violence experienced as a child and/or as an adult in six European countries (BIDENS-­‐study). Key message A history of abuse is common among pregnant women in Europe, overall lifetime prevalence of any abuse was reported by 34.8% of the women. The lifetime prevalence ranges across the six countries were 9.7–30.8% for physical violence, 16.2–27.7% for emotional abuse, and 8.3–21.1% for sexual violence, with Belgium at the lowest end of the continuum for all forms of violence and abuse. Few women reported current sexual violence, 0.4% compared with 2.2% current physical violence and 2.7% current emotional abuse. About one in ten of them experiences severe current suffering from the reported abuse. 115
A C TA Obstetricia et Gynecologica
AOGS M A I N R E SE A RC H A R TIC LE
Prevalence of emotional, physical and sexual abuse among
pregnant women in six European countries
MIRJAM LUKASSE1,2, ANNE-METTE SCHROLL3, ELSA LENA RYDING4, JACQUELYN CAMPBELL5, HELLE
KARRO6, HILDUR KRISTJANSDOTTIR7,8, MADE LAANPERE9, THORA STEINGRIMSDOTTIR10, ANN
TABOR3,11, MARLEEN TEMMERMAN12, AN-SOFIE VAN PARYS12, ANNE-MARIE WANGEL13 &
BERIT SCHEI1,14
1
Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim,
Norway, 2Department of Health, Nutrition and Management, Faculty of Health Sciences, Oslo and Akershus University
College of Applied Sciences, Oslo, Norway, 3Center for Fetal Medicine and Pregnancy, Copenhagen University Hospital,
Rigshospitalet, Copenhagen, Denmark, 4Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden, 5Johns Hopkins University, School of Nursing, Baltimore, Maryland, USA,
6
Department of Obstetrics and Gynecology, University of Tartu, Tartu University Hospital Women’s Clinic, Tartu, Estonia,
7
Health Directorate, Reykjavik, Iceland, 8Faculty of Nursing, Department of Midwifery, University of Iceland, Reykjavik, Iceland, 9Department of Obstetrics and Gynecology, University of Tartu, Tartu Sexual Health Clinic, Tartu, Estonia, 10Landspitali University Hospital, Reykjavik, Iceland, 11Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark,
12
Faculty of Medicine and Health Sciences Ghent University, International Centre for Reproductive Health, Ghent,
Belgium, 13Malm€
o University, Faculty of Health and Society, Malm€
o, Sweden, and 14Department of Obstetrics and
Gynecology, St Olav’s University Hospital, Trondheim, Norway
Key words
Abuse, violence against women, pregnancy,
prevalence
Correspondence
Mirjam Lukasse, Faculty of Health Sciences,
PB 4. St. Olavs plass, 0130 Oslo, Norway.
E-mail: [email protected]
Conflicts of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Lukasse M, Schroll
A-M, Ryding EL, Campbell J, Karro H,
Kristjansdottir H, et al. Prevalence of
emotional, physical and sexual abuse among
pregnant women in six European countries.
Acta Obstet Gynecol Scand 2014; 93:669–
677.
Received: 16 December 2013
Accepted: 2 April 2014
DOI: 10.1111/aogs.12392
Abstract
Objectives. The primary objective was to investigate the prevalence of a history
of abuse among women attending routine antenatal care in six northern European countries. Second, we explored current suffering from reported abuse.
Design. A prospective cohort study. Setting. Routine antenatal care in Belgium,
Iceland, Denmark, Estonia, Norway, and Sweden between March 2008 and
August 2010. Population. A total of 7174 pregnant women. Methods. A questionnaire including a validated instrument measuring emotional, physical and
sexual abuse. Main outcome measure. Proportion of women reporting emotional, physical and sexual abuse. Severe current suffering defined as a Visual
Analogue Scale score of ≥6. Results. An overall lifetime prevalence of any abuse
was reported by 34.8% of the pregnant women. The ranges across the six
countries of lifetime prevalence were 9.7–30.8% for physical abuse, 16.2–27.7%
for emotional abuse, and 8.3–21.1% for sexual abuse. Few women reported
current sexual abuse, 0.4% compared with 2.2% current physical abuse and
2.7% current emotional abuse. Current severe suffering was reported by 6.8%
of the women who reported physical abuse, 9.8% of those who reported sexual
abuse and 13.5% for emotional abuse. Conclusion. A high proportion of pregnant women attending routine antenatal care report a history of abuse. About
one in ten of them experiences severe current suffering from the reported
abuse. In particular, these women might benefit from being identified in the
antenatal care setting and being offered specialized care.
Abbreviations: NorAQ, NorVold Abuse Questionnaire; G, Goodman–Kruskal c;
OR, odds ratio.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 669–677
116
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M. Lukasse et al.
Introduction
Material and methods
Abuse of women and girls is a widely recognized public
health issue (1). The term abuse is generally used when
violence or acts of violation are part of an ongoing pattern or behavior. The World Health Organization defines
violence against women as “any act of gender-based
violence that results in, or is likely to result in, physical,
sexual or mental harm or suffering to women, including
threats of such acts, coercion or arbitrary deprivation of
liberty, whether occurring in public or private life” (1,2).
When acts of violence and abuse occur within the privacy of the home they can also be defined as domestic
violence (3), whereas violence inflicted by a current or
previous partner falls under the term intimate partner
violence (3). Partner violence is the leading cause of death
among women of reproductive age (4,5). Other detrimental consequences of abuse on mental and physical health
are well documented (6–9). Evidence suggests that
women are particularly vulnerable to abuse during pregnancy and the postnatal period (10,11). Violence and
abuse have been shown to influence women’s health during pregnancy and birth and may affect the health of the
fetus and newborn child (12–16). The different pathways
described are direct injury, neurobiological changes, and
an increase in health-detrimental behaviors such as eating
disorders and drug abuse (13,15,17).
Previously published estimates of prevalence of past
and present violence and abuse among pregnant women
vary greatly and may be difficult to compare, as they differ regarding the type of abuse assessed, time of occurrence, and perpetrator (11). In addition, methodological
factors such as study design, measuring instrument and
population studied can influence results (11). There are
two previous studies presenting internationally comparable data on the population prevalence of violence against
women and estimates of the occurrence during pregnancy
(7,18). These studies were restricted to intimate partner
violence and so excluded abuse that women had experienced as a child and violence perpetrated by people other
than a present or previous intimate partner (7,18). The
method in both studies was a standardized household
survey including women at all ages and asking them to
recall whether violence had occurred during pregnancy
(7,18). Although these studies present valuable information, their relevance to a European setting is limited
(7,18). There are no international population-based studies conducted among pregnant women attending routine
antenatal care, estimating the prevalence of physical,
emotional and sexual violence abuse experienced as a
child or as an adult. This was the primary aim of our
study. Second, we explored current suffering from
reported abuse.
The Bidens study, a six-country (Belgium, Iceland,
Denmark, Estonia, Norway, and Sweden) cohort study of
unselected pregnant women, was the result of a European
Union-funded collaboration between the Norwegian
University of Science and Technology (NTNU) and partners from universities and hospitals in five European
countries. A short description of the study sites is given
as Supporting Information (Table S1). There were
between one and seven urban antenatal care sites of data
collection in each country with the most in Norway (five
sites) and Sweden (seven sites).
Recruitment took place between March 2008 and
August 2010. A total of 7200 women who consented, subsequently completed a questionnaire and allowed the
extraction of specified data on their delivery from their
medical notes. Due to country-specific organization as
well as the requirements of local ethics committees,
minor variations in the recruitment procedure occurred.
In Belgium, women were approached by the midwife
or secretary when attending antenatal care. Women were
asked to complete the questionnaire in the privacy of a
separate room. In Iceland women were recruited when
attending routine ultrasound and returned completed
forms by mail. In Denmark women were given information about the study when attending early routine ultrasound screening and were mailed the questionnaire later.
They returned the questionnaire by mail or when attending their next ultrasound examination. In Estonia women
were invited to participate while visiting for an antenatal
consultation. After completing the questionnaire, it was
left in a mailbox at the clinic. In Norway, women
received the questionnaire by mail and returned it by
mail, after attending routine ultrasound. Nonresponders
were sent one reminder. In Sweden, the questionnaire
was administered to women when attending routine
glucose tolerance tests and filled out during the 2 hours
between the blood samplings.
The right to obtain information on nonparticipating
women varied between countries and hence the basis for
calculating response rates. In Belgium and Sweden regis-
670
Key Message
A history of abuse is common among pregnant
women in northern Europe. About one in ten women
reports severe suffering from previous or current
abuse. Routine antenatal care provides a window of
opportunity to identify suffering and offer specialized
care.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 669–677
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M. Lukasse et al.
trations of nonparticipants was not allowed, the response
rate was estimated at 50% and 78%, respectively. In Iceland and Denmark the response rate was 65% and 57.3%,
respectively (no reminder). In Estonia, the response rate
was 90%, based on number of questionnaires given to the
assigned study midwives and number of filled out forms
returned. In Norway the participation rate was 50% (one
reminder). The estimated response rate varied between
50% in Norway to 90% in Estonia.
All women required sufficient language skills to fill out
the form. In Estonia women could choose to complete an
Estonian or Russian language questionnaire. In Belgium,
Iceland and Denmark women less than 18 years of age
were excluded. In Denmark, only women from the local
geographical area were invited. In Belgium, women who
could not be separated from their accompanying person
were not recruited. In Iceland, Denmark and Norway,
women with major fetal pathologies were excluded from
the study.
The questionnaire included questions on socioeconomic background, general and mental health and
obstetric history. The questions on abuse were taken from
the NorVold Abuse Questionnaire (NorAQ), which was
developed in a Nordic multi-centre study among gynecological patients (19). This validated instrument includes
13 descriptive questions measuring emotional, physical
and sexual abuse (20). A complete version of the questionnaire was developed in English. Where a previously
translated version of the NorAQ was available, this was
used. Additional items of the questionnaire were translated into the required languages by a native speaker
(Flemish, Icelandic, Danish, Estonian, Russian, Norwegian
and Swedish) and then translated back again into the
source language. The original and back-translated versions
were used to determine the final consensus version.
Emotional, physical, and sexual abuse were assessed in
three identically structured sections. For each type and
level of abuse the answer categories were no, yes as a
child, yes as an adult, or yes both as a child and as an
adult. These were classified according to the most severe
level reported (mild, moderate, and severe). Two items
addressing ‘mild sexual abuse with no genital contact’
and ‘mild humiliating sexual abuse’ were combined in the
analysis into one category of ‘mild sexual abuse’. For each
type of abuse women were asked if they experienced the
indicated abuse during the past 12 months, which was
coded as current. The degree of current suffering was
measured on a visual analogue scale (0–10) and recoded
into no suffering (0), moderate suffering (1–5) and severe
current suffering (≥6), based on the distribution of the
data. Women were defined as having experienced any
abuse if they answered yes to at least one of the questions
of sexual, emotional and physical abuse. The question
measuring mild physical abuse has shown low specificity
in the validation study (20). Hence results are presented
including and excluding this item.
The study was conducted in accordance with the ethical guidelines developed by the World Health Organization (21), which highlight the importance of ensuring
women’s safety, confidentiality and privacy. The information letter instructed women to complete the form in a
place where they could be undisturbed, and included
local telephone numbers and e-mail addresses to contact
if help was desired. Additionally, in Belgium, Estonia and
Sweden the participants had the opportunity to complete
the questionnaires at the clinic, and measures were taken
to avoid accompanying persons being present while they
filled out the survey. Formal approvals of local ethics
committees and data protection agencies were obtained at
all sites, as listed below.
In Belgium the Ethics Committee of Ghent University
acted as the central ethics committee for the study; U(Z)
Gent, 22012008/B67020072813, date of approval: 1 February 2008, Waregem hospital date added: 21 October 2008.
In Iceland the scientific board approved the study
(24.06.2008-VSN-b2008030024/03-15) according to Icelandic regulations, date: 24 June 2008. In Denmark, even
though ethical approval for non-invasive studies is not
required, the study was presented to the Research Ethics
Committee of the Capital Region, who found no objections to the study (H-A-2008-002), date: 11 February
2008. Permission was obtained from the Danish Data
Protection Agency (J.nr. 2007-41-1663). In Estonia, ethical permission was given by the Ethics Review Committee
on Human Research of the University of Tartu, Estonia;
190/M-29, 192/-22, 196/X-2, date: 17 December 2007,
East-Tallinn Central Hospital added: 19 January 2009,
Russian language and prolonged period added: 22 February 2010, East-Viru Central Hospital added: 26 April
2010. In Norway, the Regional Committee for Medical
Research Ethics in North approved the study (72/2006),
date: 29 August 2007; and the Data Inspectorate (NSD)
(15214/3/) also approved the study, date: 19 December
2007. In Sweden, the study was approved by the Regional
Ethics Committee in Stockholm (2006/354-31/1), date: 14
June 2006.
The data were anonymized before analysis.
Statistical analysis
Pearson’s chi-squared test was applied to assess demographic and abuse differences between countries. Level of
significance was set at p < 0.05, two-sided Kruskal–Wallis
test was used to compare medians between countries for
the visual analogue scale scores for current suffering. The
correlation between the level of severity of emotional,
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 669–677
118
671
Abuse among European pregnant women
M. Lukasse et al.
physical and sexual abuse and current suffering was tested
by Goodman–Kruskal c (G). For comparison between
countries of the proportion of lifetime abuse for each
type of abuse we calculated odds ratios (OR) with 95%
CI using logistic regression analysis adjusting for age,
education and gestational age when completing the questionnaire with the largest group Norway as a reference.
Analyses were performed in PASW Statistics version 18.0
(SPSS Inc., Chicago, IL, USA).
In all, 3530 women (49.2%) reported any type of emotional, physical or sexual abuse, 34.8% when excluding
mild physical abuse. Of all the women, 523 (7.3%)
reported emotional abuse only, 460 (6.4%) sexual abuse
only and 492 (6.9%) physical abuse only (excluding mild
physical abuse). One hundred and eighty-eight (2.6%)
women reported both emotional and sexual abuse, 355
(4.9%) emotional and physical abuse, 187 (2.6%) physical
and sexual abuse, and 294 (4.1%) all three types of abuse.
Tables 2–4 show the proportions of women for each
country who reported emotional, physical and sexual
abuse by age at time of abuse, severity of the abuse,
whether it had occurred within the last year, lifetime
abuse, and current suffering. Current moderate or severe
suffering from reported emotional abuse was highest
among Icelandic women (88.8%) and lowest among Estonian women (68.1%) (Table 2). Seventy percent of the
Icelandic women who reported the experience of physical
abuse (excluding mild) reported current moderate or
severe suffering, compared with 46% of Estonian women
(Table 3). The proportion of women reporting no current
suffering from their abuse was highest among women
who had reported physical abuse, 4.9% (excluding mild
physical abuse) compared with 21.3% for emotional
abuse and 28.6% for sexual abuse (Tables 2–4). The median scores ranged from 0 for physical abuse only for Denmark, Estonia and Norway to 4 for emotional and sexual
abuse combined for Iceland (see Table S2). On the whole,
Results
A total of 7200 women responded, 26 women were
excluded because of missing response to the NorAQ, leaving a total of 7174 in the study: 861 from Belgium, 602
from Iceland, 1290 from Denmark, 975 from Estonia,
2424 Norway and 1022 from Sweden. Sociodemographic
characteristics are presented in Table 1. Significant differences between countries in our sample were observed:
nearly a quarter of the women were below 25 years of age
in Estonia, but only around 3% were below 25 years of
age in Denmark. Norway had the highest proportion of
educated women (13 years or more of education), while
the lowest proportion was found in Estonia. Most women
were married or cohabiting. Iceland and Estonia had the
highest proportion of women not married or cohabiting,
as well as the highest proportion of women who were
unemployed or on social benefit.
Table 1. Baseline characteristics for pregnant women in the Bidens cohort study, 2008–10.
Age (years)a
<25
25–34
≥35
Education (years attained)a
<9
10–13
>13
Civil statusb
Married/cohabiting
Others
Occupationa
Employed/student
Pregnancy leave
Housewife
Unemployed/social benefits
Belgium
n = 861
Iceland
n = 602
Denmark
n = 1290
Estonia
n = 975
Norway
n = 2424
Sweden
n = 1022
Total
n = 7174
n
%
n
%
n
%
n
%
n
%
n
%
n
%
149
632
74
17.4
73.9
8.7
91
396
107
15.3
66.7
18.0
41
923
311
3.2
72.4
24.4
238
619
112
24.6
63.9
11.6
286
1609
526
11.8
66.5
21.7
112
708
191
11.1
70.0
18.9
917
4887
1321
12.9
68.6
18.5
13
322
516
1.5
37.8
60.6
44
142
405
7.4
24.0
68.5
19
119
1133
1.5
9.4
89.1
76
324
564
7.9
33.6
58.5
58
618
1723
2.4
25.8
71.8
34
307
655
3.4
30.8
65.8
244
1832
4996
3.5
25.9
70.6
822
25
97.0
3.0
549
41
93.1
6.9
1218
51
96.0
4.0
913
54
94.4
5.6
2314
86
96.4
3.6
971
38
96.2
3.8
6787
295
95.8
4.2
604
182
19
45
71.1
21.4
2.2
5.3
532
1
17
44
89.6
0.2
2.9
7.4
1200
19
10
46
94.1
1.5
0.8
3.6
628
199
83
59
64.8
20.5
8.6
6.1
2208
63
68
71
91.6
2.6
2.8
2.9
926
23
10
50
91.8
2.3
1.0
5.0
6098
487
207
315
85.8
6.9
2.9
4.4
a
p < 0.001.
p = 0.001, Pearson’s chi-squared test.
b
672
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 669–677
119
Abuse among European pregnant women
M. Lukasse et al.
Table 2. Prevalence of emotional abuse and current suffering among pregnant women in the Bidens cohort study, 2008–10.
Belgium
n = 861
n
Severity of abuse
Milda
<18 years
≥18 years
Both
Moderatea
<18 years
≥18 years
Both
Severea
<18 years
≥18 years
Both
Abuse past 12 monthsa
Any lifetime abuseb
Current sufferingc
None
Moderate
Severe
Missing
%
Iceland
n = 602
Denmark
n = 1290
Estonia
n = 975
n
n
n
%
%
%
Norway
n = 2424
Sweden
n = 1022
Total
n = 7174
n
n
n
%
%
%
31
19
1
3.6
2.2
0.1
21
6
0
3.5
1.0
66
46
17
5.1
3.6
1.3
60
21
12
6.2
2.2
1.2
70
48
14
2.9
2.0
0.6
27
25
10
2.6
2.4
1.0
275
165
54
3.8
2.3
0.8
13
10
8
1.5
1.2
0.9
13
22
7
2.2
3.7
1.2
20
12
1
1.6
0.9
0.1
48
18
6
4.9
1.9
0.6
35
56
8
1.4
2.3
0.3
12
23
5
1.2
2.3
0.5
141
141
35
2.0
2.0
0.5
25
28
4
23
139
2.9
3.3
0.5
2.7
16.2
16
10
3
11
98
2.7
1.7
0.5
1.8
16.3
36
49
5
28
252
2.8
3.8
0.4
2.2
19.6
55
43
6
49
269
5.7
4.4
0.6
5.0
27.7
90
92
23
57
436
3.7
3.8
1.0
2.4
18.0
28
22
14
22
166
2.8
2.2
1.4
2.2
16.3
250
244
55
190
1360
3.5
3.4
0.8
2.7
19.0
29
91
13
6
20.9
65.5
9.4
4.3
11
64
23
0
11.2
65.3
23.5
42
168
38
4
16.7
66.7
15.1
1.6
80
157
26
6
29.7
58.4
9.7
2.2
100
278
50
8
22.9
63.8
11.5
1.8
28
105
30
3
16.9
63.3
18.1
1.8
290
863
180
27
21.3
63.5
13.2
2.0
a
NS p = 0.13.
p < 0.001, Pearson’s v2-test.
Percentage among women reporting any lifetime abuse.
b
c
women reporting having experienced more than one type
of abuse also reported a higher median score for suffering
compared with women reporting only one type of abuse,
while three types of abuse for the majority of the countries had the highest score (see Table S2). The strength of
the correlation between severity of each type of abuse and
level of suffering was overall moderate (G = 0.2,
p < 0.001) for emotional abuse and strong for sexual
abuse (G = 0.4, p < 0.001) and for physical abuse
(G = 0.47, p < 0.001), although differences existed
between countries. For Iceland and Estonia, there was no
correlation between degree of suffering and severity of the
emotional abuse.
For all the categories of “any abuse” (excluding mild
physical abuse), Estonia had the highest prevalence, with
45.4% reporting any lifetime abuse and 6.5% any current
abuse (Table 5). Belgium had the lowest prevalence,
23.3% for any lifetime abuse (excluding mild physical
abuse) and 3.0% for any abuse during the past
12 months. Adjusted analyses showed that the adjusted
odds for Estonian women to report any lifetime emotional and/or physical abuse (excluding mild physical
abuse) was significantly higher compared with Norway,
AOR 1.63 (95% CI 1.36–1.95) and 1.54 (95% CI 1.29–
1.84), respectively (Table 6). Belgian and Danish women
were significantly less likely to report physical abuse,
AOR 0.36 (95% CI 0.28–0.46) and 0.60 (95% CI 0.49–
0.73) respectively; as well as sexual abuse, AOR 0.42 (95%
CI 0.32–0.55) and 0.73 (95% CI 0.60–0.90), respectively.
Adjustment had no effect on the significance levels and
only marginally altered the odds ratios.
Discussion
This is the first European multi-country study on the
prevalence of different types of abuse among women
attending routine antenatal care. Our data suggest that a
history of abuse among pregnant women attending routine antenatal care is common. The prevalence of the different types of abuse varied significantly between the
participating countries, with or without adjusting for age,
education and gestational length at time of participation.
The prevalence of current abuse was low. About one in
10 women reported severe suffering from the experienced
abuse.
In our study, women were asked if they had experienced the reported abuse during the past 12 months.
Women were on average mid-way through their
pregnancy when they filled out the questionnaire. As a
result, we do not report abuse that happened only during
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 669–677
120
673
Abuse among European pregnant women
M. Lukasse et al.
Table 3. Prevalence of physical abuse and current suffering among pregnant women in the Bidens cohort study, 2008–10.
Belgium
n = 861
n
Severity of abuse
Milda
<18 years
105
≥18 years
12
Both
6
a
Moderate
<18 years
23
≥18 years
15
Both
6
Severea
<18 years
15
≥18 years
24
Both
0
a
11
Abuse past 12 months
206
Any lifetime abusea
Current sufferinga,b
None
106
Moderate
71
Severe
4
Missing
25
Physical abuse, mild physical abuse
83
Any lifetime abusea
Current sufferinga,b
None
26
Moderate
53
Severe
4
Missing
0
Iceland
n = 602
%
n
%
Denmark
n = 1290
Estonia
n = 975
n
%
n
Norway
n = 2424
%
n
Sweden
n = 1022
Total
n = 7174
%
n
%
n
%
12.2
1.4
0.7
46
21
6
7.6
3.5
1.0
315
82
39
24.4
6.4
3.0
93
56
6
9.5
5.7
0.6
440
98
59
18.1
4.0
2.4
115
43
18
11.3
4.2
1.8
1114
312
134
15.3
4.4
1.9
2.7
1.7
0.7
54
27
10
9.0
4.5
1.7
46
36
2
3.6
2.8
0.2
108
56
16
11.1
5.7
1.6
152
129
21
6.3
5.3
0.9
40
33
12
3.9
3.2
1.2
423
296
67
5.9
4.1
0.9
1.8
2.8
9
16
0
13
189
1.5
2.7
2.2
31.4
19
59
1
32
599
1.5
4.6
0.1
2.5
46.5
49
66
5
27
455
5.1
6.8
0.5
2.8
46.7
66
137
15
55
1117
2.7
5.7
0.6
2.3
46.1
15
39
7
18
322
1.5
3.8
0.7
1.8
31.5
173
341
28
156
2888
2.4
4.8
0.4
2.2
40.3
38.6
46.0
11.1
4.2
342
178
16
63
57.1
29.7
2.7
10.5
266
167
13
9
58.5
36.7
2.9
2.0
697
323
23
74
67.4
28.9
2.1
6.6
151
135
24
12
46.9
41.9
7.5
3.7
1635
961
101
191
55.6
33.3
3.5
6.6
19.3
163
12.6
300
30.8
520
21.5
146
14.3
1328
18.5
29.3
54.3
15.5
0.9
66
83
13
1
40.5
50.9
8.0
0.6
158
127
12
3
52.7
42.3
4.0
1.0
264
225
21
10
50.8
43.3
4.0
1.9
48
75
21
2
32.9
51.4
14.4
1.4
596
626
89
17
44.9
47.1
6.7
1.3
1.3
24.0
51.5
73
34.5
87
1.9
21
12.1
8
excluded
9.7
116
31.3
63.9
4.8
34
63
18
1
a
p < 0.001, Pearson’s chi-squared test.
Percentage among women reporting any lifetime abuse.
b
pregnancy but current abuse. The prevalence of recent
abuse in our study is consistent with 12-month estimates
from other European settings when measured during
pregnancy, such as in Norway (5%) (22), England (1–
5%) (23), Belgium (3.0–3.9%) (24), Sweden (2.8%) (25)
and Denmark (2.8% during pregnancy) (26). A number
of studies report the prevalence of abuse in high-income
settings separately for the year before pregnancy and during pregnancy, so complicating comparison to our findings (11,24,26). On the whole, the reported prevalence of
abuse is higher the year before pregnancy than during
pregnancy (7,11,18,24,27). This is consistent with the protective effect some research claims that pregnancy can
have, while other studies have noted an increase, in particular, of emotional and sexual abuse during pregnancy
and of the severity and frequency of the abuse (11). Our
study did not investigate these aspects of abuse. Alternatively, it may be only the reporting of the abuse which is
reduced and not the occurrence.
Our study suggests that in general fewer women suffered from physical abuse and more from emotional
674
abuse, which is consistent with other reports (7). However, it should be noted that 61.5% of those experiencing
lifetime emotional abuse (n = 1360) were experiencing at
least one other kind of abuse as well. Also consistent with
other studies we observed that suffering was less when
women had reported the experience of only one type of
abuse, compared with women reporting two or three
types of abuse. In addition, our results showed that the
severity of the abuse on the whole corresponded with the
degree of current suffering. This suggests a general agreement between researchers and abused women that multiple kinds and severity of abuse are associated with the
most suffering. There were differences between countries,
which could be due to cultural and contextual differences
(28). It may be that in a society with a higher tolerance
for violence, the victims tend to regard their experiences
as less offensive.
Further, not all pregnant women with a history of
abuse report that they suffer from the abuse, or at least
not to a great extent. It may be that these women have
recovered with or without the help of others, experienced
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 669–677
121
Abuse among European pregnant women
M. Lukasse et al.
Table 4. Prevalence of sexual abuse and current suffering among pregnant women in the Bidens cohort study, 2008–10.
Severity of abuse
Milda
<18 years
≥18 years
Both
Moderateb
<18 years
≥18 years
Both
Severec
<18 years
≥18 years
Both
Abuse past 12 monthsd
Any lifetime abusec
Current sufferinge,f
None
Moderate
Severe
Missing
Belgium
n = 861
Iceland
n = 602
n
n
%
%
Denmark
n = 1290
Estonia
n = 975
n
n
%
%
Norway
n = 2424
Sweden
n = 1022
Total
n = 7174
n
n
n
%
%
%
10
1
1
1.2
0.1
0.1
17
4
2
2.8
0.7
0.3
38
25
2
2.9
1.9
0.2
19
9
1
2.0
0.9
0.1
58
27
3
2.4
1.1
0.1
20
15
0
2.0
1.5
162
81
9
2.3
1.1
0.1
21
2
0
2.4
0.2
32
4
1
5.3
0.7
0.2
33
11
1
2.6
0.9
0.1
56
9
1
5.7
0.9
0.1
111
27
3
4.6
1.1
0.1
35
12
2
3.4
1.2
0.2
288
65
8
4.0
0.9
0.1
23
13
0
0
71
2.7
1.5
8.3
39
21
7
3
127
6.5
3.5
1.2
0.5
21.1
25
29
4
3
168
1.9
2.2
0.3
0.2
13.0
43
35
2
8
175
4.4
3.6
0.2
0.8
18.0
89
94
18
12
430
3.7
3.9
0.7
0.5
17.7
31
37
5
3
157
3.0
3.6
0.5
0.3
15.5
250
229
36
29
1129
3.5
3.2
0.5
0.4
15.7
14
48
3
6
19.6
67.6
4.2
8.5
22
80
19
6
17.3
63.0
15.0
4.7
52
98
14
4
31.0
58.3
8.3
2.4
58
99
13
5
33.1
56.6
7.4
2.9
135
249
36
10
31.4
57.9
8.4
2.3
42
87
22
7
26.6
55.1
13.9
4.4
323
661
107
38
28.6
58.5
9.5
3.4
a
p = 0.01.
p = 0.001.
p < 0.001.
d
NS = 0.40.
e
p = 0.01, Pearson’s chi-squared test.
f
Percentage among women reporting any lifetime abuse.
b
c
Table 5. Prevalence of any childhood, adult, lifetime and current abuse among pregnant women in the Bidens cohort study,a 2008–10.
Any
Any
Any
Any
childhood abuseb
adult abuseb
lifetime abuseb
abuse past 12 monthsb
Belgium
n = 861
Iceland
n = 602
Denmark
n = 1290
Estonia
n = 975
Norway
n = 2424
Sweden
n = 1022
Total
n = 7174
n
%
n
%
n
%
n
%
n
%
n
%
n
%
139
100
200
26
16.1
11.6
23.2
3.0
171
99
214
20
28.4
16.4
35.5
3.3
255
259
433
42
19.8
20.1
33.6
3.3
337
217
443
63
34.6
22.3
45.4
6.5
583
541
900
89
24.1
22.3
37.1
3.7
208
197
309
31
20.4
19.3
30.2
3.0
1693
1413
2499
271
23.6
19.7
34.8
3.8
a
Women with only mild physical abuse were excluded from these analyses.
p < 0.001, Pearson’s chi-squared test.
b
only a single event or a very mild form of abuse only, or
had more resilience. However, we cannot exclude that as
a coping mechanism women with abusive experiences
might repress their feeling of suffering.
The prevalence of lifetime experience of abuse among
pregnant women is relevant for two reasons. First, the
past experience may have physical and psychological consequences for the current pregnancy (6). Second, women
who report previous abuse may be at an increased risk of
abuse during pregnancy (11). The lifetime prevalence of
any abuse of 23–45% found in our study is consistent
with those reported among pregnant women in other
European studies, such as 32% in Norway (22), 23.5% in
England (23), 34.5% in Denmark (26), 19.4% in Sweden
(25), 27.6% in Belgium (24). The lifetime prevalence in
our study is expected to be lower compared with studies
including women of all ages as older women have had
more time in which to accumulate abuse. In our study,
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 669–677
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Abuse among European pregnant women
M. Lukasse et al.
Table 6. Adjusteda odds ratio (OR) (95% CI) of emotional, physical and sexual lifetime abuse, among pregnant women in the Bidens cohort
study, 2008–10.
Country
Emotional abuse
Adjusted OR
Physical abuse
Adjusted OR
Physical abuse, excluding mild physical abuse
Adjusted OR
Sexual abuse
Adjusted OR
Norway
Belgium
Iceland
Denmark
Estonia
Sweden
1
0.87
0.84
1.19
1.63
0.84
1
0.36
0.51
1.07
0.99
0.52
1
0.36
0.83
0.60
1.54
0.55
1
0.42
1.16
0.73
0.99
0.81
(0.71–1.08)
(0.66–1.08)
(1.00–1.43)
(1.36–1.95)
(0.68–1.03)
(0.30–0.43)
(0.42–0.62)
(0.93–1.23)
(0.85–1.16)
(0.44–0.61)
(0.28–0.46)
(0.65–1.05)
(0.49–0.73)
(1.29–1.84)
(0.44–0.68)
(0.32–0.55)
(0.92–1.47)
(0.60–0.90)
(0.81–1.22)
(0.65–0.99)
a
Adjusted for age, education and gestational week for filling out the questionnaire.
Estonia had the highest prevalence of any abuse and Belgium the lowest. This could be due to social and cultural
differences in what are considered abusive behaviors,
which become apparent when abuse is defined by descriptive questions.
Women were recruited while attending routine antenatal care, aiming at an unselected population that would
be representative for pregnant women in these countries.
Although the varying response rate for the participating
countries causes concern it is likely that differences in
recruitment method played a role. In some of the places
women and staff may be frequently asked to participate
in research, which may reduce their willingness to contribute. The average age of women in the country samples of our study compared well with the average age of
pregnant women in the participating countries. Participants in our study had a higher level of education than
the pregnant population in their respective countries: 59–
72% had more than 13 years of education, compared
with national averages of 39–65%. In all participating
countries, except for Iceland and Norway, the proportion
of nulliparous women was slightly higher among participants (45–54%) than the country average (43–47%). In
Belgium the sample was entirely Flemish. In Estonia the
proportions of Estonian-speaking women (80%) and
Russian-speaking women (20%) participating in the
study are similar to the national proportions of the
country.
We used an instrument previously used in a multicountry study (19) but so far only validated in a Swedish
population (20,29). In spite of quality translation into the
various languages, the validity may have varied and so
influence the estimates. Using descriptive questions, however, is a strength because it allows the researchers to
define the abuse and not the participants. Our study was
based on self-reported abuse. The results may have been
different if personal interviews had been conducted. However, previous studies have found disclosure of sensitive
topics to be higher in self-administered modes compared
with face-to-face (30).
676
Obstetricians and midwives meeting women in routine
antenatal care should be aware that a high proportion of
the women they meet have a history of abuse. Some
countries have implemented routine screening to identify
current victims of intimate partner violence in antenatal
care. It appears that not only is current ongoing abuse of
concern but also women with current suffering from earlier abuse could benefit from being identified and receiving specialized care.
Funding
The Bidens study was supported by the Daphne II Programme, European Commission for Freedom, Security,
and Justice, Brussels, Belgium (Grant no. JLS⁄2006⁄
DAP-1⁄242⁄W30-CE-0120887⁄00-87).
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Supporting information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Description of the study sites, Bidens cohort
study, 2008–2010 (N = 7174).
Table S2. Suffering among women who have experienced
abuse, median and interquartile range, Bidens cohort
study, 2008–2010 (N = 7174).
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Paper 2: Prevalence and evolution of intimate partner violence before and during pregnancy: a cross-­‐sectional study The objective of this paper is to assess the prevalence of physical, psychological and sexual partner violence 12 months before and/or during pregnancy and to provide insight into the evolution of IPV in Flanders, Belgium (MOM-­‐study). Key message The results of this study indicate that violence is a prevalent problem around the time of pregnancy in Flanders, Belgium. Partners account for the largest share of all violence reported and psychological abuse is the type IPV of that is reported most frequently. Physical partner violence before as well as during pregnancy was reported by 2.5% (95% CI: 1.7 -­‐ 3.3) of the respondents (n = 1894), sexual violence by 0.9% (95% CI 0.5 -­‐ 1.4), and psychological abuse by 14.9% (95% CI: 13.3 -­‐ 16.7). The overall percentage of IPV was 14.3% (95% CI: 12.7 -­‐ 16.0) 12 months before pregnancy and 10.6% (95% CI: 9.2 -­‐ 12.1) during pregnancy. Our data shows that physical partner violence and psychological partner abuse are significantly lower during pregnancy compared to the year preceding pregnancy. 125
Van Parys et al. BMC Pregnancy and Childbirth 2014, 14:294
http://www.biomedcentral.com/1471-2393/14/294
RESEARCH ARTICLE
Open Access
Prevalence and evolution of intimate partner
violence before and during pregnancy:
a cross-sectional study
An-Sofie Van Parys1*, Ellen Deschepper2, Kristien Michielsen1, Marleen Temmerman1 and Hans Verstraelen1
Abstract
Background: Intimate partner violence (IPV) before and during pregnancy is associated with a broad range of
adverse health outcomes. Describing the extent and the evolution of IPV is a crucial step in developing
interventions to reduce the health impact of IPV.
The objectives are to study the prevalence of psychological abuse, as well as physical & sexual violence, and to
provide insight into the evolution of IPV 12 months before and during pregnancy.
Methods: Between June 2010 and October 2012, a cross-sectional study was conducted in 11 antenatal care clinics
in Belgium. Consenting pregnant women were asked to complete a questionnaire (available in Dutch, French and
English) in a separate room. Ethical clearance was obtained in all participating hospitals.
Results: The overall percentage of IPV was 14.3% (95% CI: 12.7 - 16.0) 12 months before pregnancy and 10.6%
(95% CI: 9.2 - 12.1) during pregnancy. Physical partner violence before as well as during pregnancy was reported by
2.5% (95% CI: 1.7 - 3.3) of the respondents (n = 1894), sexual violence by 0.9% (95% CI 0.5 - 1.4), and psychological
abuse by 14.9% (95% CI: 13.3 - 16.7). Risk factors identified for IPV were being single or divorced, having a low level
of education, and choosing another language than Dutch to fill out the questionnaire. The adjusted analysis
showed that physical partner violence (aOR 0.35, 95% CI: 0.22 - 0.56) and psychological partner abuse (aOR 0.7,
95% CI: 0.63 - 0.79) were significantly lower during pregnancy compared to the period of 12 months before
pregnancy. The difference between both time periods is greater for physical partner violence (65%) compared to
psychological partner abuse (30%). The analysis of the frequency data showed a similarly significant evolution for
physical partner violence and psychological partner abuse, but not for sexual violence.
Conclusion: The IPV prevalence rates in our study are slightly lower than what can be found in other Western
studies, but even so IPV is to be considered a prevalent problem before and during pregnancy. We found evidence,
however, that physical partner violence and psychological partner abuse are significantly lower during pregnancy.
Keywords: Intimate partner violence, Abuse, Pregnancy, Prevalence, Evolution, Pattern
Background
It is increasingly being recognized that intimate partner
violence (IPV) is a global health problem with serious
clinical and societal implications [1]. IPV is defined as
any behaviour within a present or former intimate relationship that leads to physical, sexual or psychological
harm, including acts of physical aggression, sexual
* Correspondence: [email protected]
1
Faculty of Medicine and Health Sciences, Department of Obstetrics and
Gynaecology, Ghent University, International Centre for Reproductive Health,
Belgium, De Pintelaan 185, UZP 114, 9000 Gent, Belgium
Full list of author information is available at the end of the article
coercion, psychological abuse and controlling behaviour
patterns [2]. IPV is also known as domestic/family violence, spouse/partner abuse/assault, battering, violence
against women or gender-based violence [3-5]. Based on
the Centre for Disease Controle definition of IPV [6], we
have chosen to consistently use the term ‘violence’ for
physical and sexual types of violence, and ‘abuse’ for
psychological types. The word ‘abuse’ clearly refers to a
broader range of behaviours than the word ‘violence’,
which is often associated with severe forms of violent
behaviour.
© 2014 Van Parys et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
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Pregnancy and childbirth are major milestones in the
lives of most couples and their families. The transition
to parenthood brings joy but also new challenges to
couple relationships [7,8]. Pregnancy may be a stressful
time because of changes in physical, emotional, social
and economic requirements and needs in both (future)
parents. Research on this matter [9-11] demonstrates
that individual and dyadic coping strategies tend to
decrease under stress, leading to an increased risk of
physical and psychological aggression. This vulnerable
period, however, is not limited to the time between conception and birth. Researchers have clearly demonstrated
that risk factors for IPV associated with pregnancy encompass the time frame of one year before conception
until one year after childbirth [11-15]. The mechanisms
and determinants that influence the interaction between
IPV and pregnancy, are not well-known. Four different
patterns of (partner) violence around the time of pregnancy have been identified in the literature: (a) commencement of violence (no violence before pregnancy,
but violence during pregnancy), (b) continuation of violence (violence both before and during pregnancy, either
remaining unchanged or increasing/decreasing), (c) termination of violence (violence before pregnancy, but no
violence during pregnancy), and (d) no violence (either
before or during pregnancy). These patterns remain an
important pathway to research because little is understood about how partner violence may change throughout a woman’s pregnancy, what factors contribute to the
varying patterns, and why pregnancy appears to be a
protective period for some women while it is a period of
increased risk for others [9,12,16].
In the last 30 years, in the medical and psycho-social
field more than one hundred studies on violence during
pregnancy have been published in the Western world.
Recently, more evidence has been emerging from low
and middle-income countries [17]. Despite this considerable amount of research, sound estimates of the prevalence of abuse and violence during the childbearing
period are difficult to obtain [18]. Available estimates of
IPV around the time of pregnancy vary between 3 and
30%. Although estimates within regions and countries
are highly variable, the majority of studies show prevalence rates ranging from 3.9% to 8.7% [19]. A recent
systematic review [12] of prevalence studies of violence
during pregnancy, reported 0.9 - 30% physical violence,
1 – 3.9% sexual violence and 1.5 – 36% psychological
abuse during pregnancy. James et al. [20] calculated a
mean reported prevalence rate of domestic (partner) violence among pregnant women of 19.8% over 92 studies.
In Belgium, 10 years ago Roelens and colleagues [21]
found a prevalence of 2.4% with respect to physical and/
or sexual partner violence 12 months preceding pregnancy and of 2.2% with respect to physical and/or sexual
partner violence during pregnancy. The variation in prevalence rates is influenced by the considerable differences in definitions (e.g. physical and/or sexual and/or
psychological violence/abuse, domestic violence vs. IPV),
study populations (e.g. small health-care based samples
vs. population-based samples), the mode of inquiry (e.g.
face-to-face interview vs. self-administered questionnaire), type of questions (e.g. general questions vs. specific behaviour) and the timing of inquiry (e.g. single
measurement early in pregnancy vs. multiple measurements throughout the whole pregnancy). In other words,
myriad study design features have influenced the prevalence rates reported, making comparison across studies
a true challenge [12,15,18,22,23].
Over the last decades, research has generated growing
evidence that IPV is linked to a broad range of adverse
health outcomes and risk behaviour. A cohort study of
Australian women aged 18–44 years estimated that intimate partner violence was responsible for 7.9% of the
overall burden of disease, which was larger than other
risk factors such as blood pressure, tobacco, and obesity
[24]. IPV is therefore considered as an important contributor to the global burden of disease for women of reproductive age.
There is a large consensus among researchers and
caregivers that the perinatal-care context is an ideal
‘window of opportunity’ to identify and address IPV, for
it is often the only moment in the lives of many couples
when there is (regular) contact with health care providers [19,25]. Knowing the precise national prevalence
of IPV is a first step in helping to inform the development and implementation of interventions to prevent
and treat sequelae [19].
The objective of this paper is to determine the
prevalence of physical, sexual (partner) violence and
psychological (partner) abuse 12 months before and/or
during pregnancy in Flanders, Belgium. First, this paper
will explore the prevalence in subgroups offering rich
information about the type of violence (physical, sexual,
psychological), the perpetrator, the timing and the association with socio-demographic characteristics. Second, this
paper will elaborate on the evolution of IPV 12 months
before and/or during pregnancy.
Methods
Setting/study population
We conducted a multi-centre cross-sectional study in
Flanders, the Northern part of Belgium. The Belgian
perinatal health-care system is based on the medical
model [26] and is generally considered highly accessible,
with women choosing their own health care provider(s).
Obstetricians/gynaecologists function as primary perinatal health-care providers and the majority of the care
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is hospital-based. Screening or systematic inquiry for
IPV is not part of routine perinatal care.
This study was part of a RCT (Randomized Controlled
Trial) that aims to assess the impact of an intervention
on psychosocial health, IPV, safety and help-seeking behaviour. We recruited in 11 antenatal care clinics, in
order to obtain a representative sample of the general
obstetric population. The convenience sample of hospitals was geographically spread over Flanders, and had a
balanced mix of rural and urban settings, as well as
small and large hospitals, providing services to economically and ethnically diverse populations.
From June 2010 until October 2012, pregnant women
consecutively seeking antenatal care were invited to participate in the study if they were at least 18 years old
and able to fill out a Dutch, French or English questionnaire. The study was limited to one questionnaire per
woman and we did not impose limits on the gestational
age. The midwife or secretary introduced the study as a
survey on difficult moments and feelings during pregnancy and briefly explained the procedure. Consenting women were handed a questionnaire, including an
informed-consent form, which was filled in in a separate
room without any accompanying person present. If the
woman was unable to fill in in private, she was excluded
from the study for safety reasons. The overall response
rate was 76.7%.
The study was approved by the Ethics Committee of
Ghent University and local ethical clearance from all 11
participating hospitals was obtained (Ethisch Comité
Middelheim Ziekenhuis Netwerk Antwerpen, Ethisch
Comité Universitair Ziekenhuis Antwerpen, Ethisch Comité
Onze Lieve Vrouw Ziekenhuis Aalst, Ethisch Comité
Gasthuis Zusters Ziekenhuis St Augustinus Antwerpen,
Ethisch Comité Algemeen Ziekenhuis Sint Jan Brugge,
Ethisch Comité Algemeen Ziekenhuis Jan Palfijn Gent,
Ethisch Comité Onze Lieve Vrouw van Lourdes Ziekenhuis
Waregem, Ethisch Comité Universitair Ziekenhuis Gent,
Ethisch Comité Algemeen Ziekenhuis Groeninge Kortrijk,
Ethisch Comité Virga Jesse Ziekenhuis Hasselt, Ethisch
Comité Ziekenhuis Oost-Limburg Genk) (Belgian registration number 67020108164). The trial was registered at www.clinicaltrials.gov, identifier NCT01158690
(http://clinicaltrial.gov/ct2/show/NCT01158690?term=
violence+and+pregnancy&rank=1).
Figure 1 gives an overview of the study sample
collection.
The questionnaires were scanned and processed using
the software Remark Office OMR version 7 and exported to SPSS version 21. The data file was rigorously
checked by two researchers for data entry errors. To
check the quality of the scanning process, a random
sample of 100 questionnaires was controlled by hand,
yielding an error rate of 1%.
Figure 1 Flow diagram recruitment.
Questionnaire/measures
The self-administered questionnaire (see Additional file 1)
consists of four main parts: socio-demographics, psychosocial health, violence, and satisfaction with care. This
paper focuses on the prevalence and evolution of IPV.
The questionnaire was available in Dutch, French and
English and was based on a thorough translation and back
translation of the original instruments.
Physical and sexual violence was measured by using
the Abuse Assessment Screen (AAS) [27], which was
adapted in close consultation with one of the authors
(Prof. dr. Judith McFarlane). The following questions
were used:
1. Have you ever been emotionally or physically abused
by your partner or someone important to you?
2. During the 12 months prior to your pregnancy/since
you became pregnant: were you hit, slapped, kicked
or otherwise physically hurt by someone?
3. During the 12 months prior to your pregnancy/since
you became pregnant: did anyone force you to have
sexual activities?
Response alternatives were yes/no. Questions 2 & 3 also
included explicit questions about the perpetrator (spouse,
ex-spouse, partner, ex-partner, family member, stranger,
other) and frequency (rarely, occasionally, often, very
often). For the pregnancy period we explored the
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evolution through the following question ‘In terms of its
severity and/or frequency, has this behaviour increased,
decreased, or remained unchanged’. A positive answer to
question 1 was defined as lifetime abuse. A positive, negative or missing answer to questions 2 & 3 in combination
with one or more positive answers to the sub questions on
perpetrator, frequency and evolution was defined as physical and sexual violence respectively. The value was
considered as missing if it was missing for all questions
and sub questions and this never exceeded 4% (n = 75).
Women indicating a spouse, ex-spouse, partner, ex-partner as perpetrator were classified as experiencing partner
violence. After the questions on physical and sexual violence we included the following question: ‘Are you afraid
of your partner or anyone you listed above?’ to be able to
compare the detection rates of the different screening
questions.
To measure psychological abuse, we used an adapted
version of the WHO-questionnaire [3]. The following
questions were used: When you think about your current or last partner, did he/she in the 12 months prior to
your pregnancy/since you became pregnant:
1. try to restrict your contact with male/female friends
and/or family?
2. insist on knowing where you are at all times?
3. ignore you and treat you indifferently?
4. insult you, criticize you, or react in a despising
manner to what you do or say?
5. belittle or humiliate you in front of other people?
6. do things to scare or intimidate you on purpose?
[e.g. smashing things, threatening to kill you or to
commit suicide]
7. threaten to hurt you or someone you care about?
We assessed the evolution of violence during the pregnancy period (increased, decreased, or unchanged) if a
minimum of one question was answered with at least
‘rarely’. Psychological abuse by a non-partner (family
member, stranger, other) was measured by ‘Did someone
else than your current or last partner behave in more
than one of the above-mentioned ways?’ with sub questions on who and when.
Contrary to the situation for physical and sexual violence, there is currently a lack of agreement on standard
measures for psychological (partner) abuse/violence and
the threshold at which behaviour crosses the line of becoming psychological abuse/violence [1]. In an effort to
tackle this problem, we composed a scale based on the 7
questions above with response alternatives never (=0),
rarely (=1), occasionally (=2), often (=3) and very often
(=4). Based on the limited available literature [1,3,16,28-34]
we decided to use a cut-off value of 4/28 as a threshold
for psychological abuse, and hence a score of 3 or lower
was not considered psychological abuse. Our scale had a
good internal consistency, with a Cronbach’s α value of
0.85 for 12 months before pregnancy and of 0.83 during
pregnancy. The proportion of missing values for the questions on psychological abuse was 10.2% (n = 193).
In an attempt to overcome the methodological challenges associated with comparing a measurement period
of 12 months before pregnancy with the pregnancy
period itself, which was on average 23.9 weeks, we created a frequency variable for partner violence including
the answering options of ‘never, rarely, occasionally,
often & very often’. This variable is built up in a similar
way as the above partner violence variables with the
additional condition of a valid value on the frequency
question. Since the answering categories contain a certain time dimension and the question was repeated for
both time periods, the women were asked to make a
subjective comparison of the evolution of the IPV.
Despite the fact that we cannot exclude the impact of
the time dimension, we believe that this frequency variable yields the best possible approximation of a ‘true’
evolution.
Data-analysis
A descriptive analysis of the socio-demographic variables, violence, perpetrator, frequency and evolution data
was performed. Prevalences of physical and sexual violence and psychological abuse 12 months prior to pregnancy and during pregnancy are reported together with
their 95% Wilson Score confidence intervals. The intervals were obtained in R (version 3.0.1), using the ‘scoreci’
function in the R-library PropCIs_0.2-0 [35].
The McNemar test was used to assess the significance
level of the difference between two paired proportions of
IPV (12 months before vs. during pregnancy). P values
below 0.05 were considered to be statistically significant.
For each type of violence a Generalized Estimating
Equation (GEE) analysis was used to investigate the differences in the odds of violence for both time periods
and perpetrators. The analyses were adjusted for age,
gestational age, language in which the questionnaire was
filled out, civil/marital status and education. Logistic regression analysis was used to assess socio-demographic
risk factors for IPV. Odds ratios (95% confidence intervals) were used to determine the association of the
type of violence with the time periods and sociodemographic factors. For the analysis of the evolution of
IPV based on the frequency variable, we assessed the
statistical significance using marginal homogeneity tests.
Statistical analyses were performed in IBM SPSS statistics (version 21).
This research adhered to the STROBE guidelines
for cross-sectional studies as outlined in http://
www.strobe-statement.org/fileadmin/Strobe/uploads/
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checklists/STROBE_checklist_v4_cross-sectional.pdf (checklist added as Additional file 2).
Results
Socio-demographic data
The mean age of our sample was 28.9 years (SD 4.5) and
the median gestational age was 21 weeks (P25 = 19 &
P75 = 30). The large majority (95%) of the women were
married or living together, 5% was divorced, separated or
single. 62.1% completed higher education and 37.8% did
not. Most women chose to fill out the questionnaire in
Dutch (97.5%), 0.9% in French and 1.6% in English.
More details are presented in Table 1.
Overall prevalence
The prevalence of abuse committed by a partner or a
significant other during lifetime was 12.1% (n = 225).
Twenty-two women (or 1.2% of the total sample) reported being afraid of their partner or another perpetrator at the time of filling out the questionnaire.
The detailed prevalence rates of physical and sexual violence and psychological abuse are presented in Table 2.
Table 1 Socio-demographic characteristics of sample
(n = 1894)
Characteristics
Frequency (n)
%
Age (n = 1842)
IPV in both periods (12 months before and/or during
pregnancy) was 15.8% (n = 270), non-partner violence
in both periods was 6.3% (n = 114) and overall violence
in both periods was 20.4% (n = 347). Physical violence in
both periods by any perpetrator was 4.8% (n = 88), sexual
violence in both periods by any perpetrator was 1.4%
(n = 26) and psychological abuse in both periods by any
perpetrator was 18.5% (n = 316).
Perpetrator of IPV before and/or during pregnancy
Physical partner violence 12 months before and/or
during pregnancy was reported by 2.5% (n = 45) of the
women, sexual partner violence by 0.9% (n = 16), and
psychological partner abuse by 14.9% (n = 257) of our
sample. Physical violence by a non-partner (family
member, stranger, other) 12 months before and/or
during pregnancy was 2.0% (n = 38), sexual violence
0.2% (n = 3) and psychological abuse 4.6% (n = 83).
The descriptive results of this study show that 58.3%
(n = 42) of the known perpetrators of physical violence
12 months before pregnancy were identified as (ex)partners, while 41.7% (n = 30) were non-partners. This proportion is reversed during pregnancy, with 40% (n = 14)
partners and 60% (n = 21) non-partners. The known perpetrators of sexual violence 12 months before pregnancy
consisted of 91.7% (n = 11) (ex)partners and 8.3% (n = 1)
non-partners. During pregnancy 76.9% (n = 10) of identified sexual violence perpetrators were (ex)partners and
23.1% (n = 3) non-partners. The known perpetrators of
psychological abuse 12 months before pregnancy consist
of 84.8% (n = 236) (ex)partners and 21.2% (n = 59) nonpartners. This proportion remains similar during pregnancy and is 80.3% (n = 175) and 25.2% (n = 55).
15-19 (minimum age 18)
31
1.7
20-24
262
14.2
25-29
742
40.3
30-34
626
34.0
35-39
149
8.1
40-44
31
1.7
Comparison of prevalence before and during pregnancy
45-49
1
0.1
Married
928
49.4
Living together
857
45.6
Divorced or separated
13
0.7
Single
82
4.4
None
34
1.8
Primary education
76
4.0
Secondary education
601
32.0
Non-university higher education
800
42.6
The total incidence percentage of IPV 12 months
before pregnancy was 14.3% (n = 246) and the total incidence percentage of IPV during pregnancy was 10.6%
(n = 181), based on 1684 women who reported IPV for
both periods. IPV during pregnancy is significantly
lower statistically (P < 0.001) than it is during the
12 months before pregnancy.
IPV only 12 months before pregnancy but not during
pregnancy, was reported by 4.5% of the total sample and
this is 30.4% (76/250) of the total IPV. IPV only during
pregnancy but not in the 12 months before pregnancy,
was reported by 1.0% of the total sample and this is 6.8%
(17/250) of the total IPV.
University higher education
367
19.5
Dutch
1846
97.5
French
17
0.9
English
31
1.6
Civil/marital status (n = 1880)
Education (n = 1878)
Combination of violence types
Language questionnaire (n = 1894)
Of all the women who reported IPV 12 months before
pregnancy, the majority (85.2% or n = 201) indicated
only one type (physical or sexual or psychological) of
partner violence, while 14.8% (n = 34) reported 2 or 3
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Table 2 Prevalence of physical and sexual violence and psychological abuse in the 12 months before pregnancy and
during pregnancy (n = 1894)* with 95% Wilson Score confidence intervals
Partner % (n)
Non-partner % (n)
95% CI
95% CI
95% CI
Physical violence in the 12 months before pregnancy
2.3 (42) (1.7 – 3.0)
1.6 (30) (1.1 – 2.3)
4.2 (78) (3.4 – 5.2)
Physical violence during pregnancy
0.8 (14) (0.5 – 1.3)
1.1 (20) (0.7 – 1.6)
2.4 (44) (1.8 – 3.2)
Total physical violence
2.5 (45) (1.8 – 3.3)
2.0 (38) (1.5 – 2.8)
4.8 (88) (3.9 – 5.8)
Sexual violence in the 12 months before pregnancy
0.6 (11) (0.3 – 1.1)
0.1 (1) (0.3 – 0.5)
0.8 (14) (0.5 – 1.3)
Sexual violence during pregnancy
0.5 (10) (0.3 – 1.0)
0.2 (3) (0.05 – 0.5)
1.1 (20) (0.7 – 1.7)
Total sexual violence
0.9 (16) (0.5 – 1.4)
0.2 (3) (0.05 – 0.5)
1.4 (26) (1.0 – 2.1)
13.6 (236) (12.1 – 15.3)
3.3 (59) (2.6 – 4.2)
16.3 (278) (14.7 – 18.2)
Psychological abuse during pregnancy
10.1 (175) (8.8 – 11.6)
3.1 (55) (2.4 – 4.0)
12.8 (218) (11.3 – 14.5)
Total psychological abuse
14.9 (257) (13.3 – 16.7)
4.6 (83) (3.7 – 5.7)
18.5 (316) (16.8 – 20.5)
Total violence all periods
15.8 (270) (14.2 – 17.7)
6.3 (114) (5.3 – 7.5)
20.4 (347) (18.6 – 22.4)
Psychological abuse in the 12 months before pregnancy
Total % (n)*
*The total percentages reflect violence by a partner and/or non-partner (family member, stranger, other). Since one respondent could tick off several types of
violence, the total percentages do not add up to 100. The total percentages also include women responding positive to one of the violence questions, but where
the specific perpetrator was unknown.
types of violence. The proportion during pregnancy was
91.4% (n = 149) of the respondents reporting one type of
violence and 8.6% (n = 14) 2 or 3 types. Furthermore,
women reported significantly (P < 0.001) fewer combinations of several types of violence during pregnancy as
compared to the situation in the 12 months before pregnancy, based on the 1669 women who reported IPV for
both periods.
Evolution of violence
The results from the unadjusted GEE analysis show that
physical partner violence during pregnancy (0.8%, 95%
CI: 0.5 – 1.3) is statistically significantly (P < 0.001) lower
than physical partner violence 12 months before pregnancy (2.3%, 95% CI: 1.7 – 3.0). The difference in
physical violence by a non-partner over both periods
marginally missed significance [P = 0.050, 1.6% (95% CI:
1.1 – 2.3) vs. 1.1% (95% CI: 0.7 – 1.6)]. Furthermore, the
evolution is significantly stronger (P = 0.036) for physical
partner violence than for non-partner violence.
Sexual partner violence during pregnancy (0.5%, 95%
CI: 0.3-1) is not statistically significantly lower (P = 0.772)
than sexual partner violence 12 months before pregnancy
(0.6%, 95% CI: 0.3-1.1). Sexual violence by a non-partner
did also not change significantly [P = 0.157, 0.2% (95% CI:
0.1 – 0.5) vs. 0.05% (95% CI: 0.01 – 0.4)]. No significant
difference in the evolution of sexual violence between
partners and non-partners could be found (P = 0.173).
Psychological partner abuse during pregnancy (10.1%,
95% CI: 8.8 – 11.6) is statistically significantly (P < 0.001)
lower than psychological partner abuse 12 months before
pregnancy (13.6%, 95% CI: 12.1 – 15.3). Psychological
abuse by a non-partner did not change significantly
[P = 0.433, 3.1% (95% CI: 2.4 – 4.0) vs. 3.3% (95% CI: 2.6 –
4.2)]. The evolution of psychological partner abuse is
significantly stronger (P = 0.014) than the decrease in violence by a non-partner.
The estimated odds of physical partner violence (OR
0.33, 95% CI: 0.21 – 0.54) during pregnancy decreased
by 66.7% and psychological partner abuse (OR 0.71, 95%
CI: 0.64 – 0.80) by 28.7% compared to the situation in
the 12 months before pregnancy (more details are available in Table 3).
Figure 2 provides a clear illustration of the evolution of
the different types of IPV in the period from 12 months
before pregnancy to the period during pregnancy (median
gestational age 21 weeks).
The results of the binary logistic regression analysis
for IPV (in both periods), are shown in Table 4. This
analysis demonstrates that the language used to fill out
the questionnaire, civil/marital status and education have
a significant impact on the prevalence of IPV in both periods, while age does not. In the bivariate analysis, age
was significantly correlated to IPV, but when age was
added to the model, the correlation was filtered out by
the other socio-demographic factors.
When a woman reported lifetime abuse, we found an
aOR of 5.37 (95% CI: 4.03 – 7.15) for IPV in both periods.
In a second GEE analysis, we investigated the differences in adjusted odds of partner and non-partner
violence over both time periods (see Table 3). After correction for age, language used to fill out the questionnaire,
civil/marital status and education, the aOR for physical
partner violence during pregnancy (0.35, 95% CI: 0.22 –
0.56) turned out to be significantly (P < 0.001) lower than
in the period of 12 months before pregnancy. The aOR
for physical non-partner violence during pregnancy (0.7,
95% CI: 0.45 – 1.08) is not significantly (P = 0.104) lower
than that of the period 12 months before pregnancy. The
adjusted odds for physical partner violence during
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Table 3 Overview of odds and adjusted odds of violence for both time periods and perpetrators
OR 95% CI (GEE 1)
P-value
aOR 95% CI (GEE 2)**
P-value
Partner violence during pregnancy*
0.33 (0.21 – 0.54)
< 0.001
0.35 (0.22 – 0.56)
< 0.001
Non-partner violence during pregnancy
0.66 (0.44 – 1.00)
0.052
0.70 (0.45 – 1.08)
0.104
Partner violence during pregnancy
0.91 (0.49 – 1.70)
0.772
0.95 (0.48 – 1.90)
0.894
Non-partner violence during pregnancy
3.01 (0.61 – 14.93)
0.177
3.11 (0.62 – 15.74)
0.170
Partner violence during pregnancy
0.71 (0.64 – 0.80)
<0.001
0.70 (0.63 – 0.79)
<0.001
Non-partner violence during pregnancy
0.93 (0.78 – 1.12)
0.433
0.93 (0.77 – 1.12)
0.432
Physical
Sexual
Psychological
*Reference category 12 months before pregnancy.
**Adjusted for language of the questionnaire, civil/marital status, education and age.
pregnancy decrease with 65% as compared to those in the
12 months before pregnancy, whereas physical nonpartner violence decreased with 30%. The evolution of
physical partner violence was statistically significantly
(P = 0.043) stronger than the evolution in physical nonpartner violence.
The aOR for sexual partner violence during pregnancy
(1.06, 95% CI: 0.53 – 2.13) is not significantly (P = 0.869)
lower than during the 12 months before pregnancy. The
aOR for sexual non-partner violence during pregnancy
(2.05 95% CI: 0.50 – 8.43) is not statistically significantly
(P = 0.318) lower than that of the 12 months before
pregnancy. No statistical significant (P = 0.413) difference in evolution of sexual violence between partners
and non-partners could be found.
The aOR for psychological partner abuse during pregnancy (0.70, 95% CI: 0.63 – 0.79) is significantly (P < 0.001)
lower than that in the 12 months before pregnancy. The
aOR for psychological non-partner abuse during pregnancy (0.93, 95% CI: 0.77 – 1.12) is not statistically significantly (P = 0.432) lower than that of the 12 months before
pregnancy. The odds for psychological partner abuse
during pregnancy decrease with 30% compared to those
for the period of 12 months before pregnancy. Psychological non-partner abuse decreased with 7% but this was
not statistically significant. The evolution of psychological
partner abuse is significantly (P = 0.014) stronger than the
evolution in psychological non-partner abuse. We observed a larger decrease in physical partner violence as
compared to that in psychological partner abuse.
When a woman reported IPV in the 12 months before
pregnancy, she had an aOR of 165.39 (95% CI: 90.52 –
302.19) for IPV during pregnancy. The likelihood of
reporting physical partner violence is 30.7% (95% CI:
Table 4 Overview of socio-demographic risk factors for
IPV
aOR IPV (both periods) 95% CI
P-value
Language
questionnaire
Dutch (ref)
1
French
4.68
1.36 – 16.10 0.014
English
7.44
3.07 – 18.1
< 0.001
2.55 – 7.88
< 0.001
Civil/marital status
Married/
cohabiting (ref)
1
Divorced/single
4.48
Education
Higher/university 1
education (ref)
Figure 2 Comparison of prevalence rates 12 in the months
before pregnancy with those during pregnancy (median
gestational age 21 weeks). The upper side of the box refers to
upper limit of 95% CI, lower side to lower limit of 95% CI of the
prevalence. The middle line in the box indicates the prevalence rate.
Age
132
No/primary
education
6.74
3.94 – 11.55 < 0.001
Secondary
education
2.64
1.94 – 3.358 < 0.001
0.99
0.96 – 1.02
0.475
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19.71 – 44.33). For sexual partner violence it is 54% (95%
CI: 35.6 – 71.32), and for psychological abuse 68.74%
(95% CI: 65.8 – 71.54) in cases where the different types
of partner violence were reported in the 12 months before
pregnancy.
Subsequently, we explored the impact of gestational
age on the evolution of IPV over both time periods. We
found that gestational age is significantly associated with
IPV during pregnancy and has an aOR of 1.03 (95% CI:
1.01 – 1.05).
As already pointed out in the Methods section, the
outcome variables used in the above analysis include two
different time periods i.e. 12 months before pregnancy and
the period during pregnancy with a median gestational age
of 21 weeks. In an effort to address this methodological
challenge, we created a frequency variable for partner
violence. Since the answering categories of this variable
contain a certain time dimension and the question was
repeated for both time periods, the women were asked to
make a subjective comparison of the evolution of the IPV.
Despite the fact that we cannot exclude the impact of the
time dimension, we believe that this frequency variable
yield the best possible approximation of a ‘true’ evolution.
The results of the bivariate analysis of the IPV frequency
variable, based on the marginal homogeneity test, showed
that the frequency of physical partner violence during
pregnancy is significantly lower than the frequency of
physical partner violence in the period 12 months before
pregnancy (P < 0.001). The frequency of sexual partner
violence during pregnancy is not statistically significantly
different than the frequency of sexual partner violence
12 months before pregnancy (P = 0.537). The frequency of
6 out of 7 sub questions of psychological partner abuse
during pregnancy is statistically significantly lower than
those for 12 months before pregnancy (P-values between
0.002 and < 0.001). There was no significant change found
(P = 0.091) for the sub question ‘Did your (ex)partner
threaten to hurt you or someone you care about’.
Finally, in addition to the analysis above, we explored
in a third GEE whether physical and sexual partner
violence and psychological partner abuse increased, decreased, or remained unchanged during the pregnancy
itself. We found no significant differences in the evolution of IPV (P = 0.19) during the pregnancy period.
Discussion
The results of this study indicate that violence is a
prevalent problem around the time of pregnancy in
Flanders, Belgium. One fifth (20.4%) of the women report some form of IPV in the 12 months before and/or
during pregnancy. (Ex-)partners account for the largest
share (77.8%) of all violence reported and family members, strangers or others for 22.2%. Psychological abuse
is the type IPV of that is reported most frequently.
Estimates of IPV around the time of pregnancy vary
between 3 to 30%. Prevalence rates in African and Latin
American countries are mainly situated at the high end
of the continuum and the European and Asian countries
are positioned at the lower end [19]. A recent systematic
review [12] reported 0.9 - 30% physical violence, 1 –
3.9% sexual violence and 1.5 – 36% psychological abuse
during pregnancy. We found 2.4% physical, 1.1 sexual
and 12.8% psychological abuse during pregnancy. James
et al. [20] reported a mean prevalence rate of domestic
(partner) violence among pregnant women of 19.8% over
92 studies, whereas we found 10.5%. An earlier Belgian
study by Roelens et al. [21] using a related assessment
tool, reported 2.4% physical and/or sexual partner violence 12 months before pregnancy, whereas we found
2.6%. In contrast to the 2.2% physical and/or sexual partner violence during pregnancy in Roelens’ study [21], we
only found 1.1%. Caution is recommended when interpreting and comparing results of different studies, as
methodological differences and challenges are substantial (cf. introduction). Nonetheless, our results seem to
be situated at the lower end of the different continuums
found in other studies in Western antenatal clinical settings, and this was also confirmed by a European multicountry study in which we participated [36]. Possible hypotheses for this relatively low prevalence rate are that,
compared to the general obstetric population in Flanders,
our sample is more educated and only a minority chose to
fill out the questionnaire in another language, which can
both be considered as a proxy for a higher socio-economic
status. Moreover, women were on average 24 weeks pregnant when they filled out the questionnaire, and it is not
unthinkable that the violence starts after this gestational
age. This may account for the lower recording rate of IPV
during pregnancy in our study. Furthermore, the lower
prevalence rates may also be attributed to the 25% of the
women that opted not to participate in our study. A more
optimistic hypothesis is that the women in our study actually experienced less violence compared to women in the
above-mentioned studies. However, they might as well be
more hesitant to disclose experiences of violence in a
hospital-based survey or may not acknowledge certain
behaviour as being transgressive.
The analysis of the prevalence and the frequency
variable showed that physical partner violence and psychological partner abuse are significantly lower during
pregnancy as compared to the 12-months period before
pregnancy. Moreover, the evolution was stronger for physical partner abuse than for psychological partner abuse,
suggesting that partners are generally less physically
violent but not necessarily less psychologically abusive.
We were not able to detect any evolution in sexual partner
violence and this is probably linked to the small sample
size. Similarly, other researchers have demonstrated that
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prevalence of violence during pregnancy is consistently
lower than violence occurring before pregnancy, both in
developed [14,15,37-50] and less developed nations
[51-56]. Furthermore, we found that 6.3% of the total IPV
occurred only during pregnancy (and not in the 12 months
before), 28.1% of the women indicated that they only experienced IPV in the 12 months before (and not during)
pregnancy. Likewise, Taillieu [12] found that 31 to 69% of
the women indicate that IPV stopped during pregnancy.
We do not dispose of concrete data explaining why IPV is
lower during pregnancy, but one could hypothesize that
pregnancy changes the social status of a woman [57] and
that it increases social control and respect for the woman.
Another hypothesis is that in Western societies a pregnant
woman is seen as a receptacle for the vulnerable unborn
child. Partners may realize that physical and sexual (not
necessarily psychological) violence can harm the baby and
therefore use less (physical) violence. We could also
hypothesize that women feel more vulnerable during
pregnancy and actually use more tactics to avoid violent
escalations.
Though the prevalence of violence during pregnancy
is found to be consistently lower than that of the prepregnancy period, 60% to 96% of the women who are
abused during pregnancy also report having been abused
in the past, suggesting that pregnancy violence represents a continuation of pre-existing violence for most
pregnant victims [12]. This was confirmed by our finding that lifetime abuse and IPV in the 12 months before pregnancy are very strong predictors for IPV during
pregnancy.
Similarly to what is found in most other studies
[12,19,20,58,59], the results of our study illustrate that
filling out the questionnaire in another language than
Dutch, being divorced or single, and having a lower than
secondary education (as proxies for low socio-economic
status) are important risk factors which increase odds
for the reporting of IPV substantially.
In the scientific literature, there is currently a debate
on what question(s) should be used to identify (partner)
violence. Some authors [60-64] have suggested that single question screening using ‘Are you afraid of…’, would
be sufficient. When we compare the results of ‘Are you
afraid of your partner or anyone you listed above?’ (1.2%,
n = 22) with the results of a set of specific behavioural
questions assessing IPV in the 12 months before and/or
during pregnancy (20.4%, n = 347), it is clear that measuring violence by means of one general question detects
much less violence. This finding has been confirmed by
several other authors [12,15,18,22,23,45]. An exploratory
analysis of the 22 women that declared themselves to
be afraid, revealed that these women had a lower
socio-economic status, more psycho-social problems
and higher violence prevalence rates. Using the ‘are you
afraid’ question only seems to detect the tip of the iceberg and proves to be an inappropriate screening question in our study population.
The findings in this study are subject to several limitations. First, there is currently a lack of agreement on
standard measures of emotional/psychological partner
abuse/violence and the threshold at which acts can be
considered being emotional/psychological abuse/violence
[1]. The threshold we chose for psychological abuse was
based on a thorough literature search and extensive
discussions with experts in the field. Nevertheless, it remains an arbitrary choice that is open for discussion.
Contrary to many other authors, we made the decision
to actively contribute to the development of a standard
measure and cut-off value for psychological partner
abuse. Yet, we clearly acknowledge that our threshold is
not beyond debate. Second, the comparison of prevalence rates of violence during pregnancy to those of the
period of 12 months before pregnancy, should be interpreted with caution, since the period referring to pregnancy was on average half of the 12 months before
pregnancy, which obviously reduces the chances of
experiencing violence. In an attempt to overcome this
methodological challenge, we analysed the frequency
data as a best possible approximation of a ‘true’ evolution and found a similar evolution of IPV. However,
since the questions on frequency were also linked to the
time periods, we cannot exclude that the results are
biased by the difference in measurement period. Moreover, we need to be careful about making statements
about the evolution of violence since we do not dispose
of data on the postpartum period and many researchers
have shown that this is a period of increased violence
[9,11,16,58,59,65-67]. Third, we did not explicitly measure child abuse, financial distress or economic violence.
These factors are known to be linked to violence and
could have been used to adjust our analysis. Fourth, this
part of the study only disposes of data on female victimization. Growing evidence shows that IPV not only
involves female victims and male perpetrators, but that
it is rather a matter where both partners/sexes contribute mutually [68,69]. We therefore do not claim to create a representative image of reality where both partners
play their roles.
Conclusions
Our results demonstrate that in Flanders, Belgium, one
out of five women experiences violence around the pregnancy period. Psychological abuse inflicted by (ex-)partners is the most frequent type of violence. Increasing
evidence shows that the consequences of psychological
abuse are as serious as those of physical and sexual violence. Although IPV seems to be lower during pregnancy, it remains a prevalent problem and not much is
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known about the specific reasons for this decrease. We
call upon fellow researchers to breathe new life into the
debate on the current methodological challenges associated with measuring IPV, especially the problem of
comparing different measurement periods and the lack
of a threshold for psychological abuse.
Additional files
Additional file 1: Study questionnaire.
Additional file 2: STROBE Checklist.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ASVP conceived the study, acquired the data, did the analysis and drafted
the manuscript. ED assisted ASVP with the statistical analysis. KM, MT and HV
participated in the design of the study, were involved in drafting the article
and gave critical input. All authors read and approved the final manuscript.
Acknowledgements
We would like to thank all the women in our study for the courage they
showed in filling out a questionnaire on this difficult topic. Our thanks are
due to Prof Olivier Degomme for the methodological support, Ms. Roos
Colman for the statistical help, Prof Fred Louckx, Prof Kristien Roelens,
Dr. Ines Keygnaert, Ms. Heleen Vermandere for their useful comments and
Prof Michael B. Drennan for the graphic support.
Author details
1
Faculty of Medicine and Health Sciences, Department of Obstetrics and
Gynaecology, Ghent University, International Centre for Reproductive Health,
Belgium, De Pintelaan 185, UZP 114, 9000 Gent, Belgium. 2Faculty of
Medicine and Health Sciences, Department of Public Health, Biostatistics
Unit, Ghent University, De Pintelaan 185, 4K3, 9000 Gent, Belgium.
Received: 17 March 2014 Accepted: 19 August 2014
Published: 28 August 2014
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Paper 3: Intimate partner violence and psychosocial health, a cross-­‐sectional study in a pregnant population The objective of this paper is to explore whether IPV 12 months before and/or during pregnancy is associated with psychosocial health in Flanders, Belgium (MOM-­‐study). Key message We found a significant correlation between IPV and poor psychosocial health: lower psychosocial health scores were associated with increased odds of reporting IPV. A decrease of 10 points on the psychosocial health scale (total of 140) increased the odds of reporting IPV by 55 %. The association between overall psychosocial health and IPV remained significant after adjusting for socio-­‐demographic status. When accounting for the 6 psychosocial health subscales (depression, anxiety, self-­‐esteem, mastery, worry and stress), the analysis revealed that all subscales are strongly correlated to reporting IPV. However, when accounting for all subscales simultaneously, only depression (aOR 0.87; 95 % CI 0.84–
0.91) and stress (aOR 0.85; 95 % CI 0.77–095) remained significantly associated with IPV. 137
Van Parys et al. BMC Pregnancy and Childbirth (2015) 15:278
DOI 10.1186/s12884-015-0710-1
RESEARCH ARTICLE
Open Access
Intimate partner violence and psychosocial
health, a cross-sectional study in a
pregnant population
An-Sofie Van Parys1*, Ellen Deschepper2, Kristien Michielsen1, Anna Galle1, Kristien Roelens1,
Marleen Temmerman1 and Hans Verstraelen3
Abstract
Background: The objective of this paper is to explore whether IPV 12 months before and/or during pregnancy is
associated with poor psychosocial health.
Methods: From June 2010 to October 2012, a cross-sectional study was conducted in 11 antenatal care clinics in
Belgium. Consenting pregnant women were asked to complete a questionnaire on socio-demographics,
psychosocial health and violence in a separate room. Overall, 2586 women were invited to participate and we were
able to use data from 1894 women (73.2 %) for analysis. Ethical clearance was obtained in all participating hospitals.
Results: We found a significant correlation between IPV and poor psychosocial health: within the group of women
who reported IPV, 53.2 % (n = 118) had poor psychosocial health, as compared to 21 % (n = 286) in the group of
women who did not report IPV (P < 0.001).
Lower psychosocial health scores were associated with increased odds of reporting IPV (aOR 1.55; 95 % CI 1.39–1.72),
with adjustments made for the language in which the questionnaire was filled out, civil/marital status, education and
age. In other words, a decrease of 10 points on the psychosocial health scale (total of 140) increased the odds of
reporting IPV by 55 %.
When accounting for the 6 psychosocial health subscales, the analysis revealed that all subscales (depression, anxiety,
self-esteem, mastery, worry and stress) are strongly correlated to reporting IPV. However, when accounting for all
subscales simultaneously in a logistic regression model, only depression (aOR 0.87; 95 % CI 0.84–0.91) and stress (aOR
0.85; 95 % CI 0.77–095) remained significantly associated with IPV. The association between overall psychosocial health
and IPV remained significant after adjusting for socio-demographic status.
Conclusion: Our research corroborated that IPV and psychosocial health are strongly associated. Due to the limitations
of our study design, we believe that future research is needed to deepen understanding of the multitude of factors
involved in the complex interactions between IPV and psychosocial health.
Keywords: Intimate partner violence, Abuse, Pregnancy, Psychosocial health
* Correspondence: [email protected]
1
Department of Obstetrics and Gynaecology, Faculty of Medicine and Health
Sciences, International Centre for Reproductive Health, Ghent University, De
Pintelaan 185, UZP 114, 9000 Ghent, Belgium
Full list of author information is available at the end of the article
© 2015 Van Parys et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
138
Van Parys et al. BMC Pregnancy and Childbirth (2015) 15:278
Page 2 of 8
Background
Intimate partner violence (IPV) is currently recognised as
a global health problem with serious clinical and societal
implications, which affects women and men from all backgrounds, regardless of age, ethnicity, socio-economic status, sexual orientation or religion [1–4]. IPV is defined as
any behaviour within a present or former intimate relationship that leads to physical, sexual or psychological
harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviour patterns [5]. IPV is also known as domestic/family violence,
spouse/partner abuse/assault, battering, violence against
women or gender-based violence [6–8]. Based on the
Centers for Disease Control and Prevention’s definition of
IPV [9], we have chosen to consistently use the term ‘violence’ for physical and sexual types of violence, and ‘abuse’
for psychological types. The word ‘abuse’ clearly refers to a
broader range of behaviours than the word ‘violence’,
which is often associated with severe forms of violent
behaviour.
Pregnancy and childbirth mark an important turning
point at which the roles and relationships of couples and
their families are redefined on different levels. While
parenthood can bring joy, it also confronts couple relationships with new challenges [10, 11]. As pregnancy
may generate changes in physical, emotional, social and
economic needs, it can be a stressful time. This period is
associated with increased demands on individual capacities, the intimate partner relationship and household
economic resources, and a reduction in leisure time and
opportunities to socialise, which can exert adverse effects on emotional wellbeing [10]. Individual and dyadic
coping strategies tend to decrease under stress, leading
to an increased risk of physical and psychological aggression [12–14]. The vulnerable period for IPV associated
with pregnancy extends further than the time between
conception and birth - from a year before conception
until one year after childbirth [4, 12–15].
A wide range of prevalence rates, from 3 to 30 %, have
been reported for IPV around the time of pregnancy.
Prevalence rates are mainly situated at the high end of
the continuum in African and Latin American countries,
and at the lower end in European and Asian countries.
Although estimates are highly variable due to methodological challenges, the majority of studies show rates
within the range of 3.9 to 8.7 % [3, 4, 6, 8, 10–17].
Although the exact prevalence of IPV around the time of
pregnancy remains unclear, it is evident that it affects a
substantial group of women. In Belgium, we recently
showed [17] that as many as 15.8 % (95 % CI 14.2–17.7)
of women experience IPV (incl. psychological abuse)
before and/or during pregnancy. In other words IPV
during the perinatal period is more common than
several maternal physical health conditions (e.g. pre-
eclampsia, placenta praevia), yet IPV receives considerably less attention within perinatal care [3, 4, 18, 19].
The Belgian perinatal health care system is based on the
bio-medical model [20] with obstetrician/gynaecologists
(ob/gyn’s) not only accounting for obstetric and gynaecologic pathology, but also acting as primary care physicians to the general female population, e.g. in providing
primary obstetric care and in offering preventive
women's health medicine [16, 21]. Although pregnancy
brings women into regular contact with the health care
system and therefore offers strategic opportunities to
identify and ameliorate psychosocial concerns and risk
factors [22], screening or systematic inquiry for IPV and/
or psychosocial health is not part of routine perinatal
care (yet).
In recent decades, research from the Western world,
and increasingly, from low and middle income countries [23], has generated growing evidence that violence
is associated with detrimental effects on the physical
health of women, men and children, such as infection,
miscarriage/abortion, placental abruption, foetal injury
and perinatal death [8, 18, 19, 24–35]. Evidence is
emerging that on the one hand, poor psychosocial
health is a negative consequence of IPV, and on the
other hand, poor psychosocial health is simultaneously
found to be a risk factor for IPV. Moreover, poor psychosocial health status is linked to adverse pregnancy
outcomes. Women reporting depressive symptoms and
poor overall psychosocial health during pregnancy are
at increased risk of low birth weight (LBW) and preterm birth [36]. Furthermore, reporting IPV, is associated with increased risk for anxiety disorders, eating
disorders, anxiety attacks, nervousness, concentration
problems, sexual dysfunctions, fear of intimacy, loss of
self-esteem, psychosomatic complaints (e.g. headaches),
pre- and postnatal depression, trauma symptoms (such
as sleeping problems, flashbacks, panic attacks) posttraumatic stress syndrome, postpartum psychosis, and
(attempted) suicide [18, 19, 24–35]. Additionally, IPV is
strongly linked with harmful health behaviours such as
using tobacco, alcohol or illicit drugs, poor maternal
nutrition, and high-risk sexual behaviour [2, 8, 18, 19,
24–28, 31–35, 37–41].
The objective of this paper is to explore whether IPV
12 months before and/or during pregnancy is associated
with poor psychosocial health in Flanders, Belgium.
Methods
Setting/study population
We conducted a multi-centre cross-sectional study in
Flanders, the Northern part of Belgium. The Belgian perinatal health care system is based on the medical model
[20] and is generally considered to be highly accessible,
with women choosing their own health care provider(s).
139
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Page 3 of 8
Obstetricians/gynaecologists (OB/GYN) merely function
as primary perinatal health care providers and the majority of the care is hospital-based. Screening or
systematic inquiry for IPV is not part of routine perinatal care.
This study was part of an RCT (Randomized Controlled Trial) that aimed to assess the impact of an intervention on psychosocial health, IPV, safety- and helpseeking behaviour. The methods have been previously
published [20] and will only be summarized here.
Participants were recruited between June 2010 and
October 2012 in 11 antenatal care clinics that were
selected through a convenience sample (based on geographic location, including rural and urban settings,
small and large hospitals). The selection criteria for participants were: being pregnant, minimum 18 years old
and able to fill out a Dutch, French or English questionnaire. Overall, 2586 women were invited to participate
and we were able to use data from 1894 women (73.2 %)
for analysis. The study was introduced by the midwife or
receptionist as a survey on difficult moments and feelings during pregnancy. Informed consent was obtained
from all participants and consenting women were invited
to fill out the questionnaire in a separate room without
any accompanying person present. The questionnaire
was returned to the health professional in a coded and
sealed envelope. If the woman was unable to fill in the
questionnaire in private, she was excluded from the
study for safety reasons. All measures were taken to
ensure that women could get additional support (from
social services) if this was deemed necessary by the
respondent or the staff. The information letter clearly
indicated that the aim of the study was not to provide
support or guidance. If women needed additional support (after filling out the questionnaire), they were referred to a 24/24 h telephone hotline. The involvement
and training provided to the recruiting professionals was
kept to a strict minimum since the aim of the RCT, of
which this study was part, is to measure the effect of intervention in as unbiased a way as possible. The study was
approved by the Ethics Committee of Ghent University
and local ethical clearance was obtained from all 11 participating hospitals (Ethisch Comité Middelheim Ziekenhuis Netwerk Antwerpen, Ethisch Comité Universitair
Ziekenhuis Antwerpen, Ethisch Comité Onze Lieve
Vrouw Ziekenhuis Aalst, Ethisch Comité Gasthuis Zusters
Ziekenhuis St Augustinus Antwerpen, Ethisch Comité
Algemeen Ziekenhuis Sint Jan Brugge, Ethisch Comité
Algemeen Ziekenhuis Jan Palfijn Gent, Ethisch Comité
Onze Lieve Vrouw van Lourdes Ziekenhuis Waregem,
Ethisch Comité Universitair Ziekenhuis Gent, Ethisch
Comité Algemeen Ziekenhuis Groeninge Kortrijk, Ethisch
Comité Virga Jesse Ziekenhuis Hasselt, Ethisch Comité
Ziekenhuis Oost-Limburg Genk) (Belgian registration
number 67020108164). The trial was registered at www.cli
nicaltrials.gov, identifier (NCT01158690).
The overall response rate was 76.7 %.
Figure 1 provides a flow diagram of the recruitment.
Questionnaire/measures
The questionnaire consisted of four main parts: sociodemographics, psychosocial health, violence and satisfaction with care. This paper focuses on the correlation of IPV
with psychosocial health, while results on IPV prevalence
and the evolution of IPV 12 months before and during
pregnancy were published in another paper [17].
Physical and sexual (partner) violence was measured
through an adapted version of the Abuse Assessment
Screen (AAS) [42], which was adapted in consultation
with one of the authors (Prof. dr. Judith McFarlane). To
measure psychological abuse, we used an adapted version
of the WHO-questionnaire [6]. Based on the limited available literature [1, 6, 43–50] and after long debate and
extensive consultations with several experts in the field,
we constructed a 7-item scale of questions with answer
options ranging from 0 to 4 and we decided to use a cutoff value of 4/28 as a threshold for psychological abuse.
We previously documented the assessment of abuse in
detail [17]. Our scale had good internal consistency, with
140
Fig. 1 Flow diagram recruitment
Van Parys et al. BMC Pregnancy and Childbirth (2015) 15:278
Page 4 of 8
a Cronbach’s α value of 0.85 for 12 months before pregnancy and of 0.83 during pregnancy. For the purpose of
this paper, we used a dichotomised variable including
physical and/or sexual and/or psychological partner
violence 12 months before pregnancy and/or during
pregnancy.
Psychosocial health was measured through the Abbreviated Psychosocial Scale [51]. This scale is composed of
5 existing scales, namely, for trait anxiety (Speilberger
Trait Anxiety Scale), self-esteem (Rosenberg Self-Esteem
Scale), mastery (Pearlin Mastery Scale), depression
(Centre for Epidemiologic Studies Depression Scale) and
subjective stress (Schar Subjective Stress Scale). The
Abbreviated Psychosocial Scale is well-validated and was
recently identified as the best currently available instrument for measuring multiple psychopathological symptoms [52]. It consists of 6 subscales: negative affect
(depression), positive affect (anxiety), positive selfesteem, low mastery, worry (anxiety) and stress. The
scale consists of 28 questions, with response alternatives
scored from 1 to 5, resulting in a minimum score of 28,
indicating poor psychosocial health, and a maximum
score of 140, indicating good psychosocial health. If one
answer is missing, the overall score is coded as missing a
value. Unfortunately, no clear clinical cut-off values for
psychosocial health are currently available. Therefore,
most authors [36, 51–55] use the median or P25-value
as a threshold to dichotomize the scale into ‘poor’ or
‘good’ psychosocial health. Due to the lack of a clinical
cut-off value, we used the scale as a continuous variable
where possible. The scale has a Cronbach’s α of 0.93,
indicating a high degree of reliability and internal
consistency.
Results
Socio-demographic data
The mean age of the women in our sample (n = 1894)
was 28.9 years (SD 4.5) and the median gestational age
was 23.9 weeks (IQR: 19–30). The large majority (95 %)
of the women were married or living together with their
partners; 5 % were divorced, separated or single. Sixtytwo percent had completed higher education and 37.8 %
had not. Most women (97.5 %) chose to fill out the
questionnaire in Dutch, 0.9 % in French and 1.6 % in
English. More details are presented in Table 1.
IPV prevalence
The overall percentage of IPV 12 months before and/
or during pregnancy was 15.8 % (95 % CI 14.2–17.7)
(n = 270), while it was 14.3 % (95 % CI 12.7–16.0) (n =
246) 12 months before pregnancy, and 10.6 % (95 % CI
9.2–12.1) during pregnancy, as we have previously reported in detail [17]. Physical partner violence before
as well as during pregnancy was reported by 2.5 %
(95 % CI 1.8–3.3) of the respondents, sexual violence
Table 1 Socio-demographic characteristics of sample (n = 1894)
Characteristics
Data analysis
A descriptive analysis of socio-demographic variables,
IPV and psychosocial health was performed. The bivariate correlation between IPV and psychosocial health
was explored using the Pearson chi2 test. Binary logistic
regression analysis was used to investigate the unadjusted and adjusted odds ratios (95 % confidence intervals) of reporting IPV correlated to psychosocial
health (total score and subscale scores). Model selection was based on best model fit, statistical significance
levels and clinical relevance. P- values below 0.05 were
considered to be statistically significant. All statistical
analyses were performed with IBM SPSS statistics software (version 22).
This research adhered to the STROBE guidelines for
cross-sectional studies as outlined in http://www.strobestatement.org/fileadmin/Strobe/uploads/checklists/STR
OBE_checklist_v4_cross-sectional.pdf (checklist added
as Additional file 1).
Frequency (n)
Percent
Age (n = 1842) - years
15–19
31
1.7
20–24
262
14.2
25–29
742
40.3
30–34
626
34.0
35–39
149
8.1
40–44
31
1.7
45–49
1
0.1
Civil/marital status (n = 1880)
Married
928
49.4
Living together
857
45.6
Divorced or separated
13
0.7
Single
82
4.4
1.8
Education (n = 1878)
None
34
Primary education
76
4.0
Secondary education
601
32.0
Non-university higher education
800
42.6
University higher education
367
19.5
Dutch
1846
97.5
French
17
0.9
English
31
1.6
Language questionnaire (n = 1894)
141
Van Parys et al. BMC Pregnancy and Childbirth (2015) 15:278
Page 5 of 8
by 0.9 % (95 % CI 0.5–1.4), and psychological abuse by
14.9 % (95 % CI 13.3–16.7). The proportion of missing
values ranged between 4 % (n = 75) for physical and sexual
violence and 10.2 % (n = 193) for psychological abuse.
only depression and stress remained significantly associated with IPV. The association between total psychosocial
health and IPV remained significant after adjusting for
socio-demographic status. All socio-demographic factors
except age were significantly associated with reporting IPV.
Psychosocial health
The median score for psychosocial health in our sample
was 111 (IQR: 100–120), with a range from 55 to 140.
The proportion of missing values was 10.1 %.
As noted above, the psychosocial health scale consists
of 6 subscales: negative affect (depression), positive
affect (anxiety), positive self-esteem, low mastery, worry
(anxiety) and stress. Table 2 provides an overview of
the subscale scores for the total population.
Correlation of IPV and psychosocial health
The bivariate analysis demonstrated a statistically significant correlation between IPV and psychosocial health.
Within the group of women that reported IPV, 53.2 %
(n = 118) had poor psychosocial health scores, as compared to 21 % (n = 286) in the group of women that did
not report IPV (P < 0.001). Conversely, it can be stated
that 29.2 % (n = 118) of the women with poor psychosocial
health reported IPV, whereas 8.8 % (n = 104) of women
with good psychosocial health reported IPV (P < 0.001).
Correlation between psychosocial health, sociodemographics and IPV
Using a multivariable model, we found that a lower total
psychosocial health score was associated with increased
odds of reporting IPV (aOR 1.04; 95%CI 1.03–1.06),
adjusted for the language in which the questionnaire was
filled out, civil/marital status, education and age. This
correlation means that a decrease of only one point on
the total psychosocial health scale of 140 points is associated with an increased adjusted odds of reporting IPV
of 4 %. In other words, a decrease of 10 points on the
scale is associated with an increased adjusted odds of
reporting IPV of 55 % (aOR 1.55; 95 % CI 1.39–1.72).
When accounting for the 6 psychosocial health subscales, as shown in Table 3, the binary analysis revealed
that all psychosocial health subscales (depression, anxiety,
self-esteem, mastery, worry and stress) were strongly correlated to reporting IPV. However, when accounting for all
subscales simultaneously in a logistic regression model,
Discussion
In this multi-centre cohort of pregnant women, we found
a strong correlation between IPV and psychosocial health.
Several other researchers have previously demonstrated a
correlation between reporting IPV and poor psychosocial
health [2, 8, 18, 24–28, 31–34, 38, 56–58]. Notably, poor
psychosocial health is frequently reported as a negative
consequence of IPV, and simultaneously, psychosocial
health is found to be a risk factor for IPV. As this association has been repeatedly documented mostly in crosssectional studies, it remains to be determined whether
poor psychosocial health puts women at risk of IPV, or
whether IPV induces worse psychosocial health, though it
is plausible that both pathways co-exist. Literature on this
specific matter is scarce; most studies have focussed on
the association between poor psychosocial health and
pregnancy outcomes such as low birth weight and prematurity, though the influence of psychosocial factors (such
as stress, anxiety, and depression) on birth outcomes
remains inconclusive [36, 51, 52]. However, psychosocial
resources including self-esteem and mastery have been
reported to protect women against stress from life events
and chronic strains. These psychosocial resources could
be even more relevant when women adapt to manage
their lives and cope with the stress and vulnerability associated with IPV during pregnancy [54].
Our data further suggest that, after taking all measured
variables into account, the correlation between IPV and
psychosocial health was mainly explained by “depression”
and “stress” as psychosocial health indices. It has been
noted that scales measuring affective states such depression
or anxiety are likely to be highly correlated with each other
and measure generalized distress rather than symptoms
unique to depression or anxiety [51]. Our results confirm
the finding that there is a strong correlation between the
different psychosocial health subscales. The strong association between the total psychosocial health scale and IPV
might indeed refer to a more general form of distress in
our population interconnected with a multitude of factors.
Table 2 Overview subscales psychosocial health
Subscale depression Subscale anxiety Subscale
Subscale mastery Subscale worry Subscale stress
self-esteem
Median total sample (IQR)
28 (25–31)
24 (23–27)
16 (15–18)
24 (21–27)
11 (9–13)
7 (5–8)
Median score women reporting IPV (IQR)
25 (21–28)
23 (20–24)
16 (14–17)
22 (18–24)
10 (8–11)
6 (5–7)
Median scores women not reporting IPV (IQR) 29 (25–31)
25 (23–27)
16 (15–18)
25 (22–27)
11 (10–13)
7 (6–8)
Maximum score subscales
30
20
30
15
10
35
142
Van Parys et al. BMC Pregnancy and Childbirth (2015) 15:278
Page 6 of 8
Table 3 Association of psychosocial health with reporting IPV
Subscales psychosocial health
Unadjusted OR (95 % CI)
P-value
Adjusted OR (95 % CI)
P-value
Depression
0.83 (0.80–0.86)
<0.001
0.87 (0.84–0.91)
<0.001
Anxiety
0.82 (0.79–0.85)
<0.001
/
/
Self-esteem
0.86 (0.81–0.90)
<0.001
/
/
Mastery
0.84 (0.81–0.87)
<0.001
/
/
Worry
0.78 (0.73–0.83)
<0.001
/
/
Stress
0.73 (0.67–0.79)
<0.001
0.85 (0.77–095)
0.005
Total psychosocial health score
0.95 (0.94–0.96)
<0.001
/
/
Socio-demographics
Age
/
/
1.00 (0.97–1.04)
0.700
Civil/marital status (single vs. married/cohabiting)
/
/
3.53 (1.89–6.60)
<0.001
Education
No/primary vs. higher
/
/
5.62 (3.01–10.51)
<0.001
Secondary vs. higher
/
/
2.48 (1.78–3.45)
<0.001
/
/
5.75 (2.4–13.7)
<0.001
Language questionnaire (not Dutch vs. Dutch)
Recently, there has been a shift towards envisaging psychosocial health as a multidimensional concept [52]. We
acknowledge that psychosocial health is a complex construct with many known and, presumably, many unknown
determinants, although our study was not designed to explore this. Future research should be done to try to shed
some light on the multitude of factors involved in the
complex interaction between psychosocial health and IPV.
Our results need to be viewed within the context of
certain limits. There is currently a lack of agreement on
standard measures for psychological (partner) abuse/
violence and in an effort to tackle this problem, we
decided to construct our own scale and threshold for
psychological abuse cut-off value. The threshold we
chose for psychological abuse was based on a thorough
literature search and extensive discussions with experts
in the field. Nevertheless, it remains an arbitrary choice
that is open for discussion. We have some indication
that the cut-off might be on the low side, but this hypothesis obviously needs further investigation. Furthermore, our study design did not allow us to determine
causal pathways between the factors analysed. Moreover, we were not able to analyse in depth the multitude of factors involved in the complex interaction
between IPV and psychosocial health, and as a consequence, might have oversimplified reality. The findings
presented in this paper are based on a sample of the
Belgian obstetrical population and cannot be generalised
to other populations or health care systems without the
necessary caution.
Conclusion
Our research has demonstrated that IPV and psychosocial
health are strongly associated. Due to the cross-sectional
nature of our study design, we are not able to make any
statements on causality with regard to these associations.
However, it seems reasonable that a multitude of factors
could have influenced the interaction, and more longitudinal and in-depth, qualitative analysis needs to be done
to shed light on the complex interactions and confounding factors that define the relationship between IPV and
psychosocial health.
Furthermore, linked to the important role of psychosocial health found in our study, we believe that the recommendation to routinely screen for IPV during
pregnancy should be broadened and that IPV should not
been seen as an isolated theme. IPV research is providing increasing evidence that addressing the multitude of
risk factors related to IPV simultaneously has a larger
effect than addressing a single factor. Therefore, we
would like to join the growing number of authors advocating for the inclusion of IPV within a broader psychosocial health assessment as a standard part of antenatal
care. Addressing psychosocial health in antenatal care
has the potential to improve the health and well-being
of women and their families.
Additional file
Additional file 1: STROBE Statement—Checklist of items that
should be included in reports of cross-sectional studies. (PDF 18 kb)
Abbreviations
AAS: Abuse Assessment Screen; IPV: Intimate Partner Violence; IQR: Inter
Quartile Range; OB/GYN: Obstetrician/Gynaecologist; RCT: Randomized
Controlled Trial; SD: Standard Deviation; SES: Socio Economic Status;
SPSS: Statistical Package for the Social Sciences..
Competing interests
The authors declare that they have no competing interests.
143
Van Parys et al. BMC Pregnancy and Childbirth (2015) 15:278
Page 7 of 8
Authors’ contributions
ASVP conceived the study, acquired the data, performed the analysis and
drafted the manuscript. ED assisted ASVP with the statistical analysis. KM, AG,
MT and HV participated in the design of the study, were involved in drafting
the article, and gave critical input. All authors read and approved the final
manuscript.
Acknowledgements
We would like to thank all the women that participated in our study for the
bravery they showed filling out a questionnaire on this difficult topic. Our
thanks are due to Prof Olivier Degomme for methodological support, and to
Prof Fred Louckx, Prof. Kristien Michielsen, Dr. Ines Keygnaert, and Ms. Heleen
Vermandere for their support and useful comments.
Author details
1
Department of Obstetrics and Gynaecology, Faculty of Medicine and Health
Sciences, International Centre for Reproductive Health, Ghent University, De
Pintelaan 185, UZP 114, 9000 Ghent, Belgium. 2Department of Public Health,
Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University,
Ghent, Belgium. 3Department of Obstetrics and Gynaecology, Faculty of
Medicine and Health Sciences, Ghent University, Ghent, Belgium.
Received: 21 January 2015 Accepted: 19 October 2015
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146
Paper 4: A History of abuse and operative delivery – results from a European multi-­‐country cohort study The objective of this paper is to explore whether a history of abuse/violence was associated with operative delivery and if the association varied according to the type of abuse/violence reported as a child or an adult in six European countries (BIDENS-­‐study). Key message Our research showed that the correlation between a history of abuse/violence and mode of delivery was limited. Having experienced sexual violence as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-­‐obstetrical reasons. Among multiparous women, a history of physical violence increases the risk of an emergency CS. 147
A History of Abuse and Operative Delivery – Results from
a European Multi-Country Cohort Study
Berit Schei1,2, Mirjam Lukasse1,3*, Elsa Lena Ryding4, Jacquelyn Campbell5, Helle Karro6,
Hildur Kristjansdottir7,8, Made Laanpere6, Anne-Mette Schroll9, Ann Tabor9,10,
Marleen Temmerman11, An-Sofie Van Parys11, Anne-Marie Wangel12, Thora Steingrimsdottir7,13
1 Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway, 2 Department of Obstetrics and Gynaecology,
St.Olav’s University Hospital, Trondheim, Norway, 3 Department of Health, Nutrition and Management, Oslo and Akershus University College of Applied Sciences, Oslo,
Norway, 4 Department of Women’s and Children’s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet/University Hospital, Stockholm, Sweden, 5 John
Hopkins University, School of Nursing, Baltimore, Maryland, United States of America, 6 Department of Obstetrics and Gynaecology, University of Tartu, Tartu, Estonia,
7 Department of Obstetrics and Gynaecology, Landspitali University Hospital, Reykjavik, Iceland, 8 Directorate of Health, Reykjavik, Iceland, 9 Centre of Fetal Medicine,
Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 10 Faculty of Health Sciences, University of Copenhagen, Copenhagen,
Denmark, 11 Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium, 12 Malmö University, Faculty of Health and Society, Malmö, Sweden,
13 Primary Health Care of the Capital Area, Centre of Development, Reykjavik, Iceland
Abstract
Objective: The main aim of this study was to assess whether a history of abuse, reported during pregnancy, was associated
with an operative delivery. Secondly, we assessed if the association varied according to the type of abuse and if the
reported abuse had been experienced as a child or an adult.
Design: The Bidens study, a cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Norway, and
Sweden) recruited 6724 pregnant women attending routine antenatal care. History of abuse was assessed through
questionnaire and linked to obstetric information from hospital records. The main outcome measure was operative delivery
as a dichotomous variable, and categorized as an elective caesarean section (CS), or an operative vaginal birth, or an
emergency CS. Non-obstetrically indicated were CSs performed on request or for psychological reasons without another
medical reason. Binary and multinomial regression analysis were used to assess the associations.
Results: Among 3308 primiparous women, sexual abuse as an adult ($18 years) increased the risk of an elective CS,
Adjusted Odds Ratio 2.12 (1.28–3.49), and the likelihood for a non-obstetrically indicated CS, OR 3.74 (1.24–11.24). Women
expressing current suffering from the reported adult sexual abuse had the highest risk for an elective CS, AOR 4.07
(1.46–11.3). Neither physical abuse (in adulthood or childhood ,18 years), nor sexual abuse in childhood increased the risk
of any operative delivery among primiparous women. Among 3416 multiparous women, neither sexual, nor emotional
abuse was significantly associated with any kind of operative delivery, while physical abuse had an increased AOR for
emergency CS of 1.51 (1.05–2.19).
Conclusion: Sexual abuse as an adult increases the risk of an elective CS among women with no prior birth experience, in
particular for non-obstetrical reasons. Among multiparous women, a history of physical abuse increases the risk of an
emergency CS.
Citation: Schei B, Lukasse M, Ryding EL, Campbell J, Karro H, et al. (2014) A History of Abuse and Operative Delivery – Results from a European Multi-Country
Cohort Study. PLoS ONE 9(1): e87579. doi:10.1371/journal.pone.0087579
Editor: Shannon M. Hawkins, Baylor College of Medicine, United States of America
Received September 24, 2013; Accepted December 23, 2013; Published January 31, 2014
Copyright: ! 2014 Schei et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The Bidens study was supported by the Daphne II Program, European Commission for Freedom, Security, and Justice, Brussels, Belgium (Grant no. JLS/
2006/DAP-1/242/W30-CE-0120887/00-87). Mirjam Lukasse received a postdoctoral fellowship from the Norwegian Research Council, Grant no. 204292. The
funders had no role in study design, data collection and analysis, decision to publish, or presentation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: [email protected]
Violence against women (VAW) is a broad term covering a
large range of traumatic events and abuse occurring during a
woman’s life-span. VAW has been shown to increase the risk for
complications during pregnancy and may thereby increase
interventions during delivery [4–8]. VAW also increases the risk
of psychological distress and fear of childbirth, which in turn may
become the indication for CS on maternal request [9–11].
Furthermore, VAW may alter a woman’s stress response and
affect ability to communicate with obstetric staff during labor, thus
Introduction
Interventions during childbirth, such as operative delivery, aim
to ensure best possible health for the mother and child. There are
interventions that are obviously necessary and life-saving for both
mother and child [1]. However, sometimes the indication for
intervention is subject to debate and even considered non-medical,
such as caesarean section (CS) performed for fear of childbirth or
on maternal request only [2,3].
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A History of Abuse and Operative Delivery
Participants
increasing the risk of interventions [12]. Few studies exists which
examine the association between abuse and mode of delivery. The
studies that exist are limited in terms of the type of abuse addressed
and inconclusive in their findings [13–18]. Two studies show a
major increase in risk of CS for women who have been subjected
to rape in adulthood [15,18]. However, the women included were
referred to a mental health team for known psychological
problems and because of their desire to give birth by elective CS
[15,18]. The association between abuse and mode of delivery may
not be the same among women attending routine antenatal care.
The aim of this study was to test the a priori hypothesis that a
history of abuse is associated with an increased risk of operative
delivery, i.e. a caesarean section (elective or emergency) or an
operative vaginal delivery, among women attending routine
antenatal care. Secondly, we wanted to assess if potential
associations varied between types of abuse (emotional, physical
or sexual), and whether the abuse had occurred during childhood
or adulthood. Thirdly, where an association between a type of
abuse and CS was found, we explored the association with nonobstetric indication.
Recruitment took place between March 2008 and August 2010.
Women who consented subsequently completed a questionnaire
and allowed the extraction of specified data on their delivery from
their medical notes. Due to country specific organization as well as
requirements of local ethical committees, minor variations in the
recruitment procedure occurred.
In Belgium, women were approached by the midwife or secretary
when attending antenatal care. Consenting women were asked to
complete the questionnaire in a separate room. In Iceland women
were recruited when attending routine ultrasound and returned
completed forms by mail. In Denmark, women were given
information about the study when attending early routine
ultrasound screening and were mailed the questionnaire later.
They returned the questionnaire by mail or when attending their
next ultrasound examination. In Estonia, women were invited to
participate while visiting for an antenatal consultation. After
completing the questionnaire, it was left in a mailbox at the clinic.
In Norway women, after attending routine ultrasound, received the
questionnaire by mail and returned it by mail. Non-responders
were send one reminder. In Sweden, the questionnaire was
administered to women when attending routine glucose tolerance
test and filled out during the two hours gap between the blood
samplings. Belgium and Sweden were not permitted to record
non-participation. The estimated response rate varied between
50% in Norway to 90% in Estonia.
Methods
The Bidens study, a six-country (Belgium, Iceland, Denmark,
Estonia, Norway, and Sweden) cohort study of unselected
pregnant women, was the result of an EU-funded collaboration
between the Norwegian University of Science and Technology
(NTNU) and partners from Universities and Hospitals in six
European countries. A short description of the study sites is given
in Table 1.
Inclusion and exclusion criteria
All women required sufficient language skills to fill out the form.
In Estonia, women could choose to fill out an Estonian or Russian
Table 1. Presentation of recruitment sites in the Bidens study.
Country
Belgium
City
Characteristics
(inhabitants)
Recruitment Site
Number of
deliveries in 2008
Number of deliveries in
geographical area
Gent
Third largest city (240.000)
Gent University Hospital
1217
6674
Waregem
(36.000)
Onze Lieve Vrouw van
Lourdes/‘Our Lady from Lourdes’
721
721
Ieper
(35.000)
Jan Yperman Hospital
1091
1091
Iceland
Reykjavik
Capital (200.000)
Landspitali University Hospital
3373
4118
Denmark
Copenhagen Capital (1.811.239)
University Hospital
3730
211011
Estonia
Tallinn
West-Tallinn Central Hospital
3283
7421
East-Tallinn Central Hospital
4386
Norway
Sweden
Capital (400 000)
Tartu
Second largest city in
Estonia (100 000)
Tartu University Hospital
2325
1994
Kohtla-Järve
North-East Estonia (46 000)
80% Russian speaking
East-Viru Central Hospital
515
1490
Drammen
(60 000)
Buskerud Regional Hospital
1961
3003*
Oslo
Capital (560 000)
Rikshospitalet, OUS
2238
10252*
Tromsø
Most northern city (67 000)
University hospital in North -Norway
1509
1961*
Trondheim
(165 000)
St.Olavs University hospital
3483
3830*
Ålesund
(42 000)
Hospital in Ålesund
1291
2813*
Malmö
(295 000)
Antenatal Care Clinics (ANC):
University Hospital
MAS 4359
Selected ANC represent Approx. 60% of
all births of the catchments area
References for number of deliveries in the geographical area: Belgium: SPE (Studiecentrum Perinatale Epidemiologie) 2008. Iceland: The Icelandic Birth register for 2008.
Denmark: http://www.sst.dk/Indberetning%20og%20statistik/Sundhedsdata/Foedsler_fertilitetsbehandling_og_abort/foedsler1.aspx.
1
Born at hospital Estonia: http://www.tai.ee/et/tegevused/registrid/meditsiiniline-sunniregister-ja-raseduskatkestus-andmekogu/statistika; Estonian Medical Birth
Registry.
Sweden regional data: http://www.socialstyrelsen.se/register/halsodataregister/medicinskafodelseregistret Norway: Medical Birth Registry.
*Number of newborn $22 weeks gestation.
doi:10.1371/journal.pone.0087579.t001
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A History of Abuse and Operative Delivery
language questionnaire. In Belgium, Iceland and Denmark women
less than 18 years of age were excluded. In Denmark, only women
from the local geographical area were invited. In Belgium, women
who could not be separated from their accompanying person were
not recruited. In Iceland, Denmark and Norway, women with
major fetal pathology were excluded from the study.
Sample size for this study. Of the 7200, women who
consented and returned the questionnaire 6724 were included in
this study. Of the 476 excluded, 47 had failed to answer two or
more of the questions on abuse, 304 lacked information about
mode of delivery, 122 lacked parity, and the pregnancy of three
women ended before 22 weeks gestation.
dystocia, breech, maternal exhaustion, maternal request, psychosocial indications, other obstetrical indications, and unknown. A
CS was defined as non-obstetrically indicated when ‘‘maternal
request’’ or ‘‘psychosocial indication’’ were the reported reasons
without another medical indication. The indication for the
operative delivery was taken from the hospital record, as was
gestational age (based on ultrasound during pregnancy) at birth.
Ethical considerations
The study was conducted in accordance with the ethical
guidelines developed by WHO [24]. The information letter
instructed women to complete the form in a place where they
could be undisturbed and included telephone numbers and e-mail
addresses to contact if needed. Additionally, in Belgium, Estonia
and Sweden the participants had the opportunity to complete the
questionnaires at the clinic, and measures were installed to avoid
accompanying persons to be with them. Formal approvals of local
ethical committees and data protection agencies were obtained at
all sites, as listed below.
Belgium: The Ethical Committee of Ghent University acted as
the central ethical committee for the study; U(Z) Gent, 22012008/
B67020072813, date of approval: 1st February 2008, Waregem
hospital date added: 21st October 2008.
Iceland: The scientific board approved the study (24.06.2008VSN-b2008030024/03-15) according to Icelandic regulations,
date: 24th June 2008.
In Denmark, even though ethical approval for non-invasive
studies is not required, the study was presented to the Research
Ethics Committee of the Capital Region, who found no objections
to the study (H-A-2008-002), date: 11th February 2008. Permission
was obtained from the Danish Data Protection Agency (J.nr. 200741-1663).
In Estonia, ethical permission was given by the Ethics Review
Committee on Human Research of the University of Tartu,
Estonia; 190/M-29, 192/-22, 196/X-2, date: 17th December
2007, East-Tallinn Central Hospital added: 19th January 2009,
Russian language and prolonged period added: 22nd February
2010, East-Viru Central Hospital added: 26th April 2010.
In Norway, the Regional Committee for Medical Research
Ethics in North approved the study (72/2006), date: 29th August
2007; and the Data Inspectorate (NSD) (15214/3/) also approved
the study, date: 19th December 2007.
In Sweden, the study was approved by the Regional Ethical
Committee in Stockholm (2006/354-31/1), date: 14th June 2006.
The data was anonymised prior to analysis.
Questionnaire
The main instrument of the present study is a 68 items
questionnaire, partly based on the NorAQ (Norvold Abuse
Questionnaire, Figure 1), which was developed in a previous
multi-centre study among gynaecological patients in the Nordic
countries [19]. The different types of abuse and severity of abuse
were defined in NorAQ by a validated set of thirteen descriptive
questions [20]. Also included in the questionnaire were questions
on post-traumatic stress symptoms [21], fear of childbirth, using
the Wijma Delivery Expectancy Questionnaire (W-DEQ) [22],
and a short version of the Edinburgh Postpartum Depression Scale
(EPDS-5) [23]. Method and experience of previous deliveries, as
well as preference of mode of delivery, were assessed. A complete
version of the questionnaire was developed in English. Where a
previously translated version of the NorAQ, W-DEQ or EPDS
was available, this was used. Otherwise, the questionnaire was
translated into the required languages by a native speaker
(Flemish, Icelandic, Danish, Estonian, Russian, Norwegian and
Swedish) and then translated back again into the source language.
The original and back-translated versions were used to determine
the final version.
Follow-up
Birth outcome data was collected from hospital records and
recorded on the outcome sheet prepared for this study.
Variables
Main exposure: Emotional, physical and sexual abuse was
assessed in three identically structured sections [19]. For each type
and level of abuse, the answer categories were no, yes as a child,
yes as an adult, or yes both as a child and as an adult and classified
according to the most severe level reported (mild, moderate and,
severe). Women were asked if they experienced the indicated
abuse during the past 12 months, which was coded as recent. The
degree of current suffering was measured on a visual analogous
scale (0–10) and recoded into zero for values 0–4 and 1 for values
5–10. Women were defined as having experienced any abuse if
they answered yes to at least one of the questions of sexual,
emotional and physical abuse, except mild physical abuse, which
showed low specificity in the validation study [20].
Education was coded into four levels: primary school (9 years),
secondary school (13 years), higher education (university or
college), ,4 years and $4 years. Women were considered to
have a twin pregnancy if they had reported this in the
questionnaire.
The outcome, operative delivery was defined as a dichotomous
yes or no variable to test the main hypothesis for this study, and as
a categorical variable with the following categories: 0) spontaneous
vaginal 1) elective Caesarean Section (CS) 2) forceps or vacuum
extraction and 3) emergency CS. Indications options on the
outcome sheet for operative deliveries included: fetal distress,
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Statistical analyses
Power calculation was based on the main hypotheses that
exposure to any abuse increased the risk of any operative delivery,
OR 1.4 (a = 0.05, b = 0.20), assuming one exposed and four nonexposed within an unselected cohort of pregnant women [19,25].
In total, 2500 women needed to be recruited, allowing for
stratified analysis based on parity approximately 5000.
Cross-tabulation was used to quantify socio-demographic, lifestyle and obstetric characteristics factors by country of residence
and mode of delivery. Frequency analyses were used to quantify
the prevalence of the different types of abuse by category, age ,18
or $18, level of severity, current suffering and recentness. All
regression analyses were stratified for parity. The main hypothesis
was tested by binary logistic regression analysis. The association
between different abuse categories and the different kinds of
operative delivery were analysed by multinomial regression
analyses. Based on the literature and our experience, we included
all of the variables (which we had information on) correlated with
3
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A History of Abuse and Operative Delivery
Figure 1. The Norvold Abuse Questionnaire (NorAQ) questions on emotional, physical and sexual abuse.
doi:10.1371/journal.pone.0087579.g001
operative delivery (outcome) and, for each of them evaluated if
they were likely to be the result of the exposure (abuse). Of the
factors influencing operative delivery we considered the following
as correlated to but not the result of the exposure: age, twin
pregnancy, gestational age at birth, and country of residence.
These variables were included in the adjusted regression analyses.
Smoking status [25,26], alcohol consumption [26,27], use of
epidural analgesia [14,18], birth weight [26,27] could be the result
of the independent variable (abuse) and were not included in the
model. Factors such as depressive symptoms, post-traumatic stress
symptoms and fear of childbirth were also excluded from the
model as we considered them to fall on the pathway between
exposure (abuse) and operative delivery. As a previous CS could be
the result of abuse before the related pregnancy, we did not want
to enter it into all the analyses, but estimated its impact on the
significant association(s) found for multiparous women. We
estimated crude and adjusted odd ratios (AORs) and 95%
confidence intervals (CIs). All analyses were two-sided at
a = 0.05. The comparison group for all analyses was women
without a reported history of abuse. The statistical program used
was PASW 20.
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Results
Among the 6724 women in our study, 2323 (34.5%) reported
having experienced any abuse (of any type) at some point in their
lives, 1567 (23.3%) as a child, 1309 (19.5%) as an adult and 553
(8.2%) both as a child and an adult. The distribution of responses
between countries, for socio-demographic and obstetrical characteristics are presented in Table 2. The participants in Denmark
(both primiparous and multiparous women) were older than
women elsewhere, while the youngest primiparous women were in
Iceland and multiparous in Belgium. The caesarean section (CS)
rate was highest in Denmark and lowest in Sweden. Birth weight
below 2500 g was highest in Denmark and birth weight $4000 g
was most common in Iceland and least common in Belgium.
Socio-demographic and obstetric characteristics by mode of
delivery can be found in table 3.
A history of any abuse was not associated with any operative
delivery (as a dichotomous variable), neither among primiparous
or multiparous women delivery, AOR 1.16 (0.99–1.36) and AOR
1.04 (0.86–1.25) respectively (not in the tables). Among multiparous women, only a history of physical abuse was associated with a
significant increase in emergency CSs (Table 4), AOR 1.51 (1.05–
2.19). This association was attenuated when we added previous CS
as a covariate into the analysis, OR 1.48 (1.001–2.18). Of the 512
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n (%)
n (%)
301 (36.8)
338 (41.39
161 (19.7)
6 (0.7)
Secondary (10–13 years)
College/University ,4 year
College/University $4 years
Missing
25 (3.19
10 (1.29
Other
Missing
5
152
439 (53.6)
Primiparous
776 (94.7)
1 (0.1)
192 (23.4)
552 (67.4)
$37 weeks
Missing
Induced
Epidural Analgesia
229 (28.0)
71 (8.7)
98 (12.0)
60 (7.3)
Operative delivery
Elective CS
Operative vaginal
Emergency CS
733 (89.5)
59 (7.2)
2 80.2)
2500–4000 g
$4000 g
Missing
Apgar score
25 (3.1)
,2500 g
Birth weight
590 (72.0)
Spontaneous vaginal
Mode of delivery
42 (5.1)
,37 weeks
Gestational age at birth
380 (46.4)
Multiparous
Parity
784 (95.7)
Married/Cohabiting
Civil status
13 (1.6)
Primary (6–9 years)
Education
31.6 (4.5)
29.8 (4.2)
Multiparous mean (SD)
0
158 (27.0)
410 (70.1)
17 (2.9)
49 (8.4)
57 (9.7)
40 (6.8)
146 (25.0)
439 (75.0)
197 (33.7)
117 (20.0)
0
561 (95.6)
24 (4.1)
229 (39.1)
356 (60.9)
4 (0.7)
39 (6.7)
542 (92.6)
3 (0.5)
215 (36.8)
184 (31.5)
141 (24.1)
42 (7.2)
26.8 (4.4)
27.2 (4.0)
29.7 (5.0)
28.4 (4.3)
Primiparous mean (SD)
Iceland n = 585
Age mean (SD)
Belgium n = 819
8 (0.6)
196 (15.5)
1003 (79.1)
61 (4.8)
118 (9.3)
117 (9.2)
138 (10.9)
373 (29.4)
895 (70.6)
387 (30.5)
245 (19.3)
1 (0.1)
1194 (94.2)
73 (5.8)
733 (57.8)
535 (42.2)
13 (1.0)
49 (3.9)
1206 (95.6)
11 (0.9)
660 (52.1)
460 (36.3)
118 (9.3)
19 (1.5)
n (%)
33.4 (3.6)
30.7 (4.0)
31.9 (4.0)
Denmark n = 1268
2 (0.2)
162 (18.5)
680 (77.8)
30 (3.4)
82 (9.4)
50 (5.7)
63 (7.2)
195 (22.3)
679 (77.7)
112 (12.8)
112 (12.8)
2 (0.2)
826 (94.5)
46 (5.3)
406 (46.5)
469 (53.5)
1 (0.1)
45 (5.1)
828 (94.7)
7 (0.8)
270 (30.9)
242 (27.7)
286 (32.7)
69 (7.9)
n (%)
30.5 (4.7)
25.5 (4.2)
28.2 (5.1)
Estonia n = 874
Table 2. Socio-demographic and obstetric characteristics of women in the Bidens study N = 6724.
7 (0.3)
391 (17.5)
1756 (78.8)
80 (3.6)
178 (8.0)
189 (8.5)
171 (7.7)
538 (24.1)
1696 (75.9)
585 (26.2)
408 (18.3)
11 (0.5)
2102 (94.1)
121 (5.4)
958 (42.9)
1276 (57.1)
13 (0.6)
77 (3.4)
2144 (96.0)
12 (0.5)
913 (40.9)
688 (30.8)
568 (25.4)
53 (2.4)
n (%)
32.0 (4.4)
28.6 (4.9)
30.5 (5.0)
Norway n = 2234
3 (0.3)
183 (19.4)
728 (77.1)
30 (3.2)
81 (8.6)
69 (7.3)
59 (6.3)
209 (22.1)
735 (77.9)
181 (19.2)
83 (8.8)
1 (0.1)
888 (94.1)
55 (5.8)
543 (57.5)
401 (42.5)
3 (0.3)
37 (3.9)
904 (95.8)
13 (1.4)
401 (42.5)
221 (23.4)
278 (29.4)
31 (3.3)
n (%)
32.1 (4.4)
29.1 (4.4)
30.4 (4.6)
Sweden n = 944
22 (0.3)
1149 (17.1)
5310 (79.0)
243 (3.6)
568 (8.4)
580 (8.6)
542 (8.1)
1690 (25.1)
5034 (74.9)
2014 (30.0)
1157 (17.2)
16 (0.2)
6347 (94.4)
361 (5.4)
3308 (49.2)
3416 (50.8)
44 (0.7)
272 (4.0)
6408 (95.3)
52 (0.8)
2620 (39.0)
2133 (31.7)
1692 (25.2)
227 (3.4)
n (%)
31.7 (4.4)
28.4 (4.7)
30.1 (4.9
Total N = 6724
A History of Abuse and Operative Delivery
January 2014 | Volume 9 | Issue 1 | e87579
(15.0%) multiparous women who had a CS, 76 (14%) had a nonobstetrically indicated CS. No significant association between a
history of physical abuse and non-obstetrically indicated CS was
observed, crude OR 0.94 (0.52–1.70). The most common reason
for emergency CS among multiparous women with a history of
physical abuse was fetal distress, followed by other medical reasons
and dystocia. Table 5 presents different types of childhood and
adult abuse by operative delivery among primiparous women.
Women with no prior birth experience who reported a history of
adult sexual abuse were significantly more likely to be delivered by
elective CS, AOR 2.12 (1.28–3.49). This likelihood increased
when they in addition reported either physical or emotional abuse
experienced as an adult (Table 6). Primiparous women expressing
current suffering from the reported adult sexual abuse had the
highest risk for an elective CS, AOR 4.07 (1.46–11.3). Of all the
primiparous women, 18% (598) were delivered by CS. Of these,
42 (7.0%) had a non-medical indication. Adult sexual abuse
increased the odds of a CS without a medical indication, OR 3.74
(1.24–11.24). The most common indication for an elective CS
among primiparous women who reported adult sexual abuse was a
breech presentation, followed by other medical reasons and
maternal request.
20 (2.1)
53 (2.4)
156 (2.3)
17 (1.8)
16 (0.7)
62 (0.9)
910 (96.4)
2199 (98.4)
6588 (98.0)
17 (1.8)
19 (0.9)
74 (1.1)
n (%)
n (%)
n (%)
A History of Abuse and Operative Delivery
45 (3.5)
14 (1.6)
In our multi-country study of pregnant women attending
routine antenatal care, followed through to delivery, the main
hypothesis that a history of any abuse was associated with an
operative delivery was not confirmed. Rather, among multiparous
women, a reported history of physical abuse was the only type of
abuse associated with operative delivery, as it increased the odds
for emergency caesarean section. Among primiparous women,
only a history of adult sexual abuse was associated with operative
delivery, through an increase in elective CS. Primiparous women
with a history of adult sexual abuse were more likely to have a
non-obstetrical indication when delivered by CS. In addition was
current suffering from adult sexual abuse associated with an
increased risk for an emergency CS.
A great strength of our study is that it is based on pregnant
women attending routine antenatal care. The recruitment
procedure varied across sites, both for the invitation to participate,
where the questionnaire was completed and how it was returned.
This may have introduced information bias. The participation
rates varied between countries, but the background characteristics
did not indicate any significant selection bias when compared to
information from official health authorities. Guidelines for
antenatal care and interventions during delivery vary between
the participating countries. For example, neither in Belgium nor in
Estonia is maternal request alone an accepted indication for
medical interventions such as delivery by CS. The uniform results
across the participating countries strengthen our finding that
among primiparous women a history of sexual abuse as an adult
increases the risk for elective CS, regardless of maternal request
being an acceptable indication. At all the sites included in the
study, epidural analgesia during labour is available, however the
rates of use varied greatly between the countries. We do not know
how this may influence our results.
Victims of adult sexual abuse with posttraumatic stress
symptoms may avoid triggers like participation in our study and
have a particular high risk of interventions during delivery. On the
other hand, simply answering our questionnaire could be
considered an intervention in itself. Recalling abuse when
completing the questionnaire may trigger fear of childbirth and
symptoms of depression, which again may affect the mode of
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doi:10.1371/journal.pone.0087579.t002
19 (2.3)
Twins
5 (0.9)
5 (0.6)
11 (0.9)
8 (1.0)
Missing
5 (0.9)
860 (98.4)
9 (1.0)
4 (0.3)
1253 (98.8)
562 (96.1)
804 (98.2)
$7 after 5 min.
18 (3.1)
7 (0.9)
,7 after 5 min.
Table 2. Cont.
n (%)
n (%)
n (%)
n (%)
Discussion
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A History of Abuse and Operative Delivery
Table 3. Socio-demographic and obstetric characteristics of women in the Bidens study (N = 6724) by mode of delivery.
Elective CS n = 542
Spontaneous vaginal n = 5034 Operative vaginal n = 580
Emergency CS n = 568
Age: mean (SD)
31.9 (5.0)
30.0 (4.8)
29.5 (4.7)
30.1 (5.1)
Primiparous
30.1 (5.3)
28.1 (4.6)
29.1 (4.6)
29.1 (4.9)
Multiparous
32.9 (4.5)
31.6 (4.4)
31.2 (4.6)
32.5 (4.6)
n (%)
n (%)
n (%)
n (%)
Primary (6–9 years)
11 (2.1)
182 (3.6)
12 (2.1)
22 (3.9)
Secondary (10–13 years)
135 (25.3)
1275 (25.5)
140 (24.4)
142 (25.2)
College/University ,4 year
168 (31.5)
1574 (31.5)
188 (32.8)
203 (36.1)
College/University $4 years
219 (41.1)
1972 (39.4)
233 (40.7)
196 (34.8)
Married/Cohabiting
518 (96.3)
4800 (95.9)
552 (96.3)
538 (95.2)
Other
20 (3.7)
204 (4.1)
21 (3.7)
27 (4.8)
Multiparous
338 (62.4)
2789 (55.4)
115 (19.8)
174 (30.6)
Primiparous
204 (37.6)
2245 (44.6)
465 (80.5)
394 (69.4)
,37 weeks
57 (10.5)
196 (3.9)
22 (3.8)
86 (15.1)
$37 weeks
485 (89.5)
4838 (96.1)
558 (96.2)
482 (84.9)
Induced
13 (2.4)
813 (16.2)
143 (24.7)
188 (33.1)
Epidural Analgesia
67 (12.4)
1322 (26.3)
342 (59.0)
283 (49.8)
,2500 g
45 (8.3)
114 (2.3)
12 (2.1)
72 (12.7)
2500–4000 g
478 (88.4)
4746 (94.6)
552 (95.8)
459 (80.8)
$4000 g
18 (3.3)
157 (3.1)
12 (2.1)
37 (6.5)
,7 after 5 min
4 (0.7)
34 (0.7)
20 (3.5)
16 (2.8)
$7 after 5 min.
537 (99.3)
4948 (99.3)
556 (96.5)
547 (97.2)
Twins
43 (8.1)
74 (1.5)
17 (3.0)
22 (3.9)
Education
Civil status:
Parity:
Gestational age at birth
Birth weight:
Apgar score:
doi:10.1371/journal.pone.0087579.t003
findings of a large population based study from Norway, which
found no association between childhood abuse and CS before
labor and only a slight increase for CS during labour [14]. The
lack of association between childhood abuse and mode of delivery
in our study could be due to low power in our study due to few
cases. Alternatively, it may be the result of effective psychosocial
counselling. An increased recognition and optimal intervention for
depression and fear of delivery may prevent interventions. A
Norwegian study including women attending a specialised clinic
aimed at caring for women with fear of childbirth, reported that
sexual abuse in the form of rape after the age of 16 years was
associated with a major increase in risk for CS [15]. This is in
agreement with our results. However, theirs was a selected
population with whom mode of delivery was actively discussed as
part of the consultation and hence the association may have been
the consequence of an active choice during the consultation.
Sexual abuse is likely to affect pregnant women more than other
types of abuse since the female reproductive organs are involved
both in sexual acts and in giving birth [12,28]. For this reason, the
woman and/or the obstetrical staff may be anxious about a vaginal
delivery, perhaps more so than for a history of physical or
emotional abuse. An obstetrician who is aware of such a history
may be more inclined to grant a CS on maternal request without
delivery; hence, the observed associations may be seen as results of
the study as an intervention. However, if this were the case, we
would have likely seen increases in the estimated associations in all
types of abuse.
Another important strength of our study is that we used a
previously validated instrument to measure abuse. The validity of
the NorAQ compared to clinical interviews and other instruments
has been shown to be high [20]. Still women may have opted not
to report abuse. This may have biased the estimated association
towards zero. As this is a longitudinal study, a recall bias based on
outcome is unlikely. Our study did not include questions on the
onset, length of time and frequency of the abuse, nor who the
perpetrator was. The influence of these factors could therefore not
be studied. Our findings are based upon women from selected
European countries, and may not be generalized to other locations
with very different health care system.
Some of our findings are in conflict with other studies. A cohort
study from Trondheim found that childhood abuse, whether it was
physical or sexual, was associated with an increased risk of
interventions during childbirth, both CS and instrumental vaginal
delivery [13]. This study made no distinction between primiparous
and multiparous women [13]. However, the lack of associations
between childhood abuse and operative delivery agrees with the
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A History of Abuse and Operative Delivery
Table 4. The association between (Adjusted OR*) different types of abuse and operative delivery for multiparous women
(n = 3416) in the Bidens study.
Abuse
Elective CS
Elective CS
Operative vaginal
Operative vaginal
Emergency CS
Emergency CS
n (%)
%
OR (95% CI)
%
OR (95% CI)
%
OR (95% CI)
No abuse
2214 (64.8)
9.8
1
3.6
1
4.9
1
Any abuse
1202 (35.2)
10.1
1.05 (0.83–1.33)
3.0
0.83 (0.56–1.23)
5.4
1.11 (0.80–1.53)
Any abuse ,18
797 (23.3)
10.3
1.08 (0.82–1.41)
3.1
0.88 (0.55–1.39)
5.5
1.13 (0.78–1.64)
Any abuse $18
704 (20.6)
9.7
0.98 (0.73–1.31)
2.8
0.79 (0.48–1.31)
5.0
1.00 (0.67–1.49)
Emotional abuse
638 (18.7)
9.7
1.00 (0.74–1.35)
2.2
0.61 (0.34–1.09)
6.3
1.30 (0.89–1.91)
Emotional abuse ,18
385 (11.3)
10.6
1.12 (0.78–1.61)
2.3
0.66 (0.33–1.33)
6.2
1.31 (0.82–2.10)
Emotional abuse $18
369 (10.8)
8.7
0.86 (0.58–1.28)
2.4
0.67 (0.33–1.36)
5.7
1.15 (0.70–1.87)
Physical abuse
653 (19.1)
11.3
1.24 (0.93–1.65)
3.5
1.03 (0.64–1.66)
6.9
1.51 (1.05–2.19)
Physical abuse ,18
328 (9.6)
11.6
1.28 (0.88–1.86)
3.0
0.89 (0.46–1.75)
7.3
1.57 (0.97–2.52)
Physical abuse $18
383 (11.2)
10.7
1.13 (0.79–1.62)
3.4
0.99 (0.54–1.80)
6.0
1.30 (0.81–2.08)
Sexual abuse
561 (16.4)
10.5
1.09 (0.80–1.49)
2.7
0.74 (0.42–1.30)
4.8
0.97 (0.62–1.51)
Sexual abuse ,18
398 (11.6)
10.1
1.05 (0.73–1.50)
2.8
0.77 (0.40–1.46)
4.8
0.96 (0.58–1.60)
Sexual abuse $18
221 (6.5)
11.3
1.14 (0.73–1.78)
2.7
0.77 (0.33–1.80)
4.5
0.91 (0.46–1.79)
*Adjusted for age, twin pregnancy, gestational age less than 37 weeks, and country of residence.
Compared to women not reporting any abuse.
doi:10.1371/journal.pone.0087579.t004
any other medical indication, as our observed association indicate.
In a situation where there is uncertainty about mode of delivery,
knowledge of a woman’s history of abuse and/or her wish for CS
may influence the decision towards a CS with a medical
indication. In our study, we had no knowledge about whether
women revealed their history and/or preference for CS at any
stage before delivery. There is no consensus about the optimal
mode of delivery for women with a traumatic history of adult
sexual abuse, nor do we know how alternative approaches may
affect the mother-infant relationship and the long-term psychological effects of delivery/childbirth. However, our results suggest
that efforts should be made to reduce suffering from the
experienced abuse as current suffering increased the risk of not
only elective but also emergency CS.
Women with a previous delivery and a history of abuse did not
have an increased risk of operative delivery associated with the
abuse. A possible explanation could be that victims of adult sexual
abuse who either had an operative delivery and/or suffered a poor
Table 5. The association (Adjusted OR*) between different types of abuse and mode of delivery for primiparous women (n = 3308)
in the Bidens study.
Abuse
Elective CS
Elective CS
Operative
vaginal
Operative
vaginal
Emergency CS
Emergency CS
n (%)
%
OR (95% CI)
%
OR (95% CI)
%
OR (95% CI)
No abuse
2187 (66.1)
5.9
1
13.8
1
11.5
1
Any abuse
1121 (33.9)
6.7
1.22 (0.90–1.66)
14.5
1.11 (0.97–1.37)
12.7
1.16 (0.92–1.45)
Any abuse ,18
770 (23.3)
5.6
1.04 (0.72–1.51)
14.7
1.13 (0.89–1.44)
13.0
1.21 (0.94–1.56)
Any abuse $18
605 (18.3)
8.6
1.45 (1.02–2.06)
13.2
0.97 (0.74–1.27)
12.6
1.09 (0.82–1.45)
Emotional abuse
623 (18.8)
7.4
1.38 (0.96–1.98)
15.1
1.21 (0.93–1.57)
13.3
1.24 (0.94–1.64)
Emotional abuse ,18
422 (12.7)
6.6
1.28 (0.82–1.98)
14.2
1.15 (0.84–1.56)
14.2
1.37 (1.00–1.88)
Emotional abuse $18
316 (9.5)
8.5
1.50 (0.96–2.36)
13.9
1.07 (0.76–1.53)
13.3
1.17 (0.82–1.69)
Physical abuse
566 (17.1)
6.7
1.21 (0.82–1.78)
14.1
1.03 (0.78–1.36)
10.2
0.93 (0.68–1.27)
Physical abuse ,18
339 (10.2)
5.6
1.05 (0.63–1.76)
14.2
1.07 (0.76–1.50)
10.6
1.00 (0.69–1.47)
Physical abuse $18
297 (9.0)
8.8
1.45 (0.92–2.30)
13.8
0.97 (0.68–1.40)
9.4
0.81 (0.53–1.23)
Sexual abuse
495 (15.0)
7.7
1.42 (0.96–2.10)
14.1
1.07 (0.80–1.43)
12.7
1.19 (0.88–1.61)
Sexual abuse ,18
342 (10.3)
5.5
1.00 (0.60–1.67)
12.9
0.93 (0.66–1.32)
12.0
1.07 (0.75–1.54)
Sexual abuse $18
200 (6.0)
11.0
2.12 (1.28–3.49)
16.0
1.31 (0.87–1.98)
14.0
1.39 (0.90–2.16)
*Adjusted for age, twin pregnancy, gestational age less than 37 weeks, and country of residence.
Compared to women not reporting any abuse.
doi:10.1371/journal.pone.0087579.t005
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Table 6. The association between adult sexual abuse and mode of delivery for primiparous women (n = 3308) in the Bidens study.
Elective CS
Operative vaginal delivery
Emergency CS
Exposure
n
%
Adjusted OR (95% CI)
%
Adjusted OR (95% CI)
%
Adjusted OR (95% CI)
No abuse
2187
5.9
1
13.8
1
11.5
1
Any adult sexual abuse*
200
11.0
2.12 (1.28–3.49)
16.0
1.31 (0.87–1.98)
14.0
1.39 (0.90–2.16)
Adult sexual abuse*
mild
46
15.2
2.21 (0.93–5.26)
6.5
0.42 (0.13–1.38)
8.7
0.69 (0.24–1.99)
moderate
41
9.8
1.77 (0.57–5.52)
19.5
1.72 (0.75–3.92)
17.1
1.83 (0.76–4.40)
severe
113
9.7
2.15 (1.10–4.23)
18.6
1.66 (1.00–2.77)
15.0
1.60 (0.91–2.79)
adult physical*
70
12.9
2.88 (1.34–6.19)
17.1
1.52 (0.78–2.95)
14.3
1.61 (0.79–3.30)
adult emotional*
59
13.6
2.93 (1.30–6.60)
20.3
1.84 (0.93–3.63)
11.9
1.27 (0.55–2.93)
adult emotional and physical*
38
10.5
2.69 (0.88–8.21)
23.7
2.34 (1.04–5.26)
15.8
2.02 (0.79–5.16)
current suffering*
37
13.5
4.07 (1.46–11.3)
16.2
1.86 (0.72–4.74)
21.6
2.97 (1.26–6.98)
child sexual abuse*
47
6.4
1.09 (0.32–3.69)
12.8
0.93 (0.38–2.27)
12.8
1.08 (0.44–2.65)
recent experience{
12
16.7
3.52 (0.73–16.8)
0
0
8.3
0.82 (0.10–6.48)
Adult sexual abuse and:
*Adjusted age, twin pregnancy, gestational age less than 37 weeks, and country of residence.
{
Due to few cases adjusted only for age.
Compared to women not reporting any abuse.
doi:10.1371/journal.pone.0087579.t006
birth experience chose not to become pregnant again and hence
they were not among the multiparous women in our study. It is
also possible that the previous birth experience was a healing
experience as described by Simpkin and Klaus [29].
An obvious possible reason for an increase in emergency CS
among women reporting physical abuse would be placental
abruption after trauma. This indication was not among the
options in the outcome sheet in our study. The most common CS
indications for these women were fetal distress and other medical
indications, which could be related to direct physical trauma to the
abdomen. However, when we added previous CS into the analysis,
the association was clearly attenuated, indicating that this factor
played a major role. The CS in the previous pregnancy could have
been due to abuse prior to that. Our results indicated that a history
of abuse has limited impact on mode of delivery for women with a
previous birth experience. As in obstetrics in general, the method
of the first birth has a great influence on subsequent mode of
delivery [30].
more likely to have a non-obstetrically indicated CS. Identifying a
woman’s sexual abuse status during pregnancy may influence
decision-making regarding mode of delivery.
Acknowledgments
We are greatly indebted to all women participating in the study. Likewise
to all the staff actively participating and facilitating the study in all the
different study sites. We would like to thank Professor Svein Ove
Samuelsen for statistical advice.
Author Contributions
Conceived and designed the experiments: BS JC MT. Performed the
experiments: AMS H. Kristjansdottir AMW M. Lukasse M. Laanpere
ASVP H. Karro AT MT ELR BS TS. Analyzed the data: Mirjam L.
Contributed reagents/materials/analysis tools: AMS H. Kristjansdottir
AMW M. Lukasse M. Laanpere ASVP H. Karro AT MT ELR BS TS JC.
Wrote the paper: BS M. Lukasse ELR TS H. Karro. Commented on drafts
and approved the final manuscript: AMS H. Kristjansdottir AMW M.
Lukasse M. Laanpere ASVP H. Karro AT MT ELR BS TS JC. Developed
the questionnaire: BS M. Lukasse ELR JC H. Karro H. Kristjansdottir M.
Laanpere AMS AT MT ASVP AMW TS. Finalized the research protocol:
BS M. Lukasse ELR JC H. Karro H. Kristjansdottir M. Laanpere AMS
AT MT ASVP AMW TS. Collected data: AMS AMW M. Lukasse M.
Laanpere ASVP.
Conclusions
Among primiparous women sexual abuse experienced as an
adult was associated with increased elective caesarean sections.
Primiparous women with a history of adult sexual abuse were also
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158
Paper 5: Intimate partner violence and pregnancy: a systematic review of interventions The objective of this paper is to provide a systematic literature overview of the existing evidence on effectiveness of pregnancy-­‐associated IPV interventions. Key message We found few randomized controlled trials evaluating interventions for IPV around the time of pregnancy. Moreover, the nine studies identified did not produce strong evidence that certain interventions are effective. Nonetheless, home visitation programs and some multifaceted counselling interventions did produce promising results in addressing pregnancy-­‐associated IPV. 159
Intimate Partner Violence and Pregnancy: A Systematic
Review of Interventions
An-Sofie Van Parys*, Annelien Verhamme, Marleen Temmerman, Hans Verstraelen
Department of Obstetrics and Gynaecology/International Centre for Reproductive Health, Faculty of Medicine and Health Sciences Ghent University, Ghent, Belgium
Abstract
Background: Intimate partner violence (IPV) around the time of pregnancy is a widespread global health problem with
many negative consequences. Nevertheless, a lot remains unclear about which interventions are effective and might be
adopted in the perinatal care context.
Objective: The objective is to provide a clear overview of the existing evidence on effectiveness of interventions for IPV
around the time of pregnancy.
Methods: Following databases PubMed, Web of Science, CINAHL and the Cochrane Library were systematically searched
and expanded by hand search. The search was limited to English peer-reviewed randomized controlled trials published from
2000 to 2013. This review includes all types of interventions aiming to reduce IPV around the time of pregnancy as a primary
outcome, and as secondary outcomes to enhance physical and/or mental health, quality of life, safety behavior, help
seeking behavior, and/or social support.
Results: We found few randomized controlled trials evaluating interventions for IPV around the time of pregnancy.
Moreover, the nine studies identified did not produce strong evidence that certain interventions are effective. Nonetheless,
home visitation programs and some multifaceted counseling interventions did produce promising results. Five studies
reported a statistically significant decrease in physical, sexual and/or psychological partner violence (odds ratios from 0.47
to 0.92). Limited evidence was found for improved mental health, less postnatal depression, improved quality of life, fewer
subsequent miscarriages, and less low birth weight/prematurity. None of the studies reported any evidence of a negative or
harmful effect of the interventions.
Conclusions and implications: Strong evidence of effective interventions for IPV during the perinatal period is lacking, but
some interventions show promising results. Additional large-scale, high-quality research is essential to provide further
evidence about the effect of certain interventions and clarify which interventions should be adopted in the perinatal care
context.
Citation: Van Parys A-S, Verhamme A, Temmerman M, Verstraelen H (2014) Intimate Partner Violence and Pregnancy: A Systematic Review of Interventions. PLoS
ONE 9(1): e85084. doi:10.1371/journal.pone.0085084
Editor: Sten H. Vermund, Vanderbilt University, United States of America
Received July 16, 2013; Accepted November 22, 2013; Published January 17, 2014
Copyright: ! 2014 Van Parys et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: ASVP received a PhD bursary for her studies from the Research Foundation Flanders (www.fwo.be, grant number 69579). The funders had no role in
study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: [email protected]
Introduction
Pregnancy can be a time of particular vulnerability to IPV because
of changes in physical, emotional, social and economic demands
and needs. This vulnerable period, however, is not limited to the
time between conception and birth. Researchers have clearly
demonstrated that the risk factors for IPV associated with
pregnancy encompass the timeframe of one year before conception until one year after childbirth [3,9–12].
A wide range of prevalence rates, from 3 to 30% of IPV around
the time of pregnancy, has been reported. Prevalence rates in
African and Latin American countries are mainly situated at the
high end of the continuum and the European and Asian countries
at the lower end. Although estimates within regions and countries
are highly variable, the majority of studies show rates within the
range of 3.9% to 8.7% [2,13]. Most studies focus mainly on
physical and/or sexual partner violence, while psychological
violence remains difficult to delineate and measure. Although
Intimate partner violence (IPV) is increasingly recognized as a
global health problem with crucial societal and clinical implications. IPV affects women and men from all backgrounds,
regardless of age, ethnicity, socio-economic status, sexual orientation or religion [1–3]. IPV is defined as any behavior within a
current or former intimate relationship that causes physical, sexual
or psychological harm, including acts of physical aggression, sexual
coercion, psychological abuse and controlling behaviors [4]. It is
sometimes referred to as domestic/family violence, spouse/partner
abuse/assault, battering, violence against women or gender based
violence. [4–6].
Pregnancy and childbirth are major milestones in the lives of
many couples and their families. The transition to parenthood
brings joy as well as new challenges to couple relationships [7,8].
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Inclusion criteria
the exact prevalence of IPV around the time of pregnancy remains
unclear, it is evident that it affects a substantial group of women. In
fact, IPV during the perinatal period is more common than several
maternal health conditions (e.g. pre-eclampsia, placenta praevia),
nevertheless IPV receives considerably less attention within
perinatal care [2,3,14,15].
In recent decades, research from the western world and
increasingly from low and middle income countries [16] has
generated growing evidence that violence is associated with
detrimental effects on the physical and mental health of women,
men and children [17]. IPV is associated with adverse pregnancy
outcomes such as low birth weight, preterm delivery, infection,
miscarriage/abortion, placental abruption, fetal injury and perinatal death. Adverse mental health consequences and behavioral
risks including depression, anxiety disorders, post-traumatic stress
disorder, suicide (attempts), delayed entry into prenatal care, poor
maternal nutrition and use of tobacco, alcohol and illicit drugs are
consistently associated with IPV around the time of pregnancy
[4,14,17–29]. Most researchers and caregivers agree that perinatal
care is an ideal ‘window of opportunity’ to address IPV, for it is
often the only moment in the lives of many couples when there is
regular contact with health care providers [2,30]. There is a
growing consensus that routine enquiry is a safe effective practice
and an important first step in tackling IPV in general [24,31–35].
Nevertheless, a lot remains unclear about how to deal with IPV in
the perinatal care context and which interventions should be
adopted.
The objective of this paper is, therefore, to provide a clear
overview of the existing evidence on the effectiveness of
interventions for IPV for women (and their partners/children if
the intervention involves them) during the perinatal period. This
review surveys randomized controlled trials (RCTs) of all types of
interventions aiming to reduce IPV, and/or enhance physical
and/or mental health, Quality Of Life (QOL), safety behavior,
help seeking behavior, and social support.
Several criteria for inclusion in the systematic review were
applied.
First of all, the type of participants included in the studies for
this review were pregnant women of any age and/or women who
had given birth in the past year (plus their partners/children if the
intervention involved them).
Second, the studies had to aim at evaluating some type of
intervention for IPV. Peer-reviewed papers reporting on interventions only addressing non-partner violence, reproductive
coercion, child abuse/neglect, parenting, teen pregnancies,
substance abuse, and disclosure of IPV were therefore excluded.
Publications were also examined to ensure that they did not
display the same data set as that displayed in other articles.
Third, the primary outcome of the studies had to be any
measure of IPV. The secondary outcomes were physical and/or
psychosocial health (e.g. pregnancy and neonatal outcome,
depression, anxiety, QOL, substance use, stress), help seeking
behavior, safety behavior and social support.
Fourth, we included only published RCTs, regardless of the
nature, intensity or duration of the intervention, length of followup, or country or setting in which the participants were recruited.
Quality assessment
After full text evaluation, the risk of bias and the quality of the
selected studies was assessed by two reviewers (ASVP & AV)
separately, based on ‘‘The Cochrane Collaboration’s tool for
assessing risk of bias’’ [36]. Key domains of this risk of bias
assessment were sequence generation, allocation concealment,
blinding, incomplete outcome data, selective outcome reporting
and ‘other issues’. The reviewers independently assessed risk of
bias for each study and classified every study as low, high or
unclear risk of bias. Final classifications and inclusion in this review
were determined by consensus. For a detailed overview of the
quality assessment, see Table 1: Characteristic of the included
primary studies.
Methods
Data extraction
Search strategy
Using a specially designed data extraction form, the two
reviewers independently extracted information from the selected
papers. Data items compromised country, setting, sample size &
participants, sampling methods, measuring tools, description of the
intervention and control group(s), outcomes, and follow-up period.
Authors were contacted if additional information was required.
Initially, we planned a meta-analysis to quantify and compare
the interventions identified. Unfortunately it was not feasible to
perform a meta-analysis due to the limited amount of data and the
large variation in interventions, outcome measures and measurement time points.
The PRISMA guidelines were used as a framework for this
review [37].
This systematic literature review was based on an extensive
search in the electronic databases PubMed, Web of Science,
CINAHL, and the Cochrane Library. The search was limited to
peer-reviewed articles reporting results from RCTs published in
English from 2000 to 2013. The searches were systematically
updated during the writing process, the last update taking place in
March 2013. The following search strategy was used in PubMed:
‘‘((‘‘violence’’[MeSH Terms] OR ‘‘violence’’[All Fields]) AND
(‘‘pregnancy’’[MeSH Terms] OR ‘‘pregnancy’’[All Fields]) AND
(‘‘Intervention (Amstelveen)’’[Journal] OR ‘‘Interv Sch Clin’’[Journal] OR ‘‘intervention’’[All Fields])) AND (Randomized
Controlled Trial[ptyp] AND (‘‘2000/01/01’’[PDAT] : ‘‘2013/
12/31’’[PDAT]) AND ‘‘humans’’[MeSH Terms])’’. The search
strategy for Web of Science was: ‘‘Topic = (violence) AND
Topic = (pregnancy) Refined by: Topic = (intervention) AND
Document Types = (ARTICLE) Timespan = 2000–2013. Databases = SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH’’.
We started our search in PubMed and applied the same strategy
in Web of Science, CINAHL and the Cochrane Library.
Reference lists of retrieved articles were checked and relevant
articles were added by hand search. The database search was
executed by two reviewers (ASVP & AV) independently, findings
were discussed and differences resolved.
Figure 1 gives a detailed overview of the search strategy.
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Results
Through our electronic database search, we retrieved 412
potentially relevant articles based on keywords and limits set (60 in
PubMed, 343 in Web of Science, seven in CINAHL and two in
the Cochrane database). Fifteen additional articles were identified
through hand search. After title and abstract evaluation, 69
duplicates were removed, leaving 343 to be included in the next
step. Thereafter, out of 358 articles (343+15 articles retrieved
through hand search) screening resulted in 17 articles deemed
eligible for more detailed evaluation. After full text evaluation
another eight were excluded because they did not meet the
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Figure 1. Search strategy flowchart.
doi:10.1371/journal.pone.0085084.g001
inclusion criteria, leaving nine studies submitted to critical
appraisal and included in this systematic review [17,38–45].
Details on setting/participants, intervention/control activities and
outcomes are given in Table 1: Characteristic of the included
primary studies.
Out of these nine studies, six were conducted in the USA, one in
Peru, one in Australia, and one in China. All studies recruited
participants through hospital-based antenatal care, with sample
sizes ranging from 50 to 1054 women.
Three studies measured the impact of a home visitation
program involving paraprofessionals (non-professionals trained to
do the home visits and deliver the intervention), mentor mothers
(lay mothers trained to do the home visits, provide peer support
and mentoring), and/or nurses and followed participants for
between one up to nine years.
The six other studies evaluated the effect of some form of
supportive counseling, varying from one 30-minute session up to
six 60-minutes sessions or 24/7 access to a Nurse Case Manager
(NCM). Most (n = 6) of the interventions were specifically designed
to target IPV as the main objective, but some (n = 3) were part of a
larger, multifaceted intervention in which IPV was one of the
targets parallel to e.g. smoking, depression, child health, parenting.
All studies compared the intervention to usual or standard care,
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which, due to ethical considerations, generally implied that
patients were provided a referral card or a list of community
resources.
Throughout the rest of this paper the term IPV will be used to
refer to the combination of physical and sexual and psychological
partner violence, unless specified otherwise.
Home visitation programs
Primary outcome. After three years of program implementation Bair-Merritt et al. [41] found that, intervention women
reported a lower, albeit statistically marginally non-significant,
adjusted rate of IPV victimization [Incidence Rate Ratio (IRR)
0.86, 95% CI, 0.73–1.01] and a significantly lower rate of
perpetration (IRR 0.83, 95% CI, 0.72–0.96) than the control
group. Intervention women showed significantly lower rates of
physical assault victimization (IRR 0.85; 95% CI, 0.71–1.00) and
significantly lower perpetration (IRR 0.82, 95% CI, 0.70–0.96).
Although rates of overall IPV victimization and perpetration were
also lower after 9 years, these results were not statistically
significant. In other words, perpetration rates decreased significantly and victimization rates showed a trend towards decrease
after three years, but not after nine years.
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Setting & participants
(inclusion/exclusion criteria)
643 families Inclusion criteria:
English-speaking mother, infant at
high risk for child maltreatment born
between November 1994 and
December 1995, not involved in
child protective services.
1035 pregnant women attending
antenatal care from January to July
2007 in a national referral hospital.
Inclusion criteria: positive on AAS,
Spanish-speaking, between 18–45
years old.
1000 women attending antenatal
care recruited between 2001–2003
Inclusion criteria: English-speaking,
13–23 weeks pregnant.
50 women attending antenatal
care from June 2006 to December
2007 Inclusion criteria: Englishspeaking, 18 years or older, ,26
weeks pregnant, not first prenatal
visit.
Author, Year,
Country
Bair-Merritt
et al., 2010 USA
(Hawaii)
Cripe et al.,
2010 Peru
Curry et al.,
2006 USA
Humphreys et al,
2011 USA
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Unclear risk
All participants completed 2 research assessments, one
prior to 23 weeks (T1 measures included sociodemographics, AAS and PPP) and one between 32 weeks
and delivery (T2 measures included AAS and PPP.
Before a regularly scheduled prenatal appointment,
participants completed a baseline risk assessment
(socio-demographics, pregnancy history & status, tobacco,
alcohol, drug use & lifetime IPV)+post-visit interview.
Follow-up assessment 1 month after baseline+post-visit
interview. IP(or someone important to them) V was
measured through AAS (physical/sexual violence year
before and since pregnancy). Other outcome measures:
patient-provider discussion of IPV and perceived
helpfulness.
CG = 501 (101 women
were identified as high
risk in the CG) Offer to
see video ‘Faces of abuse’.
Women in the CG who
screened positive for
abuse, did not receive any
other intervention except
for a small resource card
(except 10 women with
high danger assessment
scores).
CG = 25 Baseline risk
assessment, no interaction
with video doctor, usual
clinic care.
IG = 110 Empowerment intervention: abuse
assessment, wallet-size referral card (listing
agencies providing services to abused women)
and social worker case management (this
encompasses a 30 minutes supportive
counselling session with education and advice
in the areas of safety by a trained social worker).
IG = 499 (only 130 women were identified as
high risk due to a positive score on the AAS
and/or PPP stress scale and received NCM)
Referral card, offer to see video ‘Faces of abuse’,
24/7 access to the NCM (individualised care
plan providing emotional support, basic needs
assessment, assessing safety issues, discussing
family concerns and providing education)
IG = 25 A 15-minutes interactive multimedia
intervention (video doctor) and counselling.
The intervention contained risk reduction
messages simulating an ideal discussion with a
prenatal health care provider following key
principles of motivational interviewing. Messages
were tailored to the participant’s risk profile and
intention to change. Two documents were
printed automatically, cueing sheet with
suggestions for counselling statements for
providers and educational worksheet for
participants. The intervention was designed to
reduce their risks related to IPV, smoking,
alcohol and illicit drugs.
Unclear risk
Unclear risk
Screening for IPV: modified AAS (physical/sexual past 12
months) Measures pre-intervention eligibility assessment
and interviews between 12 & 26 gestational weeks: IPV
(CTS2 past year), health-related QOL (SF-36), adaptation of
safety behaviours (safety behaviours checklist), use of
community resources (community resources assessment).
Post-intervention interviews measures: IPV (CTS2 past year),
health-related QOL (SF-36), adaptation of safety behaviours
(safety behaviours checklist), use of community resources
(community resources assessment).
CG = 110 Standard
care: abuse assessment
and wallet-size referral
card.
IG = 373 families The Healthy Start Program
(HSP). consisted of home visits by paraprofessionals providing direct services (promote
child health, decrease child maltreatment by
improving family functioning and reducing
malleable risk factors such as IPV) and linked
families to community resources.
Risk of bias
Outcomes & follow-up
Low risk
Interviews with the infant’s primary caregiver (mostly
mothers): baseline interview one week after birth, followup interviews at the child’s age of 1, 2, 3, 7, 8 & 9 years.
Measures included CTS1 at baseline, CTS2 at follow-up for
IPV (always past year perpetration and victimisation of physical,
psychological and sexual violence). Mental Health Index (anxiety
and depressive symptoms), drug and alcohol use.
Control
CG = 270 families The
control group participated in the HSP assessment, baseline and
follow-up interviews,
but did not partake in
the HSP program
(usual care).
Intervention
Table 1. Characteristic of the included primary studies.
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110 women attending antenatal
between May 2002 and July 2003.
Inclusion criteria: over 18 and less
than 30 weeks pregnant and
attending first antenatal
appointment.
Tiwari et al.,
2005 Hong Kong
735 women attending antenatal care
between March 1994 and June 1995
Inclusion criteria: no previous life
births, qualified for Medicaid or no
private insurance.
Olds et al,
2004 USA
174 women attending antenatal care
from January 2006 to December 2007
Inclusion criteria: 16 years or older,
pregnant or at least one child 5
years or younger, English- or
Vietnamese speaking, disclosed IPV
or were psychosocially distressed (no
disclosure IPV but symptoms indicative
for abuse), no serious mental illness.
1044 women attending antenatal
care from July 2001 to October 2003
Inclusion criteria: self-identified as
minority, at least 18 years old, 28
weeks pregnant or less, Washington
resident and English-speaking.
Kiely et al.,
2010 USA
Taft et al.,
2011 Australia
Setting & participants
(inclusion/exclusion criteria)
Author, Year,
Country
Table 1. Cont.
Control
CG = 255 Treatment 1
(control): free developmental screening and
referral for children at 6,
12, 15, 21 and 24 months
of age+usual care.
IC = 55 Empowerment intervention, a
30 minutes one-to-one session (at enrolment)
including advice in the areas of safety, choice
making, problem solving and empathic
understanding. A brochure reinforcing the
information was given after the session.
CG = 55 Standard care:
a wallet size resource
card after enrolment.
CG = 61 Women in the
IC = 113 The women in the IC received a
CG received a resource
resource card and up to 12 months support
card and usual care.
from non-professional mentor mothers
providing: non-judgmental support, assistance
in developing safety strategies, a trusting
relationship, information and assistance in referral
to community services.
IG2(paraprofessional) = 245 & IG3 (nurse) = 235)
The trial consists of 3 arms: control group
(treatment 1), treatment 2 (paraprofessional) and
treatment 3 (nurse). All arms were provided with
free developmental screening and referral for
children at 6, 12, 15, 21 and 24 months of age.
The home visiting program has 3 broad goals,
(1) to improve maternal and fetal health during
pregnancy; (2) to improve children’s health and
development; and (3) to enhance mothers’
personal development. The visitors helped women
accomplish these goals by promoting adaptive
behaviors, by helping them improve their
relationships with key family members and friends
(especially their mothers and boyfriends), and by
promoting women’s use of needed health and
human services.
Total CG = 523 of which
Total IG = 521 of which 169 reported IPV
167 reported IPV Usual
Integrated cognitive behavioural
prenatal care
intervention delivered immediately before or
after routine prenatal care (2 to 8 sessions of +/
235 minutes & up to 2 postpartum booster
sessions) targeting cigarette smoking,
environmental tobacco smoke exposure,
depression and IPV. The intervention for IPV
provided information about the types of
abuse the cycle of violence, a danger assessment,
and preventive options as well as the development
of a safety plan and a list of community resources.
Intervention
Outcomes & follow-up
Risk of bias
Screening: AAS (physical/sexual/emotional-psychological
male partner abuse last year) Enrolment: CTS, SF-36 &
demographics Telephone follow-up interview 6 weeks
postpartum: CTS, SF-36 & EPDS.
Baseline & 12 month follow-up questionnaires used the
following measures: CAS for IPV (emotional/physical/
sexual), EPDS for depression, SF-36 for general health &
well-being, PSI-SF for parenting stress, MOS-SF for social
support.
Low risk
Unclear risk
Unclear risk
Baseline interview (gestational age 28 & 36 weeks) and
follow-up in-home assessments at 6, 12, 15, 21, 24 and 48
months of child’s age 48 months (4 years) assessment (this
article): Mothers reported: psychologic resources (women’s
intelligence, mental health and sense of mastery), number
& outcomes subsequent pregnancies, socio-demographics,
physical IPV last 2 years/past 6 months (CTS), substance use,
behavior problems children. Observation mother-child
interactions: home environment assessment of early learning.
Children were assessed on behavioral adaptation and
emotional regulation.
Low risk
Screening for the 4 risk factors cigarette smoking,
environmental tobacco smoke exposure, depression and
IPV (AAS for physical/sexual IPV previous year) Baseline
interview (+/29 days after screening): socio-demographics,
reproductive history behavioural risks and CTS for frequency of
physical/sexual coercion (partner to self) Follow-up telephone
interviews 22–26 weeks, 34–38 weeks & 8–10 weeks
postpartum: physical/sexual IPV (CTS for baseline & follow-up
interviews). Data on pregnancy and neonatal outcomes were
extracted from the medical records.
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54 women attending antenatal
care Inclusion criteria: attending
prenatal care visit, between 18
and 40 years of age, no DSM-IV
Axis 1 disorder.
Zlotnick et al.,
2010 USA
IC = 28 The intervention consisted of four
60 minutes individual sessions over a 4
week period before delivery and 1 booster
session within 2 weeks of delivery. The content
of these sessions was based on the principles of
interpersonal psychotherapy emphasizing social
support. Following topics were a.o. covered
healthy/abusive relationships, disputes, resolving
interpersonal conflicts stress management skills,
safety plan, ‘‘baby blues,’’ and postpartum
depression, PTSD, substance use, transition to
motherhood, self-care and social support
networks.
Risk of bias
Outcomes & follow-up
Unclear risk
Screening: CTS2 (past year physical/psychological/sexual
IPV)and demographics Baseline assessment: current affective
disorders, PTSD and substance use (SCID-NP). Assessments
administered at intake, 5–6 weeks after intake, 2 weeks after
delivery, 3 months postpartum): CTS2 (past year or since the
last assessment physical/psychological/sexual), LIFE (assess
major depressive disorders and PTSD), EPDS (depression
level), Davidson trauma scale (PTSD), criterion A from the
PTSD module of the SCID-NP (history of trauma).
Control
CG = 26 Standard
(medical) care, the
educational material and a
listing of resources for IPV.
Intervention
Legend:
AAS = Abuse Assessment Screen.
CAGE = Cut down, Annoyed, Guilty, Eye-opener (alcoholism screening tool).
CAS = Composite Abuse Scale.
CG = Control Group.
CTS = Conflict Tactics Scale.
CTS2 = revised Conflict Tactics Scale.
EPDS = Edinburgh Postnatal Depression Scale.
IG = Intervention Group.
IRR = Incidence Rate Ratio.
LIFE = Longitudinal Interval Follow-up Examination.
MOS-SF = Medical Outcomes Scale - Short Form.
NCM = Nurse Case Management.
MCS = Mental Components Scores (SF36).
PCS = Physical Components Scores (SF36).
PPP = Prenatal Psychosocial Profile.
PSI-SF = Parenting Stress Index – Short Form.
SCID-NP = Structured Clinical Interview for the DSM-IV Axis Disorders – Nonpatient Version.
SF36 = Short Form Health Survey.
SVAWS = Severity of Violence Against Women Scale.
doi:10.1371/journal.pone.0085084.t001
Setting & participants
(inclusion/exclusion criteria)
Author, Year,
Country
Table 1. Cont.
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Figure 2. Overview results. PA = Paraprofessional. N = Nurse. IG = Intervention Group. CG = Control Group. MF = Multifaceted intervention.
P = Physical. S = Sexual. E = Emotional. M.O. statistical significance = statistical significant results of measured primary outcome.
doi:10.1371/journal.pone.0085084.g002
minor IPV were significantly less likely to experience further
episodes during pregnancy (first follow-up 22–26 gestational weeks
OR 0.48, 95% CI, 0.26–0.86; second follow-up 34–38 gestational
weeks OR 0.53, 95% CI, 0.28–0.99) and postpartum (OR 0.56,
95% CI, 0.34–0.93). Those with severe IPV showed significantly
reduced episodes only during postpartum (OR 0.39, 95% CI,
0.18–0.82). Women experiencing physical IPV showed a significant reduction in such violence at the first follow-up (OR 0.49,
95% CI, 0.27–0.91) and postpartum (OR 0.47, 95% CI, 0.27–
0.82). For sexual IPV the intervention did not significantly reduce
episodes of violence at any point in time.
Tiwari et al. [45] reported statistically significant less psychological [Mean Difference (MD) 21.1, 95% CI, 22.2 to 20.04)]
(but not sexual) abuse and significantly less minor (MD 21.0, 95%
CI, 21.8 to 20.17) (but not severe) physical violence in the
intervention group.
Cripe et al. [17] reported no statistically significant differences
in the occurrence of IPV between the intervention and control
groups after an empowerment counseling session.
Curry et al. [42] did not report any results on IPV, nor were the
authors able to provide the IPV data we requested.
Humphreys et al. [43] found no statistically significant
differences in prevalence of physical and/or sexual partner
violence between the two groups at baseline and did not report
partner violence after intervention.
The intervention by Zlotnick et al. [38] did not significantly
reduce the likelihood of IPV during pregnancy or up to three
months postpartum.
Secondary outcomes. Women in the IG of Kiely et al. [40]
had significantly fewer very preterm neonates (1.5% vs. 6.6%,
Olds et al. [44] found on the one hand, no adjusted statistically
significant effects of paraprofessional visits on the experience
of physical partner violence in the intervention group (IG) versus
the control group (CG) (14.2% vs. 13.6%, P = 0.88, OR 1.05, 95%
CI not reported) in the six months prior to four year follow-up. On
the other hand, nurse-visited women did report (6.9% vs.
13.6%, P = 0.05, OR 0.47, 95% CI not reported) a significant
decrease in physical partner violence.
Taft et al. [39] reported evidence of a true difference in mean
abuse scores at 12 months follow-up (15.9 vs. 21.8, AdjDiff 28.67,
95% CI, 216.2–21.15, P = 0.03).
Secondary outcomes. In the study of Olds et al. [44],
women visited by paraprofessionals reported a statistically
significant greater sense of mastery (101.25 vs. 99.31, P = 0.03) and
better mental health (101.21 vs. 99.16, P = 0.03) than control
subjects, had fewer subsequent miscarriages (6.6% vs. 12.3%,
P = 0.04, OR 0.5, 95% CI not reported), and fewer low birth
weight newborns (2.8% vs. 7.7%, P = 0.03, OR 0.34, 95% CI not
reported). There were no statistically significant effects of nurse
visits on these variables
Taft et al. [39] reported a trend favoring the intervention
regarding depression (19/85 vs 14/43; AdjOR 0.42, 95% CI
0.17–1.06), physical wellbeing mean scores (AdjDiff 2.79, 95% CI,
0.40–5.99), and mental wellbeing mean scores (AdjDiff 2.26; 95%
CI, 1.48–6) but no observed effect on parenting stress.
Supportive counseling
Primary outcome. The women in the intervention group of
Kiely et al. [40] experienced statistically significant fewer recurrent
episodes of IPV during pregnancy and postpartum than women
receiving usual care (adjOR 0.48, 95% CI, 0.29–0.80). Those with
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P = 0.03) and an increased mean gestational age (38.263.3 vs.
36.965.9, P = 0.016).
Tiwari et al. [45] reported significantly higher physical
functioning in health related QOL (MD 10, 95% CI, 2.5–1.8)
and a significant reduction of role limitation due to physical
problems (MD 19, 95% CI, 1.5–37) and emotional problems (MD
28, 95% CI, 9.0–5.0). There was, however, also more bodily pain
in this group (MD 21.3, 95% CI, 223–22.2). Significantly fewer
women in the IG reported postnatal depression at follow-up (RR
0.36, 95% CI, 0.15–0.88).
Curry et al. [42] found no statistically significant decrease of
total stress scores between the two groups, although total stress
scores of both intervention and control women significantly
decreased (P,0.001) between follow-up periods.
The intervention by Zlotnick et al. [38] did not significantly
reduce the likelihood of a major depressive episode or post
traumatic stress disorder (PTSD). They found a trend towards
decrease during pregnancy but not during postpartum.
Cripe et al. [17] found a trend towards improved QOL, safety
and help seeking behaviors (church and police) in the IG, but no
statistically significant differences between the two groups.
The following figure 2 gives illustrates the correlations between
the type of intervention and the impact on the reduction of IPV.
Concerning secondary outcomes, Kiely et al. [40] observed
significantly fewer very preterm neonates and an increased mean
gestational age in the intervention group. Tiwari et al. [45]
reported significantly fewer women with postnatal depression and
improved QOL in the intervention group.
None of the studies reported any evidence of a negative or
harmful effect of interventions, although only one study [43]
mentioned assessing potential harms caused by intervention.
The results should be interpreted with caution and within the
light of serious methodological challenges. Researching violence is
inherently associated with numerous ethical and safety issues,
making it very difficult to produce strong evidence. We identified
considerable variation in categorizing certain behavior as IPV,
research settings, study populations, sample sizes, content of the
intervention, and length of follow-up. Intrinsic to the difficulties
associated with the study subject sample sizes are small, there is a
considerable loss to follow-up, and it is impossible to blind
respondents. Moreover, few studies adjusted their analysis for
confounding factors (e.g. childhood abuse), which can create an
oversimplified image of reality. However, it should be remembered
that lack of statistically significant results does not necessarily imply
clinical irrelevance. Some interventions might be effective but not
have reached significance level due to methodological and/or
ethical challenges.
It is striking that five out of the nine studies reported decreases
in IPV after a certain point in time but that these decreases did not
significantly differ between intervention and control groups.
Apparently, with time (certain) wounds heal. However, other
explanations can also be hypothesized.
First, as far as we know, in all the studies reviewed, identifying
IPV was not part of routine perinatal care but an additional
research-related activity (also known as the Hawthorne-effect)
[31,34]. Asking IPV-related questions to women in the control
group, mostly in combination with handing out a referral card
could have had a larger impact than assumed. McFarlane et al.
[30] found that ‘‘simple assessment of abuse and offering referrals
has the potential to interrupt and prevent recurrence of IPV’’. In
other words it is possible that the ‘intervention’ in the control
group is more effective than anticipated and therefore no clear
difference between the two groups is detected.
Second, it seems reasonable to question the legitimacy of using
IPV as a main outcome measure. Given the complexity of
intervening factors between identification and IPV reduction (with
many not under the control of health care providers), interventions
should not necessarily be expected to decrease IPV [35]. Internal
changes (mental health, QOL, …) are potentially more informative for evaluating the impact of an intervention for IPV.
Significant changes in active or passive experiences of violence
may not be observable for some time [5,47,48,50]. At the time of
measurement, respondents might simply not acknowledge the
violence, or be ready to make changes or accept help. Some
counseling interventions (developing safety plans, seeking help, …)
might come too early and/or are not adapted to specific needs and
therefore prove ineffective [51,52]. In this review, we identified
only one study [43] that included some measure of ‘readiness to
change’ which might have contributed to the lack of significant
results.
Furthermore, our systematic review yielded only one study [41]
reporting both maternal victimization and perpetration behavior,
in which there is the striking observation that the rate of
perpetration acts in women was twice as high as the victimization
acts in both intervention and control groups (at baseline). The
intervention seemed to reduce mainly maternal perpetration
behavior, but paternal victimization nor perpetration behavior was
Discussion
The results of our systematic review demonstrate that there are
few RCTs evaluating interventions for IPV during the perinatal
period. Moreover, the overall quality of the nine studies identified
is limited and did not produce strong evidence that certain
interventions are effective. This finding is also endorsed by
Jahanfar et al. [46]. The evidence of IPV interventions outside the
context of pregnancy remains similarly insufficient and inconclusive [24,31,47–49].
Nevertheless, five out of nine studies in our review reported a
statistically significant decrease in some form of IPV (odds ratios
from 0.47 to 0.92). The most promising results identified by this
review are to be found in the home visitation programs and
multifaceted counseling-interventions. The three studies
[39,41,44] on home visitation programs all showed a
statistically significant decrease in IPV victimization (and one in
perpetration). However, although Olds et al. [44] noted a
significant decrease in physical IPV for the nurse-visited women,
this was not found for the paraprofessional-visited women. The
authors attributed this finding to an increased emphasis among the
nurses on partner violence, but it remains unclear if this was really
the case. With regard to the secondary outcomes, Olds [44]
reported significantly better mental health, fewer subsequent
miscarriages and low birth weight newborns in the paraprofessional-visited but not in the nurse-visited women. The different
impact of nurses and paraprofessionals raises questions about the
mechanisms through which the interventions affected the
outcomes.
It is interesting to note that out of six studies evaluating different
types of supportive counseling, only two reported a statistically
significant effect of the intervention on IPV. First, the high-quality
study by Kiely et al. [40] found that their cognitive behavioral
intervention significantly reduced recurrent episodes of IPV
(except for sexual IPV). Second, Tiwari et al. [45] reported
significantly less psychological and minor physical (except for
sexual IPV) violence in the intervention group. Sexual partner
violence seems to be a form of violence that is difficult to influence.
The other four studies [17,38,42,43] did not find a significant
difference in IPV between the intervention and control groups.
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not directly measured. This finding adds to the debate on gender
symmetry in the perpetration of violence and the discussion about
over-disclosure by women and under-disclosure by men. Yet,
pregnant women’s use of violence is virtually ignored by most
authors [3]. Moreover, Hellmuth et al. [53] found that IPV
perpetration during pregnancy and/or postpartum is associated
with negative health outcomes. Therefore, measuring only
subjection to violence as a measure of effectiveness of an
intervention seems quite insufficient. More attention should be
given to outcome measures reflecting the complex process of
changing destructive interaction dynamics.
We are aware that this systematic review has several limitations.
The choice of databases, inclusion criteria, risk of bias assessment,
and interpretation of results all required the individual judgment
of the authors. We took various steps to minimize bias at all stages
of the review process, but a different review team may not fully
agree with our assessment.
research should focus on several levels simultaneously (individual,
relations, community, and society). Intervening in a single risk
factor may be unsuccessful because other risk factors may persist as
barriers to the desired change. Readiness to change, help seeking
strategies and the complex mutuality of IPV should be taken into
account. Serious thought should be given to appropriate outcome
measures and to including process indicators in evaluating
effectiveness.
Supporting Information
Checklist S1 PRISMA checklist.
(PDF)
Acknowledgments
We would like to thank prof. dr. Olivier Degomme for the methodological
support, dr Simukai Shamu, Ines Keygnaert, dr. Kristien Michielsen and
prof. dr. Kristien Roelens for their useful comments and prof. dr. Michael
B. Drennan for the graphic support.
Conclusion
This systematic review indicates that strong evidence of effective
interventions for IPV during the perinatal period is lacking.
Nonetheless, home visitation programs and some multifaceted
counseling interventions produced promising results. It is obvious
that additional large-scale, high-quality research (with metaanalysis) is essential to tackle the remaining questions and provide
further evidence about the effect of certain interventions. Future
Author Contributions
Conceived and designed the experiments: ASVP AV. Performed the
experiments: ASVP AV. Analyzed the data: ASVP AV. Contributed
reagents/materials/analysis tools: ASVP AV HV. Wrote the paper: ASVP
AV MT HV.
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170
Paper 6: Impact of a referral card based intervention on intimate partner violence, psychosocial health, help-­‐seeking and safety behaviour during pregnancy and postpartum, a randomised controlled trial The objective of this paper is to investigate the effect of identifying IPV and handing out a referral card, on the evolution of IPV, psychosocial health, help-­‐
seeking and safety behaviour during and after pregnancy in Flanders, Belgium (MOM-­‐study). Key message Over the study-­‐period, the prevalence of IPV victimisation decreased by 31.4% (P< 0.001), psychosocial health increased significantly (5.4/140, P< 0.001), 23.8% (n=46/193) of the women sought formal help, 70.5% (n=136/193) sought informal help, and 31.3% (n=60/192) took at least one safety measure. No statistically significant differences between the IG and CG were observed, however. Adjusted for psychosocial health at baseline, the perceived helpfulness of the referral card appeared to be larger in the IG. Both the questionnaire and the interview were perceived to be significantly more helpful than the referral card as such (P< 0.001). Asking questions can be helpful even for types of IPV of low severity, although simply distributing a referral card may not qualify as the ideal intervention. 171
BMC Pregnancy and Childbirth
The impact of a Referral Card-Based Intervention on Intimate Partner Violence,
Psychosocial Health, Help-Seeking and Safety Behaviour during Pregnancy and
Postpartum: A Randomized Controlled Trial
--Manuscript Draft--
Manuscript Number:
PRCH-D-16-00424
Full Title:
The impact of a Referral Card-Based Intervention on Intimate Partner Violence,
Psychosocial Health, Help-Seeking and Safety Behaviour during Pregnancy and
Postpartum: A Randomized Controlled Trial
Article Type:
Research article
Section/Category:
Maternity care and sociological aspects of pregnancy and childbirth
Funding Information:
Fonds Wetenschappelijk Onderzoek
(69579)
Abstract:
Objective
We aimed to investigate the impact of a referral-based intervention in a prospective
cohort of women disclosing intimate partner violence (IPV) on the prevalence of
violence, and associated outcomes psychosocial health, help-seeking and safety
behaviour during and after pregnancy.
Ms. An-Sofie Van Parys
Methods
From June 2010 to October 2012, women seeking antenatal care in eleven Belgian
hospitals were consecutively invited to participate in a single-blind randomized
controlled trial (RCT) and handed a questionnaire. Participants willing to be interviewed
and reporting IPV victimisation were randomised. Participants in the Intervention Group
(IG) received a referral card with contact details of services providing assistance and
tips to increase safety behaviour. Participants in the Control Group (CG) received a
"thank you" card. Follow-up data were obtained through telephone interview at an
average of 10 months after receipt of the card.
Results
At follow-up (n= 189), 66.7% (n=126) of the participants reported IPV victimisation.
Over the study-period, the prevalence of IPV victimisation decreased by 31.4% (P<
0.001), psychosocial health increased significantly (5.4/140, P< 0.001), 23.8%
(n=46/193) of the women sought formal help, 70.5% (n=136/193) sought informal help,
and 31.3% (n=60/192) took at least one safety measure. No statistically significant
differences between the IG and CG were observed, however. Adjusted for
psychosocial health at baseline, the perceived helpfulness of the referral card
appeared to be larger in the IG. Both the questionnaire and the interview were
perceived to be significantly more helpful than the referral card itself (P< 0.001).
Conclusion
Asking questions can be helpful even for types of IPV of low severity, although simply
distributing a referral card may not qualify as the ideal intervention. Future interventions
should be multifaceted, delineate different types of violence, controlling for
measurement reactivity and designing a tailored intervention programme adapted to
the specific needs of couples experiencing IPV.
The trial was registered with the U.S. National Institutes of Health ClinicalTrials.gov
registry on July 6, 2010 under identifier NCT01158690).
Keywords: intimate partner violence, pregnancy, intervention, psychosocial health,
help-seeking behaviour, safety behaviour.
Corresponding Author:
An-Sofie Van Parys
Ghent University, Belgium
BELGIUM
Corresponding Author Secondary
Information:
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172
Corresponding Author's Institution:
Ghent University, Belgium
Corresponding Author's Secondary
Institution:
First Author:
An-Sofie Van Parys
First Author Secondary Information:
Order of Authors:
An-Sofie Van Parys
Ellen Deschepper
Kristien Roelens
Marleen Temmerman
Hans Verstraelen
Order of Authors Secondary Information:
Opposed Reviewers:
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173
Manuscript
Click here to download Manuscript Van Parys 2016 - Impact of
referral card-based intervention on IPV 160601 BMC.docx
Click here to view linked References
Title page
“The impact of a Referral Card-Based Intervention on Intimate Partner
Violence, Psychosocial Health, Help-Seeking and Safety Behaviour during
Pregnancy and Postpartum: A Randomized Controlled Trial”
An-Sofie Van Parys , Ellen Deschepper, Kristien Roelens, Marleen Temmerman, Hans Verstraelen
An-Sofie Van Parys (corresponding author)
Ghent University, Faculty of Medicine and Health Sciences, Department of Obstetrics and
Gynaecology, International Centre for Reproductive Health.
Correspondence at: [email protected]
De Pintelaan 185, UZP 114, 9000 Gent, Belgium
Ellen Deschepper
Ghent University, Faculty of Medicine and Health Sciences, Department of Public Health, Biostatistics
Unit.
Correspondence at: [email protected]
De Pintelaan 185, 3K3, 9000 Gent, Belgium
Kristien Roelens
Ghent University, Faculty of Medicine and Health Sciences, Department of Obstetrics and
Gynaecology, International Centre for Reproductive Health.
Correspondence at: [email protected]
De Pintelaan 185, P4, 9000 Gent, Belgium
174
Impact of an Intervention on Pregnancy-Associated Intimate Partner Violence
Marleen Temmerman
Ghent University, Faculty of Medicine and Health Sciences, Department of Obstetrics and
Gynaecology, International Centre for Reproductive Health.
Correspondence at: [email protected]
De Pintelaan 185, P4, 9000 Gent, Belgium
Hans Verstraelen
Ghent University, Faculty of Medicine and Health Sciences, Department of Obstetrics and
Gynaecology.
Correspondence at: [email protected]
De Pintelaan 185, P4, 9000 Gent, Belgium
2
Submission PLOSone 1/06/2016
175
Impact of an Intervention on Pregnancy-Associated Intimate Partner Violence
Abstract
Objective
We aimed to investigate the impact of a referral-based intervention in a prospective cohort of women
disclosing intimate partner violence (IPV) on the prevalence of violence, and associated outcomes
psychosocial health, help-seeking and safety behaviour during and after pregnancy.
Methods
From June 2010 to October 2012, women seeking antenatal care in eleven Belgian hospitals were
consecutively invited to participate in a single-blind randomized controlled trial (RCT) and handed a
questionnaire. Participants willing to be interviewed and reporting IPV victimisation were randomised.
Participants in the Intervention Group (IG) received a referral card with contact details of services
providing assistance and tips to increase safety behaviour. Participants in the Control Group (CG)
received a “thank you” card. Follow-up data were obtained through telephone interview at an average
of 10 months after receipt of the card.
Results
At follow-up (n= 189), 66.7% (n=126) of the participants reported IPV victimisation. Over the studyperiod, the prevalence of IPV victimisation decreased by 31.4% (P< 0.001), psychosocial health
increased significantly (5.4/140, P< 0.001), 23.8% (n=46/193) of the women sought formal help, 70.5%
(n=136/193) sought informal help, and 31.3% (n=60/192) took at least one safety measure. No
statistically significant differences between the IG and CG were observed, however. Adjusted for
psychosocial health at baseline, the perceived helpfulness of the referral card appeared to be larger in
the IG. Both the questionnaire and the interview were perceived to be significantly more helpful than
the referral card itself (P< 0.001).
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Conclusion
Asking questions can be helpful even for types of IPV of low severity, although simply distributing a
referral card may not qualify as the ideal intervention. Future interventions should be multifaceted,
delineate different types of violence, controlling for measurement reactivity and designing a tailored
intervention programme adapted to the specific needs of couples experiencing IPV.
The trial was registered with the U.S. National Institutes of Health ClinicalTrials.gov registry on July 6,
2010 under identifier NCT01158690).
Keywords: intimate partner violence, pregnancy, intervention, psychosocial health, help-seeking
behaviour, safety behaviour.
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Background
Intimate partner violence (IPV) has been increasingly recognised as a global health problem with
serious clinical and societal repercussions that affect women and men from all backgrounds, regardless
of age, ethnicity, socio-economic status, sexual orientation or religion (1-4)). IPV is defined as any
behaviour in a present or former intimate relationship that leads to physical, sexual or psychological
harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling
behaviour patterns (5). Drawing upon the IPV definition provided by Saltzman (6), we have chosen to
use consistently the term ‘violence’ for physical and sexual types of violence, and ‘abuse’ for
psychological types since the word ‘abuse’ clearly implies a broader range of behaviours compared to
‘violence’, which is often associated with the most severe forms of violent behaviour. To avoid
confusion in this paper, we will consistently use the term ‘IPVv’ (Intimate Partner Violence
victimisation), ‘IPVp’ (Intimate Partner Violence perpetration) and IPV (both victimisation and
perpetration) to refer to the specific behaviour measured in our sample. We are aware that these
terms unavoidably hold normative connotations. Yet, to the best of our knowledge, accurate and more
objective terms are currently unavailable.
The transition to parenthood brings joy as well as new challenges to couple relationships (7;8).
Pregnancy may be an exceptionally stressful time because of the multitude of changes in physical,
emotional, social and economic requirements, and in roles and needs. Research has demonstrated
that individual and dyadic coping strategies tend to decrease under stress, leading to an increased risk
of physical and psychological aggression (9-11). This vulnerable period, however, is not limited to the
time between conception and birth. Researchers have clearly pointed out that risk factors for IPV
associated with pregnancy, encompass the time frame of one year before conception until one year
after childbirth (4;10;12-14).
In terms of prevalence rate, a wide range of pregnancy associated IPVv prevalence rates, varying from
3 to 30%, have been reported. Victimisation prevalence rates in African and Latin American countries
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are mainly situated at the high end of the continuum and the European and Asian rates at the lower
end. Although estimates are highly variable due to methodological challenges, the majority of studies
show rates within the range of 3.9% to 8.7%, with most studies merely including physical and/or sexual
partner violence victimisation as psychological violence remains difficult to delineate and measure
(4;8;10;12-21). In Belgium, we recently reported (21) that 15.8% (95% CI 14.2 – 17.7) of the women
experienced IPVv (incl. psychological abuse) before and/or during pregnancy.
In recent decades, research across the western world and increasingly in low- and middle-income
countries has generated growing evidence that experiencing violence (as victim as well as perpetrator)
in the perinatal period is associated with risk behaviour and detrimental effects on the physical and
mental health of women, men and children (22-30). A cohort study of Australian women aged 18–44
years suggested that IPVv was responsible for 7.9% of the overall burden of disease, which was more
prominent than other risk factors such as high blood pressure, tobacco, and obesity (31;32). IPVv is
therefore considered an important contributor to the global burden of disease for women of
reproductive age. In fact, IPVv during the perinatal period is more common than several maternal
health conditions (e.g. pre-eclampsia, placenta praevia) with comparable negative consequences, and
yet still IPV remain under-discussed within perinatal care (3;4;33;34). Most researchers and caregivers
agree that perinatal care is an ideal ‘window of opportunity’ to address IPVv, for it is often the only
moment in the lives of many couples when there is regular contact with health care providers (3;35).
There is a growing consensus that routine enquiry is a safe effective practice and an important first
step in tackling IPVv (36-41). Nevertheless, much remains unclear concerning how to deal with IPV in
the perinatal care context and which interventions should be adopted. Despite greater recognition of
IPV as a major public health problem, much less effort has been made to develop interventions aimed
at reducing IPV or its consequences (37;42). A number of systematic reviews (38;43-45) have
concluded that there is insufficient evidence supporting specific interventions for abused women,
especially those provided in health care settings. In line with these studies, our recent research results
similarly suggested that specifically during the perinatal period, strong evidence of effective
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interventions for IPV is lacking (46). The limited available evidence indicates that providing
psychological and social support, advocacy, and appropriate referrals to social and legal resources can
potentially help women reduce their risk of violence and its consequences, and improve birth
outcomes (47-49). McFarlane and colleagues (50) found that in a non-pregnant US population,
disclosure of abuse was associated with the same reduction in violence and increase in safety
behaviours as an intensive nurse case management intervention. According to these authors, simple
assessment of abuse and provision of referrals have the potential to interrupt and prevent recurrence
of IPVv and associated trauma. Inspired by this finding, we decided to investigate the effects of
identifying IPV and distributing a referral card on the evolution of IPV, psychosocial health, helpseeking and safety behaviour within a pregnant Belgian population.
Methods
Setting and study population
We conducted a multi-centre single-blind Randomized Controlled Trial (RCT) in Flanders, the Northern
part of Belgium. The trial consisted of two phases: 1) a prevalence study involving the recruitment of
participants for the intervention; and 2) the intervention study. Data on the prevalence and evolution
of IPVv and its correlation with psychosocial health before and during pregnancy have been previously
reported (51;52).
The Belgian perinatal health-care system is based on the medical model (53) and is generally
considered highly accessible, with women freely choosing their own health care provider(s).
Obstetricians-gynaecologists function as primary perinatal healthcare providers and the majority of
the care is hospital-based. Screening or systematic inquiry for IPV is not part of routine perinatal care.
We recruited in 11 antenatal care clinics in order to obtain a balanced sample of the general obstetric
population. The convenience sample of hospitals was geographically spread across Flanders, and
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included a mix of rural and urban settings, as well as small and large hospitals that provide services to
socio-economically and ethnically diverse populations.
From June 2010 to October 2012, women seeking antenatal care were consecutively invited to
participate in the study if they were pregnant, at least 18 years old and able to fill in a Dutch, French
or English questionnaire. We did not impose limits on gestational age. The midwife or receptionist
introduced the study as a study on difficult moments and feelings during pregnancy and briefly
explained the procedure. Women that orally consented to participate were handed an informed
consent form and a questionnaire, which were both filled in in a separate room (if available) without
the presence of any accompanying person. If the woman was unable to fill in the informed consent
form and questionnaire in private, she was then excluded from the study for safety reasons. On the
first page of the questionnaire women received an invitation to participate in the intervention phase
of the study. Those willing to participate wrote their contact details down and were informed that
eligible respondents would be interviewed twice by telephone and received a gift voucher as
compensation. The selection of eligible participants for randomization was based on IPVv disclosure
and willingness to participate in the intervention study. As a consequence, the IPVv prevalence rate at
follow-up should have been 100%. However, 5 women were just below the victimisation threshold
handled (see below) but slipped through the net of randomization, however thus were excluded from
the final analysis.
The study was approved by the ‘Ethics Committee of Ghent University’ which acted as the central
review board (Belgian registration number 67020108164) and by the local ethical committees of all 11
participating hospitals (Ethisch Comité Middelheim Ziekenhuis Netwerk Antwerpen, Ethisch Comité
Universitair Ziekenhuis Antwerpen, Ethisch Comité Onze Lieve Vrouw Ziekenhuis Aalst, Ethisch Comité
Gasthuis Zusters Ziekenhuis St Augustinus Antwerpen, Ethisch Comité Algemeen Ziekenhuis Sint Jan
Brugge, Ethisch Comité Algemeen Ziekenhuis Jan Palfijn Gent, Ethisch Comité Onze Lieve Vrouw van
Lourdes Ziekenhuis Waregem, Ethisch Comité Universitair Ziekenhuis Gent, Ethisch Comité Algemeen
Ziekenhuis Groeninge Kortrijk, Ethisch Comité Virga Jesse Ziekenhuis Hasselt, Ethisch Comité
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Ziekenhuis Oost-Limburg Genk). The trial was registered with the U.S. National Institutes of Health
ClinicalTrials.gov
registry
on
July
6,
2010
under
identifier
NCT01158690)
(https://clinicaltrials.gov/ct2/show/NCT01158690?term=van+parys&rank=1)
Allocation concealment / randomization
As soon as the baseline assessment was filled in, the contact details and the related data of eligible
respondents were systematically entered into an Access database. Case numbers were randomly
assigned to the IG (intervention group) and CG (control group) by a computer generated list. The
identification key was created and safely stored by a researcher not directly involved in the study.
At the postpartum consultation (+/- 6 weeks after delivery), the participants were handed a numbered
opaque envelope. The lay-out and format of the envelopes of both groups were identical, so neither
the health care providers nor the researchers could see or feel the difference. Since the envelope
contained a referral card for the IG and a “thank you” card for the CG, it was not possible to blind the
participants as a consequence of the design of this RCT. Nevertheless, we made a number of deliberate
efforts to minimise the possibility of contamination between the two groups. First, the
midwives/receptionists involved in the recruitment were not involved in the design of the study and
had no knowledge of the hypotheses. Information about the study given to the clinical staff and
receptionists was kept to a strict minimum. Second, women were allowed a separate available room
where they filled in the questionnaire and waiting time at the clinic was minimised so that the
intervention and control group women had little time or opportunity to meet each other. Moreover,
the receptionists/midwives/doctors delivered the anonymous intervention or control envelopes to the
women individually at postpartum check-up. Finally, the women’s allocation was not recorded
anywhere, except in the secured identification key.
In total 2,587pregnant women were invited to participate and 2,338 were excluded of which 693 were
ineligible for the first phase of the study, while 1620 did not meet the inclusion criteria for the second
phase and 25 were lost before randomization. A total of 249 women were randomized, 129 allocated
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to the IG and 120 to the CG. At this stage, an additional 25 women were lost, and 10.9% in the IG and
in the CG this was 9.2% did not receive the envelope due to the lack of a postpartum consultation or
the oblivion of the midwife/receptionist. At the first follow-up interview (10-12 months after receipt
of the envelope), 12.2% was lost to follow up in the IG and 10.1% was lost in the CG, resulting in a final
sample size of 101 in the IG and 98 in the CG. More details are presented in Figure 1.
Figure 1: CONSORT flow diagram recruitment
[insert figure 1]
Sample size
Since IPVv was the only main outcome measure with hard data available, the sample size was powered
to test a reduction in the prevalence of IPVv. Calculations were based on the most recent prevalence
estimate of IPVv in a Belgian pregnant population, which reported 3.4% physical and/or sexual partner
violence in the year before and/or during pregnancy (20). Since we measured IPVv several times (54)
and also included psychological abuse, we expected to detect a prevalence that exceeded the most
recent prevalence rate with 5%, equalling an total estimate of 8.4%.
Based on other RCTs with a similar study design, we considered an IPVv decrease of 30% relative to
the 100% baseline prevalence in the IG clinically relevant, and we also hypothesised a 10%
spontaneous or unexplained decrease of IPVv in the CG (35;55;56). Assuming 30% loss to follow-up of
and an alpha significance level of 0.05, at least 89 participants had to be included in each group (total
N=178) in order to detect a difference of 0.2 with 80% power. This means that a total sample of 2,119
women was needed to retain the required number of women in both groups.
Intervention
In brief, our study-intervention consisted of three parts: a questionnaire, a referral/thank-you card,
and two interviews. Eligible women were handed an envelope by the midwife or receptionist at their
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6-week postpartum consultation. The envelope of the IG contained: an information letter, a bank cardsized referral card containing the contact details of services providing assistance for IPV on one side
and tips to increase safety behaviour on the other side, and a gift voucher. The resources and safety
tips were selected in close collaboration with other researchers and expert care workers active in the
field of IPV. The envelope of the CG contained: an information letter, a bank card-sized thank-you card,
and a gift voucher.
The participants were interviewed 10 to 12 months and 16 to 18 months after receipt of the envelope.
The optimum period for the outcome measurement for this type of intervention has not been
established. While some interventions may produce immediate positive effects, other effects may not
be evident for some time. Therefore, we decided to time the first outcome measurement in a short
term (within 12 months) and the second measurement in a medium term (from 12 to 24 months), as
defined by Ramsey et al (57). Due to the large amount of data, this paper will be limited to reporting
results of the first follow-up assessment at 10 to 12 months. Figure 2 provides an overview of the study
process.
Figure 2: Time line study process
[insert figure 2]
The information about IPV and resources for IPV provided to the health care professionals and
receptionists in the participating hospitals was kept to a strict minimum, since the study aimed to
measure the effect of the intervention in an unbiased manner with least intention to encourage help
from the professionals in this stage. Furthermore, to our knowledge, only one in 11 participating
hospitals displayed a sensitization poster and some folders concerning IPV. This led us to the
assumption that the impact of parallel interventions on our respondents was minimal.
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Measures
The primary outcome measure of this intervention study was IPVv, and the secondary were
psychosocial health, (in)formal help-seeking behaviour and safety behaviour. The full versions of all
measures used are available in the supporting information. For the analysis of this paper, we used data
from the baseline assessment and from the (first) follow-up assessment.
Baseline assessment
The baseline assessment essentially involved the assessment of physical, psychological, sexual IPVv
and psychosocial health. In particular, physical and sexual violence was measured using an adapted
version of the Abuse Assessment Screen (58). To measure psychological abuse, an adapted version of
the WHO-questionnaire was used (18). Contrary to the situation for physical and sexual violence,
currently there is a lack of consensus on standard measures and thresholds for psychological (partner)
abuse/violence (1). In an effort to tackle this problem we constructed a scale consisting of 7 questions
with the answer options ranging from 0 to 4; total score obtained ranged between 0 and 28. Based on
the limited available literature (1;18;49;59-64) and after considerable debate and extensive
consultations with several experts in the field, we did not consider a one-time minor psychological act
as IPV and decided to use a cut-off value of 4/28 as a threshold for psychological abuse. Hence, a score
of 3 or lower was not considered psychological abuse to the purpose of this study.
Psychosocial health was measured through the Abbreviated Psychosocial Scale (65), which is well
validated and is recently identified as the best currently available instrument for measuring multiple
psychopathological symptoms (66). The 28-item abbreviated psychosocial health scale consists of 6
subscales: negative affect (depression), positive affect (anxiety), positive self-esteem, low mastery,
worry (anxiety) and stress. If data for one item was missing, the total score is considered as a missing
value. A minimum score of 28 indicates ‘poor’ psychosocial health and a maximum score of 140
signifies ‘good’ psychosocial health. Unfortunately, no clear clinical cut-off values are currently
available and therefore we used the scale as a continuous variable where possible. We have previously
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reported more details on the assessment of the violence (21) and on psychosocial health measures
(51).
Follow-up assessment
The variables that were measured in the follow-up assessment are: socio-demographics (age and
mother tongue), IPV (victimisation & perpetration), psychosocial health, help-seeking behaviour,
readiness to change, safety behaviour, and helpfulness of intervention (questionnaire/referral
card/interview). IPV was measured through the short form of the revised Conflict Tactics Scale (CTS2S)
(67). Although the CTS was intended as a self-report instrument, it can also be administered as a
telephone interview (68). The revised short form of the scale consists of 10 questions formulated in
the form of paired questions (what the participant did= perpetration and what the partner did=
victimisation). The questions address the issues concerning negotiation, physical assault, psychological
aggression, injury from assault and sexual coercion. The response categories reflect the number of
times that a certain aggressive behaviour took place over the last 6 months. If data for one item was
missing, the total score was considered a missing value. There are several ways of analysing the CTS2S.
We chose to use the score as a dichotomous variable for most analyses and used the severity levels
(minor/severe) to test if the referral card would be more effective in women experiencing severe IPVv.
Based on the authors’ scoring instructions, respondents who indicated a certain behaviour (except for
negotiation) taking place at least once are considered to have experienced IPV (as a victim and/or as a
perpetrator). This implies that a one-time minor act of psychological aggression, e.g. ‘your (ex)partner
insulted you, or swore, shouted or screamed at you’, will yield a positive score. Although the CTS2S
also measures perpetration behaviour of the women included in the study, the main analysis for this
paper is based on victimisation. In comparison with the threshold for IPVv at baseline, we did not
include a one-time minor act of psychological aggression in the follow-up measurement and set the
threshold at 3 - 5 incidents (in the last 6 months). The combination of both violence measures, the AAS
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as a quick identification scale and the CTS as a more in-depth measure, is a widely used practise in
many intervention studies (52;69).
Psychosocial health was assessed using the same scale, namely the Abbreviated Psychosocial Scale as
in the baseline survey, yet with adaptations made for a telephone interview.
Measurement of formal and informal help-seeking behaviour was based on an adapted version of
‘Community agencies use questionnaire’ developed by McFarlane et al. (50) and Fanslow et al. (70).
Both variables were dichotomized, with contacting at least one agency or person being classified as a
positive score for help-seeking behaviour. Additionally, we explored causes or reasons for seeking or
not seeking help. The answers to these open questions were grouped in large categories and quantified
to gain an overview of the most frequently cited reason to seek formal help.
Readiness to change is introduced as a mediating variable for help-seeking behaviour, since it is known
that seeking help is influenced by the phase in which people are located (70-72). The answer that
indicates not considering making any changes to the situation in the next 6 months was coded as the
precontemplation phase. In contrast, considering making changes in that space of time was coded as
the contemplation phase, while thinking about making changes in the next 30 days was coded as the
preparation phase.
Safety behaviour was based on an adapted version of the ‘Safety promoting behaviour checklist’ (35).
A positive answer to at least one safety behaviour question, obtained a positive dichotomised score.
The degree of helpfulness of intervention (questionnaire/referral care/interview) was dichotomised
into ‘somewhat or very helpful’ and ‘not helpful or made things worse’.
The interview was available in Dutch, French and English and was based on a translation and backtranslation of the original instruments.
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Statistical analysis/data-analysis
The data obtained through the first interview were first recorded on paper in a structured form by the
interviewer and then entered into an SPSS (Statistical Package Social Sciences) database by another
researcher who also performed quality control and data cleaning.
A descriptive analysis was performed for both study-arms regarding socio-demographic data, IPV,
psychosocial health, formal and informal help-seeking behaviour, readiness to change, safety
behaviour and perceived helpfulness of the intervention. Baseline socio-demographic characteristics
and psychosocial health were compared between both study-arms using an independent two samples
T-test for the continuous variables and a Fisher’s exact test for the categorical variables.
The evolution of IPV from baseline to follow-up interview 1 was investigated using a McNemar test.
The difference in IPV prevalence at follow-up between IG & CG was assessed based on a binary logistic
regression model, thus adjusting for significantly different baseline characteristics between both
study-arms. The evolution of psychosocial health from baseline to follow-up interview 1 was measured
through a paired T-test, for the group as a whole and for both study-arms. A general linear model
(unianova) was employed to explore the difference between the IG & CG for psychosocial health at
follow-up, adjusting for psychosocial health at baseline. We also used Fisher’s exact tests and
corresponding 95% Wilson’s score statistic CI for difference of two independent proportions, and
multiple logistic regression adjusting for psychosocial health at baseline to assess the differences
between the IG and CG for formal and informal help-seeking behaviour, safety behaviour and
perceived helpfulness of the intervention.
The main data analysis was based on a complete case analysis, followed by a sensitivity analysis which
examines the robustness of the results regarding to missing data, especially since it is known that
women lost in IPV-studies are more likely to be abused (73;74). Different scenarios were studied with
IPV as the main outcome variable. For instance, the ‘best scenario’ refers to the situation in which all
the women lost in the study happened not to report IPVv, the ‘worst scenario’ was related to the
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possibility that all the women lost in the study did report IPVv and we also explored the ‘Last
Observation Carried Forward’ (LOCF).
In the sensitivity analysis, missing baseline IPV data were replaced by a positive IPVv score, since IPVv
was an inclusion criteria for the intervention study.
All statistical analyses were performed using the IBM SPSS statistics software (version 23).
Availability of data and materials
Due to the sensitive nature of the study and to avoid the potential identification of victims of IPV, data
will not be shared and are only available on request. Requests can be submitted to the corresponding
author or to [email protected] .
Results
Socio-demographic data
Table 1 provides an overview of the baseline and follow-up socio-demographic characteristics of the
respondents at an average of 10 months (Standard Deviation (SD) 1 month) after receipt of the
envelopes.
Table 1: Socio-demographic characteristics of the sample (n=223)*
Characteristics baseline assessment
Age in years (SD)
IG (n=115)
CG (n=108)
P value
27.87
27.67(5.39)
0.771
(4.98))
Gestational age in weeks
IG (n=112)
CG (n=103)
23.63 (8.35)
24.57 (8.28)
0.405
(SD)
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Civil/marital status
n=114
n=106
% (n)
% (n)
Married/cohabiting
87.7 (100)
89.6 (95)
Single/Divorced
12.3 (14)
10.4 (11)
n=114
n=107
% (n)
% (n)
None/ primary education
12.3 (14)
13.1 (14)
Secondary education
44.7 (51)
42.1 (45)
43 (49)
44.9 (48)
n=114
n=109
% (n)
% (n)
Dutch
93 (106)
92.7 (101)
French
1.8 (2)
1.8 (2)
English
5.3 (6)
5.5 (6)
Characteristics 10-12 months assessment
IG (n=101)
CG (n=96)
Age in years (SD)
29.7 (4.78)
29.15 (5.21)
0. 436
n=101
n=96
0.181
% (n)
% (n)
Dutch
80.2 (81)
87.5 (84)
Not-Dutch
19.8 (20)
12.5 (12)
Education
Higher education
Language questionnaire
Mother tongue
0.677
0.929
1.000
*baseline data for one woman was lost
After unblinding the raw data, we compared the key baseline characteristics of the IG and CG, to check
if the randomization was successful. No significant differences were found between the socio17
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demographic characteristics of both groups (cf. table 1). However, psychosocial health differed
significantly at baseline (P= 0.044), with the mean psychosocial health in the CG being 98.85/140 (SD
14.92) and in the IG 103.36/140 (SD 15.89). Accordingly, the multivariate analyses for main outcome
variables were adjusted for baseline psychosocial health.
IPV
At follow-up (n= 189), 66.7% (n=126) of the participants reported IPVv and 63% (n=119) reported IPVp.
Accordingly, the prevalence of IPVv in the entire cohort decreased to a significant extent [31.4% (95%
CI 24.5; 38.7), P< 0.001] at the postpartum assessment, though this trend did not differ between both
study arms [IG: 32.6% (95%CI 22.5; 43.1) and CG: 30.1% (95% CI 20.8%; 40.4), P=0.644]. Adjustment
for psychosocial health did not alter the results [OR 1.13 (95% CI 0.58; 2.2), P=0.727].
Table 2 presents an overview of the IC/CG comparison for the main outcome variables
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Outcome
(dichotomous)
IPV baseline
IPV follow-up
IG % (n)
98.2%
CG % (n)
99.1%
(112/114) (108/109)
Unadjusted OR
value
P-
0.48 (0.04 ; 5.53)
vs CG
Adjusted* OR IG
85
99
IG (n)
80
92
CG (n)
0.727
0.559
P-value
Impact of an Intervention on Intimate Partner Violence
IG vs CG (95%
0.594
1.13 (0.58 ; 2.20)
P-value
0.51 (0.05;5.80)
0.537
0.466
Difference (95%
1.000
0.83 (0.45;1.52)
81
81
0.326
CI) IG-CG
-0.8% (-5.4;3.4)
0.644
87
87
0.431
CI)
-4.2% (-17.5;9.2)
0.76 (0.37 ; 1.58)
0.71 (0.36 ; 1.40)
80
68.8%
0.143
0.112
87
64.6%
0.61 (0.31 ;
0.60 (0.32;1.13)
0.76 (0.38 ; 1.51)
(64/93)
0.177
3.1)
0.118
0.040
(62/96)
-9.0% (-21.1;
(27/95)
-10.5 (-23.1; 2.4)
0.52 (0.28;0.97)
28.4%
(19/98)
75.8%
0.044
19.4%
65.3%
(72/95)
-13.8% (-26.6; -
Formal help
Informal help-
(64/98)
38.3%
0.7)
behaviour
1.18)
seeking
24.5%
(36/94)
seeking
Safety
(24/98)
behaviour
behaviour
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192
Outcome
interview
Helpfulness
referral card
Helpfulness
questionnaire
Helpfulness
Mean
(35/97)
36.1%
(28/97)
28.9%
(35/97)
36.1%
Mean
(30/88)
34.1%
(16/91)
17.6%
(35/90)
38.9%
(95% CI) IG-CG
Difference score
15.6)
2.0% (-11.8 ;
23.2)
11.3% (-0.9 ;
11.0)
-2.8% (-16.6;
6.07)
0.55 (-5.00;
8.91)
4.52 (0.12 ;
score CG
105.26
98.85
score IG
105.81
103.36
(continuous)
Psychosocial
health baseline
(score on 140)
Psychosocial
health follow up
Table 2 : Overview results main outcome variables
*Adjusted for psychosocial health at baseline
0.763
1.90 (0.95;3.82)
0.89 (0.50;1.60)
0.777
0.070
0.692
1.21 (0.62 ; 2.34)
1.98 (0.94 ; 4.18)
0.83 (0.43 ; 1.58)
86
86
86
75
77
76
0.578
0.072
0.568
Impact of an Intervention on Intimate Partner Violence
0.085
1.09 (0.60;2.00)
/
3.29 (-1.85;8.42)
/
84
/
79
/
0.208
/
P-value
0.878
Adjusted* mean
/
/
P-value
difference score
0.044
/
(95% CI) IG-CG
0.845
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Impact of an Intervention on Intimate Partner Violence
Sensitivity analysis provided no arguments that missing data affected this comparison, 73.6% of the
women in th(e IG and 75.8% in the CG reported IPVv (P= 0.771) for the LOCF as well as for the worst
scenario which assumes all women with missing data did report IPVv. In the best scenario that assumes
all women with missing data did not report IPVv, 48.1% reported IPVv in the IG and 53.3% (P= 0.447)
in the CG.
Psychosocial health
Mean scores (n=163) for psychosocial health overall increased significantly by 5.4 points (95% CI 2.6;
8.2, P< 0.001) over the study period (baseline: 101.44; SD 16.07 and follow up: 106.83; SD 18.72),
though this evolution was only significant in the CG [IG: 2.9 (95% CI -0.7; 6.5), P= 0.113 and CG: 8.1
(95% CI 3.8; 12.3), P< 0.001]. After adjustment for psychosocial health at baseline, a significant
improvement in mean psychosocial health score was retained, though no longer between both study
arms (P=0.208).
Help-seeking behaviour
Formal
The majority (76.2%, n=147/193) of the women in our sample did not contact any service providing
assistance in dealing with problems with their partners in the last 6 months, and 23.8% (n=46)
contacted one or more services. The maximum number of services contacted by women was 5. Table
3 provides an overview of the types of formal services that were contacted. The descriptive data show
that first and foremost the women contacted legal services and the police, then psychological and
social services.
Table 3: Overview formal services contacted
Contacted services
% (n)
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Impact of an Intervention on Intimate Partner Violence
Legal services (legal aid, lawyer, court, …)
10.9% (21)
Police
8.3% (16)
Psychologist*
7.3% (14)
Centre for General Welfare (Centrum Algemeen Welzijn)
4.7% (9)
Mental Health Centre (Centrum Geestelijke Gezondheid)
3.6% (7)
Hospital Social Services
3.6% (7)
Family physician*
3.6% (7)
Psychiatrist *
1.6% (3)
Women’s shelter or safe house (Vluchthuis)
1.6% (3)
Social Service Department municipality (Openbaar 1.6% (3)
Centrum Maatschappelijk Welzijn)*
Youth Welfare Service (Comité Bijzondere Jeugdzorg)*
1.0% (2)
Victim Support Service (Slachtofferhulp)*
0.5% (1)
Service for Assisted Living (Begeleid Wonen)*
0.5% (1)
Marriage of convenience Cell (Cel Schijnhuwelijken)*
0.5% (1)
Preventive Family Welfare Agency (Kind & Gezin)*
0.5% (1)
Moral Support Service (Huis van de Mens)*
0.5% (1)
Gynaecologist*
0.5% (1)
Telephone support hotline (Tele-onthaal)
0.5% (1)
Self-help group
0% (0)
*mentioned by the respondents under the option “other”
In the IG, 19.4% (n=27/95) of the women sought formal help and 28.4% (n=27/95) did so in the CG (P=
0.177). Adjusted for psychosocial health at baseline, the difference in formal help-seeking behaviour
between the IG and CG remained insignificant (P=0.466). More details are available in Table 2. The
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Impact of an Intervention on Intimate Partner Violence
most frequently cited reason (88.6%) for not seeking help was that it was not perceived it as
‘necessary’.
Women reporting IPVv did seek significantly more formal help (31.0%, n=39/126), compared to those
not reporting IPVv (9.5%, n=6/63) (P= 0.001). Similarly, women reporting IPVp sought considerably more
formal help (29.4%, n=35/119), compared to those not reporting IPVp (14.3%, n=10/70) (P= 0.021).
Informal
Our findings indicate that 70.5% (n=136/193) of the women talked to someone about the IPV, outside
of the formal services assessed. The large majority of women spoke to family (49.7%, n=96/193) and
friends (47.7%, n= 92/193).
In the IG, 65.3% (n=64/98) of the women sought informal help and 75.8% (n= 72/95) did so in the CG
(P= 0.118). After adjusting for psychosocial health at baseline, informal help-seeking behaviour was
not different in the IG compared to the CG (P=0.326). More details can be found in Table 2.
When women reported IPVv, they sought substantially more informal help (78.6%, n= 99/126)
compared to those not reporting IPVv (54.0%, n= 34/63) (P= 0.001). If women reported IPVp, they also
sought significantly more informal help (79.0%, n= 94/119) compared to those not reporting IPVp
(55.7%, n=39/70) (P= 0.001).
In comparing the women’s formal with informal help-seeking behaviour, they sought considerably
more informal one (P< 0.001).
Readiness to change
Over half of our respondents (57.1%, n=109/191) did not consider making changes to their relationship
in the next 6 months (precontemplation phase), while 15.2% (n=29/191) of the women considered
making changes (contemplation phase) and 27.7% (n=53/191) of the women thought about making
changes in the following months (preparation phase). There was no statistical difference in readiness
to change between the IG and the CG (P= 0.159).
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Impact of an Intervention on Intimate Partner Violence
Formal and informal help-seeking behaviour was statistically significantly correlated to being in more
advanced phase of the readiness to change process (P< 0.001 and P= 0.010). After Bonferroni
correction a significantly higher proportion of formal and informal help-seeking behaviour was found
in the preparation phase compared to the precontemplation phase (p <0.001 and p=0.007).
Safety behaviour
The results for safety behaviour indicate that 31.3% (n=60/192) of the women took one or more safety
measures. The majority of the women made sure to have a small amount of money with them in case
of emergency (25.4%, n=49/193), 10.9% (n=21/193) stored an emergency bag (clothes, spare keys etc.)
in a safe location, 8.3% (n=16/192) agreed on a code with someone who will then call the police, and
2.1% (n=4/192) removed objects that could be used as a weapon.
In the IG, 24.5% (n=24/98) of the women took one or more safety measures and 38.3% (n=36/94) did
so in the CG, with significantly more safety behaviour in the CG (P= 0.044). Adjusted for psychosocial
health at baseline, the difference between the IG and the CG was no longer significant (P=0.431). More
details are available in Table 2.
We found significantly more safety behaviour when women reported IPVv (37.3%, n= 47/126)
compared to those not reporting IPVv (17.7%, n=11/62) (P= 0.007).
Perceived helpfulness of the intervention
More than a third of the women considered the questionnaire (37.4%, n=70/187) and/or the interview
(35.1%, n=65/185) to be reasonably to very helpful. Only one woman indicated that filling in the
questionnaire made things worse. The referral card was rated as somewhat to very helpful for 23.4%
(n=44/188) of the women.
The questionnaire was helpful for 36.1% (n= 35/97) of the IG and for 38.9% (n= 35/90) in the CG (P=
0.763). As far as the usefulness of the referral card is concerned, the proportion was 28.9% (n= 28/97)
in the IG and 17.6% (n= 16/91) in the CG (P= 0.085). In regard to the interview 36.1% (n= 35/97) in the
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Impact of an Intervention on Intimate Partner Violence
IG and 34.1% (n= 30/88) in the CG (P= 0.878) rated it helpful. Adjusted for psychosocial health at
baseline, the differences in helpfulness between IG and CG remained insignificant (P= 0.568, P=0.072,
P=0.578). Based on these results, the helpfulness of the referral card appeared to be greater in the IC,
although it borderline missed statistical significance. More details are available in Table 2.
In the whole sample, the perceived helpfulness of the questionnaire (37.4%, n= 70/187) and the
interview (35.1%, n= 65/185) were both significantly larger compared to that of the referral card
(23.5%, n= 44/187) (P< 0.001). We did not find a significant difference in perceived helpfulness
between the questionnaire (37%, n= 68/184) and the interview (35.3%, n= 65/184) (P= 0.368).
Lastly, we hypothesised that the referral card would be more effective in women experiencing severe
IPVv due to a more urgent need for help; our dataset, however, did not provide any evidence showing
that severity of IPVv had a significant effect on the intervention (P= 1.000).
Discussion
IPVv
First, we found a statistically significant decrease of IPVv of 31.4% over the study period, although we
are unable to attribute this decrease to the referral card. Compared to other studies with a similar
design where most authors consider a decrease of 20% clinically relevant (47;50;57;63;75;76) we
consider our decrease of IPVv over the course of the study pertinent. A significant reduction in IPVv
prevalence rates over time, regardless of the type of treatment, is consistent with findings from other
abuse-intervention studies conducted in a variety of social and health settings (50). Another important
finding is that there appear insignificant differences between the intervention and the control groups,
which is in line with that of Cripe et al. (23), Zlotnick et al. (76), Curry et al.(77), Humphreys et al. (78).
However, some RCTs, which evaluate home visit programs (29;73;79;80) and typically address several
issues (e.g. psychosocial health, parenting skills, substance abuse) simultaneously, showed promising
results and reported a significant decrease in physical, sexual and/or psychological partner violence
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Impact of an Intervention on Intimate Partner Violence
(odds ratios from 0.38 to 0.92) in their intervention groups. The Dutch equivalent of the Olds et al.
home visit program (80) reported significantly less IPV victimisation and perpetration in the
intervention group until 24 months after birth in a sample of high-risk young pregnant women.
Evidence from another two studies examining different types of supportive counselling (47;63) also
supported a statistically significant effect of their intervention. More specifically, the 30-minute oneto-one session from Tiwari et al. (63) reported significantly less psychological and minor physical
(except for sexual IPV) violence in the intervention group. Kiely et al. (47) concluded that their
comprehensive cognitive behavioural intervention significantly reduced recurrent episodes of IPV
(again except for sexual IPV).
It has been previously hypothesised that the decrease in IPV prevalence rates, regardless of the fact if
there is a difference between the intervention and the control groups, may be attributed to a simple
regression toward the mean or natural history of IPV, which may wax and wane (50). Since there is no
clear evidence-based indication of the optimum period of outcome measurement for this type of
intervention, it might be possible that we missed the immediate positive effects or other effects that
may not have been evident for some time. At the time of measurement, the respondents simply might
not acknowledge the violence as such, or be ready to make changes, seek or accept help. Some
counselling interventions (e.g. distributing a referral card, undertaking safety measures, developing
safety plans, or seeking help) might come too early/late and/or are not adapted to specific needs at
given time and therefore prove ineffective (70;81;82). Furthermore, the choice of decrease of IPV as
one of the main outcome variables to measure the impact of the intervention may not have been the
most appropriate outcome measure. An increasing number of studies have shown that IPV generally
involves a complex process, given the numerous steps and intervening factors between identification
and IPV reduction, many of which are beyond the control of the health care system or providers.
Therefore, interventions should not necessarily be expected to reduce IPV. Other measures of internal
change, such as psychosocial health and quality of life, have been suggested as potentially more
informative for evaluating the impact of an intervention for IPV (41). However, the significant
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Impact of an Intervention on Intimate Partner Violence
improvement of psychosocial health identified in our study cannot be explained by the referral card
either.
Another hypothesis for the insignificant difference between the IG and CG is that the design of the
intervention might not have been adapted to the type of IPV found in our study. Based on Johnson’s
(83) typology we can distinguish 2 types of violence: ‘mutual violence’ and ‘intimate terrorism’. In brief,
the interpersonal dynamic in mutual violence is one of conflict that escalates to minor low-frequency
forms of violence where either or both partners can be violent. Fear is not a characteristic of mutual
violence and most couples deal with it themselves. In intimate terrorism, the (usually male)
perpetrator uses violence as a tactic in a general pattern of power and control over his partner who
does not resort to violence. This type of violence is likely to escalate over time, less likely to be mutual
and more likely to result in injuries to women and draw attention from neighbours, police and health
caregivers. Our study design did not differentiate these two types of violence, however, there is
indication that we might have mainly included low severity ‘mutual violence’. First, our results show
that the number of women reporting victimisation and perpetration of IPV, respectively, is fairly close,
with 66.7% (n=126) compared with 63% (n=119). This is similar to the findings of other authors (e.g.
Bair-Merritt et al (29)). Second, we have reported earlier that only a very small proportion (1.2%; n=22)
of the women indicated being afraid of the perpetrator (52). Third, most women were dealing with the
IPV themselves, as reflected in the findings that less than one fifth (22.6%; n=40) contacted at least
one formal service and the most frequently cited reason for not seeking any formal help was that it
was perceived as ‘unnecessary’. However, besides referring to light forms of IPV, this notion of ‘not
necessary’ could also refer to the denial or minimization associated with the precontemplation phase.
Based on the structure of our intervention, which centres around IPV assessment and distribution of a
referral card in order to reduce IPV and improve psychosocial health/help seeking and safety
behaviour, it is plausible that this type of intervention is rather directed towards addressing ‘intimate
terrorism’ instead of ‘mutual violence’. Moreover, the intervention did not directly involve the partner
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Impact of an Intervention on Intimate Partner Violence
or concretely addressed female violent/abusive behaviour, which most probably are factors
preventing the development of less abusive communication.
Help-seeking behaviour
About a fourth of the women contacted one or more formal services. They contacted first and
foremost legal services and the police, then psychological and social services. In contrast, 70.5% of the
women opted for informal help and most of them talked to family and friends about the problems with
their (ex)partner. Women reporting IPV victimisation and perpetration showed significantly increased
formal and informal help-seeking behaviour.
The low use or the underutilisation of formal reources providing IPV-related assistance is in
concordance with the findings of several other authors (39;84;85), although both we and Ansara &
Hindin (86) have identified the police and health professionals as the commonly used formal resources.
In a similar vein, literature has shown that informal sources of help and social support, including family,
friends and coworkers, continue to be the primary source women turn to in dealing with violence in
their intimate relationship (87). Several population-based studies have shown that 58% to 80% of
abused women opt to disclose information about the abuse and seek support at least once from any
informal resource (88).
Based on the stage model of help-seeking behaviour of Liang et al. (85), one could argue that people
progress from making initially more private attempts to seeking informal support to deal with abuse,
and as violence worsens, to pursuing more formal/public help (89). This theory aligns with our
assumption that we probably mainly measured low-level mutal violence with regard to which IPV is
defined as temporary, survivable or reasonable and for which private attempts and informal help are
used as main resources. Furthermore, Fanslow and Robinson (70) found that 63.4% of the abused
women in their study did not seek help from formal services due to their perception of the violence to
be ‘normal or not serious’. Similar to our findings that seeking formal help was perceived as
‘unnecessary’, this perception of ‘normality’ has resulted in women enduring violence without any
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Impact of an Intervention on Intimate Partner Violence
(formal) help (90). Couples typically do not report low-level IPV as a problem in their relationship, but
research has shown that they are at high risk for future relationship dissatisfaction and instability
(67;91). Additionaly, we found that more than half of our participants were in the precontemplation
phase according to the model on readiness to change (92), which implies that they were minimising or
denying the IPV.
Several authors (57;82;93) have argued that women recruited in health care settings may differ from
those recruited elsewhere, since they may not yet be at the stage of identifying their relationship as
abusive or ready to accept help. Relationships between intimate partners involve a wide range of
activities, ranging from eating, sleeping, co-parenting, playing, working, making major and small
decisions, to sexual activity. The fluid, liberal, and intimate nature of these interactions may make
subtle violations and abuses difficult to detect and hard to understand or define. Moreover, because
the actual nature, severity, and presence of violence in an intimate relationship may be constantly
shifting, alternating between violence and loving contrition, acknowledging the relationship as abusive
may be difficult and confusing (85). If one does not identify the abuse/violence as such, one is unlikely
to utilize resources. Knowledge, attitudes, and beliefs about abuse develop within sociocultural
contexts and influence how women define and respond to experiences (88). More specifically, the
childbearing cycle strengthens the bonds between partners and their commitment to the family. For
some women the pregnancy and safeguarding the child can be a catalyst to leave the relationship
behind, whereas for other women pregnancy may weaken the ability to deal or cope with the IPV and
stimulate them to find ways to reduce the violence or modify their own response to violence (e.g.
refraining from fight back) (94;95).
There are a range of other factors, e.g. the type, extent and severity of IPV that have been associated
with help-seeking behaviour. Some authors argue that women experiencing more severe violence
(involving the use of deadly objects or the fear for one’s life) seek more help (96), while others, as
demonstrated in our results, do not reveal any sign of the connection between the impact of severity
and their help-seeking behaviour (97). Socio-demographics (including age, education, socioeconomic,
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Impact of an Intervention on Intimate Partner Violence
and marital status) and psychosocial health have also been shown to influence help-seeking behaviour
(96;98-100). Psychosocial dysfunction associated with IPV may negatively influence a woman’s
help/health seeking behaviour (99). In contrast, psychologically healthier individuals could be more
likely or better equipped to reach out for help (98). Hence, the low psychosocial health scores at
baseline might have had an impact on the effect of the intervention.
Perceived helpfulness of the intervention
Next, 37.4% of the women judged the questionnaire and 35.1% found the interview as moderately to
highly helpful. The referral card was regarded by 23.4% as moderately to highly helpful. Although we
were not able to detect significant differences between the intervention and the control groups, the
helpfulness of referral card seemed to be more prominent in the IG and approximated statistical
significance.
In contrast to McFarlane’s (35) suggestion, we are unable to conclude that the simple assessment of
IPV, in combination with offering referrals, has the potential to interrupt and prevent recurrence of
IPV and associated trauma. We found that the identification of IPV, together with the distribution of a
referral card (compared to a thank-you card), did not result in a statistically significant difference of
the measured outcomes in both arms. We hypothesise that this finding is closely related to the very
different organisation of the health care and social services systems in Belgium and the USA, as the
organizational structures and systems are strongly embedded in the countries’ own cultural contexts.
In that sense, it may be that in a society with a higher tolerance for violence (e.g. Belgium), the victims
tend to regard their experiences as less offensive or abusive. Women might not acknowledge certain
behaviours as being transgressive and consequently, feel hesitant to seek help. Conversely, the USA
have a long tradition of condemning violence and women might be more easily stimulated to find help
based on a referral card.
The women in our study perceived being asked about IPV as more helpful than receiving a referral
card. Similarly, Chang (101) has shown that screening for IPV during pregnancy can help raise
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Impact of an Intervention on Intimate Partner Violence
awareness and women’s interactions with health care providers may help change women’s
perceptions. Health psychology has demonstrated that a simple but effective means to change health
related behaviour is to ask people questions about a behaviour (e.g. their intentions), as doing so
influences the likelihood and rates of performing that behaviour (102). Indeed, IPV assessment can
have a therapeutic value on its own and that the process of measurement changes the very thing being
measured (35;103). As described earlier, screening for IPV is not part of routine antenatal care in
Belgium. A possible explanation for the perceived helpfulness of the questionnaire/interview is that
being asked about IPV in a health research related context (also known as the Hawthorne-effect) might
have had a greater impact than anticipated in both groups. Moreover, we cannot exclude the
possibility that the study may have triggered some health professionals to pay more attention to IPV
and might have increased their help-providing behaviour, although we assume that this behavioural
change was limited and of short duration.
Strengths and weaknesses
This study has a number of strengths and weaknesses. The recruitment took place in a balanced sample
of 11 antenatal care clinics spread across Flanders (Belgium). Based on a sound sample size calculation,
we were able to include a sufficiently large sample of women. Randomisation was successful for all
variables except for psychosocial health, for which we adjusted in our analysis. The number of women
lost to follow-up was limited and we found no statistical evidence that the missing data would have
altered the main findings in this study. Yet, the prevalence rates reported are most probably an
underestimation since it is know that women lost in IPV-studies are more likely to be experience IPVv.
Furthermore, the exclusion of women who were not proficient in Dutch/French/English and were not
able to fill out in private might have created a bias, although we assume that the impact is limited.
Considerable efforts were made to ensure that women were able to fill in the questionnaire or be
interviewed in private, but it is conceivable that a part of our respondents were under watch of their
(abusive) partners. Another potential source of bias is that the women willing to participate in the
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study may have been more motivated or ready to seek help or install safety behaviours and take
actions to reduce IPV, compared with women who did not consent to participate or were lost to followup. Furthermore, almost a fourth of the women indicated not having received or not recalling having
received a referral card and might have produced a biased view on the impact of the intervention.
Additionally, answering questions about the helpfulness of a questionnaire/interview in a telephone
interview directly to the researcher self might have stimulated social desirability bias and skewed the
answers towards increased helpfulness. Lastly, we did not control for measurement reactivity effects,
which might have produced a more nuanced picture of the impact of the perceived helpfulness of
identifying IPV.
Conclusion and recommendations
In this multicentre RCT we observed a significant decline in the prevalence of IPVv and an increase of
psychosocial health at follow-up, though we failed to document any additional effect of handing out a
resource referral card in women disclosing IPVv during pregnancy. More than one fifth of the women
sought formal help and 70.5% sought informal help. Women reporting IPV showed significantly
increased formal and informal help-seeking behaviour. A third of the women took at least one safety
measure, and when IPV was reported, safety measures were taken significantly more frequently. The
questionnaire and the interview in this study were perceived as moderately to highly helpful by more
than a third of our sample and this degree of helpfulness was significantly greater than that of the
referral card. We were unable to attribute any of the above findings directly to handing out the referral
card. Although the helpfulness of the referral card appeared to be more substantial in the IC, it
borderline missed statistical significance.
In other words, detection of even low severity mutual IPV can be a helpful tool in the battle against
IPV, though combining the identification with simply the distribution of a referral card is probably not
the best means of achieving that goal.
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Impact of an Intervention on Intimate Partner Violence
Based on our results, we recommend that future intervention studies address simultaneously several
risk factors such as for example psychosocial health, substance abuse, and social support. Intervening
in a single risk factor, as with IPV in our case, might be unsuccessful because other risk factors may
persist as barriers to the desired change. We believe that comprehensive IPV interventions that
address risk factors at the individual, interpersonal, societal, cultural and community levels
concurrently have higher chances of success. Interventions that involve informal networks as a
fundamental component might also be more effective. However, large-scale, high-quality research is
essential for providing further evidence of the content of these interventions and for clarifying which
interventions should be adopted in the perinatal care context. Furthermore, we recommend that
future IPV interventions include information on the typologies of IPV (intimate terrorism and mutual
violence) in their assessments. Doing so will allow researchers to accurately test and compare the
effects of different types of IPV victimisation and perpetration among pregnant and postpartum
women. Delineating these groups and taking account of the stages of change, the help-seeking
strategies and complex mutuality of IPV will offer great potential for designing a tailored intervention
that is well adapted to the specific needs of couples experiencing IPV.
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List of abbreviations
IPV: intimate partner violence
RCT: randomized controlled trial
IG: Intervention Group
CG: Control Group
IPVv: intimate partner violence victimisation
IPVp: intimate partner violence perpetration
CTS2S: revised Conflict Tactics Scale
SPSS: statistical package for social sciences
LOCF: last observation carried forward
SD: standard deviation
OR: odds ratio
Funding
The study was funded by the Research Foundation - Flanders (www.fwo.be, grant number 69579). The
funders had no role in the design of the study, nor in the data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests
The authors declare that they have no competing interests.
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Authors' Contributions
ASVP conceived the study, acquired the data, performed the analysis and drafted the manuscript. ED
assisted ASVP with the statistical analysis. KR, HV and MT participated in the design of the study, were
involved in drafting the article, and gave critical input. All authors read and approved the final
manuscript.
Acknowledgements
We would like to express our sincere thanks to all the women in our study for the courage they showed
in participating in an intervention study on this difficult topic. Our thanks are due to Bart Vanbrabandt
for the tremendous help with the input and cleaning of the data, Mieke Walraevens for the assistance
with the qualitative analysis of the open questions, Olivier Degomme for the methodological support,
Ines Keygnaert, Kristien Michielsen and Heleen Vermandere for their useful comments, and David
Welkenhuizen for the graphical support.
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Supporting information:
S1 Questionnaire
S2 Interview 1
S3 Consort checklist
Figure legends
Figure 1: CONSORT flow diagram recruitment
Figure 2: Time line study process
Tables
Table 1: Socio-demographic characteristics of the sample
Table 2 : Overview results main outcome variables
Table 3: Overview formal services contacted
48
221
Enrollment
Assessed for eligibility (n=2587)
Randomized (n=249)
(second phase)
Excluded (n=2338)
Ineligible first phase of the
study (n= 693 ): under age
(n=6), not able to fill out in
private (n=13), insufficient
language skills (n=323,
participation refusal (n=
275), filled out during
admission (n= 74), blank
questionnaire (n=2)
Did not meet the inclusion
criteria for the second phase
(n=1620)
Eligible women lost before
randomization (n=25)
se
Allocation
se
Allocated to intervention group (n=129)
Received allocated intervention (n=115)
Did not receive allocated intervention
(missed or did not make a postpartum
appointment, midwife/secretary forgot to
hand out envelope) (n=14)
Allocated to control group (n=120)
Received allocated control (n=109)
Did not receive allocated intervention
(missed or did not make a postpartum
appointment, midwife/secretary forgot to
hand out envelope) (n=11)
Follow-Up
Lost to follow-up (n=14)
Language barrier (n=7)
Unreachable through telephone (n= 4)
Declined further participation (n=3)
Lost to follow-up (n=11)
Language barrier (n= 4)
Unreachable through telephone (n=4)
Declined further participation (n=3)
Analysis
Analysed (n=101)
Analysed (n=98)
*5 women in the IG and 5 women in the CG had incomplete IPVv data
222
[BASELINE]
QUESTIONNAIRE
[FOLLOW-UP]
INTERVENTION
ENVELOPE
INTERVIEW 1
10-12 months after envelope
PREGNANCY
DELIVERY
POSTPARTUM
CONSULTATION
±6 weeks after delivery
223
[FOLLOW-UP]
INTERVIEW 2
16-18 months after envelope
224
Chapter 4: Discussion 1.
Prevalence 1.1.
Lifetime prevalence We found that a history of abuse and violence victimisation among pregnant women attending antenatal care is common, reported by between 23.2 and 45.4% of the women participating in the BIDENS-­‐study with Belgian women at the lowest end of the continuum and Estonian women at the highest end. In the MOM-­‐study, only 12.1% of the women reported lifetime abuse/violence. The BIDENS prevalence rates are comparable to the European rates of between 20 and 30% that have been reported by other authors (WHO, 2014). The lifetime prevalence rate in the MOM-­‐study is relatively low compared to the European rates, which can partially be explained by the measure used inquiring for abuse in general terms. It has been shown that women do not identify themselves as abused or subjected to violence when they are being asked in general terms. Yet, when specific abusive or violent behaviour is being used, women report higher prevalence rates (O'Doherty et al., 2015; Nelson et al., 2012). However, caution is recommended when interpreting and comparing results of different studies, as methodological differences and challenges are substantial. The variation in prevalence rates is influenced by considerable differences in definitions (e.g. physical and/or sexual and/or psychological violence/abuse, domestic violence vs. IPV), study populations (e.g. small health-­‐care-­‐based samples vs. population-­‐based samples), mode of inquiry (e.g. face-­‐to-­‐face interview vs. self-­‐administered questionnaire), type of questions (e.g. general questions vs. specific behaviour) and timing of inquiry (e.g. single measurement early in pregnancy vs. multiple measurements throughout the whole pregnancy). In other words, a myriad of study design features influence the prevalence rates reported, and need to be kept in mind when comparisons across studies are made (Taillieu & Brownridge, 2010a; Saltzman et al., 2003; Daoud et al., 2012; Brownridge et al., 2011; Roelens et al., 2008a). Both the MOM and the BIDENS-­‐study found that women reporting lifetime abuse/violence are at increased risk for violence during pregnancy; in other words, lifetime abuse/violence is a strong predictor for abuse/violence during pregnancy, as has been confirmed by numerous other scholars (Fisher et al., 2012; Garcia-­‐Moreno, Heise, Jansen, Ellsberg, & Watts, 2005a; Shamu et al., 2011; Jahanfar et al., 2013; Daoud et 225
al., 2012; Devries et al., 2010a; Roelens et al., 2008b; Perales et al., 2009; Thananowan & Heidrich, 2008; Taillieu & Brownridge, 2010b; James et al., 2013). 1.2.
Pregnancy-­‐associated prevalence In the BIDENS-­‐study, pregnant women reported relatively low percentages of abuse/violence over the last 12 months (year preceding filling in the questionnaire), namely between 3 and 6.5% with again Belgium at the lowest and Estonia at the highest end of the continuum. Contrary to the low prevalence rates of recent abuse/violence in the BIDENS-­‐study, the MOM-­‐
study found 20.4% of IPV in the 12 months before pregnancy and/or during pregnancy, which may be linked to the threshold chosen for psychological IPV (cf. infra). The rates we found are within the range of estimates of IPV around the time of pregnancy found by other authors, ranging from 3 to 30%. Prevalence rates in African and Latin American countries are mainly situated at the high end of the continuum, and the European and Asian countries are positioned at the lower end (Devries et al., 2010a). Concerning severity and combination of different types of violence, the majority of the women in the MOM-­‐study indicated having experienced only one type (physical or sexual or psychological) of partner violence. Moreover, subjects surveyed reported significantly fewer combinations of several types of violence during pregnancy compared to 12 months before pregnancy. Furthermore, the BIDENS-­‐study revealed that those who reported only one type of abuse/violence suffered less than the women reporting two or three types of abuse/violence. Also consistent with other studies (Taillieu & Brownridge, 2010a), the reported severity of the abuse/violence as a whole corresponded with the degree of current suffering. This suggests that the degree of suffering is related to the number of types as well as the severity of the abuse/violence. Comparing prevalence rates from 12 months before pregnancy to rates from during the pregnancy, the MOM-­‐study found that physical partner violence and psychological partner abuse are significantly lower during pregnancy. Moreover, in the MOM-­‐study, this decrease in IPV during pregnancy was stronger for physical partner violence than for psychological partner abuse, suggesting that partners are generally less physically violent but not necessarily less psychologically abusive during pregnancy of their partner. We 226
were not able to detect any evolution in sexual partner violence, which may be due to the low prevalence rate detected in our sample. Similarly, the BIDENS-­‐study found that, in general, pregnant women report less physical violence and more emotional abuse than before the pregnancy. Likewise, other researchers have demonstrated that the prevalence of violence during pregnancy is consistently lower than violence occurring before pregnancy, both in developed (Janssen et al., 2003; Gazmararian et al., 1996; Datner et al., 2007; Taillieu & Brownridge, 2010a; Charles & Perreira, 2007; Saltzman et al., 2003; Johnson et al., 2003; Bacchus et al., 2004; Bohn et al., 2004; Cox et al., 2004b; Dunn & Oths, 2004; Heaman, 2005; Renker & Tonkin, 2006; Yost et al., 2005) and less developed nations (Perales et al., 2009; Diaz-­‐Olavarrieta et al., 2007; Guo et al., 2004a; Farid et al., 2008; Nasir & Hyder, 2003; Thananowan & Heidrich, 2008). Several hypotheses can be formulated to clarify the results concerning the pregnancy-­‐related prevalence rates found. First, it is striking that our results seem to be consistently situated at the lower end of the different continua found in other studies in Western antenatal clinical settings. In the BIDENS-­‐ as well as the MOM-­‐study, the participants were more educated than the average pregnant population, which can be considered as a proxy for a higher socio-­‐economic status, in turn representing a decreased risk for violence. Furthermore, in both studies, study participants were on average mid-­‐way through their pregnancy when they filled in the questionnaire, and it is not unthinkable that abuse/violence may still start after this gestational age. The lower prevalence rates can possibly also be attributed to the women opting not to participate or failing to follow up. Several authors (Taft et al., 2011; MacMillan et al., 2009) have stated that women lost to IPV-­‐studies were more likely to be victimised. Additionally, the low prevalence rates might be linked to cultural and contextual differences between the different countries and studies. In a society with a higher tolerance for violence, such as Belgium, the victims might regard their experiences as less offensive or abusive. This could be due to social and cultural differences in what is considered to be abusive/violent behaviour, which becomes apparent when abuse/violence is defined by descriptive or behavioural questions. In spite of a quality translation of the different well-­‐validated violence measures, women might not acknowledge certain behaviour as being transgressive or may be hesitant to disclose experiences of violence in a hospital-­‐based survey. Furthermore, not all pregnant women with a history of abuse/violence report that they 227
suffer, or at least not to the actual extent. It is possible that these women have recovered with or without the help of others, experienced only a single event or a very mild form of abuse/violence, or are more resilient. However, we cannot exclude that, as a coping mechanism, women with abusive experience might repress their feelings of suffering. Samelius et al. (Samelius et al., 2007) showed that other factors than severity of abuse/violence, such as whether the woman herself perceives her experience as abuse/violence, seem to be more decisive for development of somatization in abused women. In other words, whether a woman perceives her experience as transgressive seems to be decisive for the development of somatization. Similarly, in trauma theory, the psychological damage caused by violence comes from the way an individual interprets and is affected by the experience of trauma, more so than the actual type and frequency of the violent experience as such (Goldstein & Martin, 2004a). Second, the decrease of IPV during pregnancy might be associated with changes in the social status of a woman. There is great societal pressure on women to view motherhood as their primary (positive) adult role. Women may therefore simply be less willing to report the abuse/violence even when they are not experiencing a decline in IPV. Bearing a child increases social control and respect for the woman (Bagcioglu et al., 2014). This increase in respect could apply to the women herself (> self-­‐respect), but could also increase the respect of her partner and her social environment. Hence, it is possible that pregnant women face an actual decrease in IPV. In Western societies a pregnant woman is seen as a receptacle for the vulnerable unborn child. Both partners may realize that physical and sexual (not necessarily psychological) violence can harm the baby and therefore use less (physical) violence. We could also theorize that women feel more vulnerable during pregnancy. Physiological changes during pregnancy attenuate psychological responding to stress and develop a higher concern for the safety and conflicts with experiencing IPV. Therefore, it is not unthinkable that women develop tactics to avoid violent escalations such as: avoiding physical conflict and keep to verbal abuse, stepping away when things are getting out of hand, trying to stay under the radar, calling for help from family or friends. Third, the interpretation of our data should be made with some caution in view of the study limitations. In addition to the methodological challenges associated with the interpretation of prevalence rates discussed earlier, the 228
data may have been affected by the use of different violence measures, the varying recruitment methods (e.g. filling out the questionnaire in the hospital or being interviewed by telephone) and response rates. Furthermore, there is currently no agreement on a standard measure for emotional/psychological (partner) abuse/violence (WHO, 2014). In an effort to tackle this issue, we constructed our own scale and cut-­‐off value for psychological abuse in the MOM-­‐study. This threshold was based on a thorough literature search and extensive discussions with experts in the field. Nevertheless, it remains an arbitrary choice that is open for discussion. There is also some indication that the cut-­‐off might be situated at the lower end of the continuum (cf. infra), but this hypothesis requires further investigation. Furthermore, we should be cautious when comparing prevalence rates of violence during pregnancy with those of the period of 12 months before pregnancy, since the average gestational age of the respondents in our study (24 weeks) was half of the 12 months before pregnancy period, which reduces the chances of IPV occurring. In an attempt to overcome this methodological challenge, we analysed the frequency data as a best possible approximation of a ‘true’ evolution and found a similar evolution for IPV. However, since the questions on frequency were also linked to the time periods, we cannot exclude that the results are biased by the difference in measurement period. Lastly, we adjusted our analysis for a limited number of risk factors (such as age, education, civil/marital status, gestational length, language) but other factors and confounders such as child abuse, financial distress or economic violence could have been used to expand the analysis. 2. Associated factors 2.1.
IPV and psychosocial health The first association we explored was whether the occurrence of IPV 12 months before and/or during pregnancy is associated with psychosocial health (MOM-­‐study). We found a strong correlation between IPV and psychosocial health. Several other researchers have previously demonstrated a correlation between reporting IPV and poor psychosocial health (Taft et al., 2009; Cripe et al., 2010; Daoud et al., 2012; Krug et al., 2002a; Chambliss, 2008; Rose et al., 2010; Johnson et al., 2003; Campbell, 2001; Bailey, 2010a; Rodrigues et al., 2008; Coker et al., 2004b; Mechanic et al., 2008; Janssen et al., 2012; Sharps et al., 2007; Gazmararian et al., 2000; Ramsay et al., 2009b). 229
As this association has been repeatedly documented mostly in cross-­‐sectional studies, it remains to be determined whether poor psychosocial health puts women at risk of IPV or whether IPV induces worse psychosocial health, although it is plausible that both pathways co-­‐exist. Literature on this specific matter is scarce; most studies have focussed on the association between poor psychosocial health (such as stress, anxiety, and depression) and pregnancy outcomes such as low birth weight and prematurity, whereas the influence of poor psychosocial health on birth outcomes remains inconclusive (Nast, Bolten, Meinlschmidt, & Hellhammer, 2013; Neggers, Goldenberg, Cliver, & Hauth, 2006; Goldenberg et al., 1997). On the other hand, psychosocial resources including self-­‐esteem and mastery have been reported to protect women against stress from life events and chronic strains. These psychosocial resources could be used to teach women to manage their lives and cope with the stress and vulnerability associated with IPV during pregnancy (Li et al., 2012). Our data further suggest that, after taking all measured variables into account, the correlation between IPV and psychosocial health was mainly explained by “depression” and “stress” as psychosocial health indices. It has been noted that scales measuring affective states such depression or anxiety are likely to be highly correlated with each other and measure generalized distress rather than symptoms unique to depression or anxiety (Goldenberg et al., 1997). Our results confirm the strong correlation between the different psychosocial health subscales. The strong association between the total psychosocial health scale and IPV might indeed refer to a more general form of distress in our population, interconnected with a multitude of factors. Recently, there has been a shift towards envisaging psychosocial health as a multidimensional concept (Nast et al., 2013). We acknowledge that psychosocial health is a complex construct with many known and, presumably, many unknown determinants, which were beyond the scope of our study. In view of this and other potential pitfalls, our results warrant caution. Our study design did not allow us to determine causal pathways between the factors analysed. We were also not able to thoroughly analyse the multitude of factors involved in the complex interaction between IPV and psychosocial health, and, as a consequence, might have oversimplified reality. Our findings are based on a sample of the Belgian obstetrical population and cannot be generalized to other populations or health care systems without the necessary caution. 230
2.2.
History of abuse and operative delivery The second association we explored indicated that in BIDENS-­‐study the correlation between a history of abuse/violence and mode of delivery was rather limited. First, we did not find any correlation between childhood abuse and operative delivery. The lack of association between childhood abuse and operative delivery in the BIDENS-­‐study generally concurs with the results of a large Norwegian population-­‐based study which found no association between childhood abuse and CS before labour and only a slight increase of CS during labour (Lukasse et al., 2010). In contrast, another Norwegian cohort study found that childhood abuse, whether physical or sexual, resulted in an increased risk of interventions during childbirth, for both CS and instrumental vaginal delivery (Heimstad, Dahloe, Laache, Skogvoll, & Schei, 2006). However, the lack of association between childhood abuse and mode of delivery in our study may be linked to the low number of cases identified and the accordingly low statistical power. Alternatively, the lack of association may be the result of effective psychosocial counselling which is a well-­‐
established and common practice in the participating Scandinavian countries, although there is a large variety among the different counselling programmes and a lack of reliable data on the effectiveness of the different programmes (Larsson, Karlstrom, Rubertsson, & Hildingsson, 2015). Increased recognition and counselling for depression and fear of delivery may prevent interventions such as operative delivery. Second, we found that having experienced sexual violence as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-­‐obstetrical reasons. In agreement with our results, a Norwegian study targeting women with a fear of childbirth attending a sexual assault clinic reported that rape after the age of 16 was associated with a major increase in risk for CS (Nerum et al., 2010). However, this was a selected population with whom mode of delivery was actively discussed as part of the consultation, and hence the association may have been the consequence of an active choice during the consultation. It is important to note that guidelines and policies on acceptability of maternal request as an indication for a CS vary greatly among the different countries included in the BIDENS-­‐study. In contrast to the four other countries, maternal request alone is not an accepted indication for a CS delivery in Belgium and Estonia. However, the uniform results across the participating 231
countries strengthen our finding that primiparous women with a history of sexual violence as an adult have a higher risk of elective CS, regardless of maternal request being an acceptable indication. Sexual violence is likely to affect pregnant women more than other types of violence/abuse since the female reproductive organs are directly involved in both sexual acts and giving birth (Rhodes & Hutchinson, 1994; Hobbins, 2004). Therefore, the woman and/or the obstetrical staff may be anxious about a vaginal delivery, perhaps more so than in the case of a history of physical violence or emotional abuse. An obstetrician who is aware of such a history may be more inclined to grant a CS on maternal request without any direct medical indication (though linked to high stress levels in the patient, increased pain perception, less cooperation, etc.), as is suggested by our observed association. Third, among multiparous women, a history of physical but not sexual violence increased the risk of an emergency CS. A possible explanation could be that victims of adult sexual violence who either had had an operative delivery and/or had suffered a poor birth experience chose not to become pregnant again and hence were not among the multiparous women in our study. It is also possible that the previous birth experience was a healing experience, as described by Simkin and Klaus (Simkin & Klaus, 2004), and decreased fear of childbirth. An obvious possible reason for an increase in emergency CS among women reporting physical violence could be placental abruption after trauma, but this was not among the options registered in our study. The most common CS indications were foetal distress and other medical indications, which can be related to direct physical trauma to the abdomen. However, when having experienced a previous CS was added to the analysis, the association was clearly attenuated, indicating that this factor played a major role. The CS in a previous pregnancy could have been due to prior abuse/violence. As in obstetrics in general, the method of the first birth has the biggest impact on the subsequent mode of delivery (Cunningham et al., 2010). We would like to note that simply answering the questionnaire could be considered as an intervention in as such (known as the Hawthorne-­‐effect). Recalling abuse/violence when completing the questionnaire may trigger a fear of childbirth and symptoms of depression, which may again affect the mode of delivery. Hence, the observed associations may result from the study 232
being perceived as an intervention. However, if this were the case, we would likely have seen increases in the estimated associations in all types of violence/abuse. The results on the association between history of abuse/violence and operative delivery in the BIDENS-­‐study must be seen in the light of certain study limitations. The recruitment procedure varied across sites and countries, in the invitation to participate, where the questionnaire was completed as well as how it was returned. This methodological diversification may have introduced an information bias. The participation rates varied between countries, but the background characteristics did not indicate any significant selection bias when compared to information from official health authorities. We were only able to explore the impact of a certain amount of variables on mode of delivery. Hence, a lot of other variables (e.g. pregnancy complications, duration of labour, medico-­‐legal pressure) might have clouded the correlation between violence/abuse and mode of delivery. Finally, our findings are unique to women from the selected European countries, and should not be generalized to other locations with different health care systems. 3. Interventions In order to gain insight into the effectiveness of IPV interventions, we first conducted a systematic literature review to get a clear overview of the existing evidence on IPV interventions before, during and after pregnancy. Secondly, we executed an RCT to investigate the effect of identifying IPV and handing out a referral card on the evolution of IPV, psychosocial health, help seeking and safety behaviour during and after pregnancy. The most important results of the systematic literature review are integrated into the discussion of the RCT results below. 3.1.
IPV First, we found a statistically significant decrease of IPV of 31.4% over the study period, though we were unable to attribute this decrease to the referral card. Since most other studies with a similar design consider a decrease of 20% clinically relevant (Tiwari et al., 2005b; McFarlane et al., 2006b; Ramsay et al., 2009b; Kiely et al., 2010; Taft et al., 2009; Zlotnick et al., 2011) the 233
decrease in IPV over the course of our study can be seen as pertinent. A significant reduction in IPV prevalence rates over time, regardless of the type of treatment, is consistent with findings from other abuse/violence -­‐
intervention studies conducted in a variety of social and health settings (McFarlane et al., 2006b). Another important finding is that there do not appear to be significant differences between the intervention and control groups, which is in line with the findings of Cripe et al. (Cripe et al., 2010), Zlotnick et al. (Zlotnick et al., 2011), Curry et al. (Curry et al., 2006), Humphreys et al. (Humphreys et al., 2011). Some RCTs which evaluate home visit programmes (Bair-­‐Merritt et al., 2010; Olds et al., 2004; Mejdoubi et al., 2013b; Taft et al., 2011) and typically address several issues (e.g. psychosocial health, parenting skills, substance abuse) simultaneously showed promising results and reported a significant decrease in physical, sexual and/or psychological partner violence (odds ratios from 0.38 to 0.92) in their intervention groups. The Dutch equivalent of the Olds et al. home visit programme (Mejdoubi et al., 2013b) reported significantly less IPV victimization and perpetration for the intervention group until 24 months after birth in a sample of high-­‐risk young pregnant women. Evidence from two other studies examining different types of supportive counselling (Tiwari et al., 2005b; Kiely et al., 2010) confirmed the statistically significant effect of such intervention. More specifically, the 30-­‐minute one-­‐to-­‐one session from Tiwari et al. (Tiwari et al., 2005b) resulted in significantly less psychological and minor physical (except for sexual IPV) violence being reported by the intervention group. Similarly Kiely et al. (Kiely et al., 2010) concluded that their comprehensive cognitive behavioural intervention significantly reduced recurrent episodes of IPV (again except for sexual IPV). It has previously been hypothesized that the decrease in IPV prevalence rates, regardless whether there is a difference between the intervention and control groups, may be attributed to a simple regression toward the mean or natural history of IPV, which may wax and wane (McFarlane et al., 2006b). Since there is no clear evidence-­‐based indication of the optimum period of outcome measurement for this type of intervention, we might have missed the immediate positive effects or other effects that may not have been evident for some time. At the time of measurement, the respondents simply may not have acknowledged the violence as such, or been ready to make changes, seek or accept help. Some counselling interventions (e.g. distributing a referral card, undertaking safety measures, developing safety plans, or 234
seeking help) might come too early/late and/or are not adapted to specific needs at a given time and therefore prove ineffective (Van Parys, Verhamme, Temmerman, & Verstraelen, 2014; Zink et al., 2004; Fanslow & Robinson, 2010). Furthermore, the choice of having a decrease in IPV as one of the main outcome variables may not have been the most appropriate to measure the impact of the intervention. An increasing number of studies have shown that IPV generally involves a complex process, given the numerous steps and intervening factors between identification and IPV reduction, many of which are beyond the control of the health care system and providers. Therefore, interventions should not necessarily be expected to reduce IPV. Other measures of internal change, such as psychosocial health and quality of life, have been suggested as potentially more informative for evaluating the impact of an intervention for IPV (O'Campo et al., 2011). However, the significant improvement of psychosocial health identified in our study cannot be attributed to the referral card either. Another hypothesis for the insignificant difference between the IG and CG is that its design might not have been adapted to the type of IPV found in our study. Based on Johnson’s (Johnson, 2005) typology, two types of violence can be distinguished: ‘mutual violence’ and ‘intimate terrorism’. In brief, the interpersonal dynamics in mutual violence, are those of conflict that escalates to minor, low-­‐frequency forms of violence where either or both partners can be violent. Fear is not a characteristic of mutual violence and most couples deal with it themselves. In intimate terrorism, the (usually male) perpetrator uses violence as a tactic in a general pattern of power and control over his partner who does not resort to violence. This type of violence is likely to escalate over time, less likely to be mutual, and more likely to result in injuries to women and draw attention from neighbours, police and health caregivers. Our study design did not differentiate between these two types of violence; however, there are several indications that mainly low-­‐severity ‘mutual violence’ was reported in our study. First, the numbers of women disclosing victimization and those reporting perpetration of IPV were found to be fairly similar, namely 66.7% (n=126) and 63% (n=119), respectively. These results confirm the findings of other authors (Bair-­‐Merritt et al., 2010). Second, we reported earlier that only a small proportion (1.2%; n=22) of the women indicated being afraid of the perpetrator (Van Parys et al., 2014). Third, most women appeared to be dealing with the IPV themselves, since less than one-­‐
fifth (22.6%; n=40) contacted at least one formal service and the most 235
frequently cited reason for not seeking any formal help was that it was perceived as ‘unnecessary’. However, besides referring to light forms of IPV, this notion of ‘not necessary’ could also imply denial or minimization, which is associated with the pre-­‐contemplation phase. Our intervention centred around IPV assessment and distribution of a referral card in order to reduce IPV and improve psychosocial health/help seeking and safety behaviour. This type of intervention is probably more directed towards addressing ‘intimate terrorism’ rather than ‘mutual violence’. Moreover, the intervention did not directly involve the partner or explicitly address female violent/abusive behaviour, which are most likely factors preventing the development of abusive/violent interactions. When we link the Johnson model (2005) with the research on risk factors of IPV and differentiate for intimate terrorism and mutual violence, it could potentially clarify some of the inconsistent findings found. Risk factors for intimate terrorism, are not necessarily a risk factor for mutual violence and vice versa. Contradictive findings could be linked to population-­‐based studies measuring perpetration and victimisation behaviour (~ detecting more mutual violence) in contrast to health care of shelter-­‐based samples measuring victimisation (~ detecting more intimate terrorism). Large-­‐scale studies that differentiate between these types of violence might link certain risk factors to specific types of violence. For example instead of studying age as a general risk factor for IPV, the age difference between both partners (with a large age gap being a proxy for a power imbalance) might be a better proxy for intimate terrorism. 3.2.
Help-­‐seeking behaviour About a fourth of the women contacted one or more formal services to reach out for help. They first contacted legal services and the police, and then psychological, social services and healthcare professionals. In contrast, 70.5% of the women opted for informal help, most of them talking to family and friends about the problems with their partner. Women reporting IPV victimization and perpetration showed significantly increased formal and informal help-­‐seeking behaviour. 236
The low use of formal resources providing IPV-­‐related assistance is in concordance with the findings of several other scholars (Hegarty et al., 2013; Powers & Kaukinen, 2012; Liang et al., 2005), and Ansara & Hindin (Ansara & Hindin, 2010) confirmed our identification of the police and health professionals as the most commonly used formal resources. Similarly, literature has demonstrated that informal sources of help and social support, including family, friends and co-­‐workers, continue to be the primary source women turn to in dealing with violence in their intimate relationship (Coker et al., 2000). Several population-­‐based studies have shown that 58% to 80% of abused women opt to disclose information about the abuse/violence and seek support at least once from an informal resource (Lucea et al., 2013a). Based on the stage model of help-­‐seeking behaviour of Liang et al. (Liang et al., 2005), one could argue that people progress from initially making more private attempts to seek informal support to deal with abuse, to pursuing more formal/public help as the violence worsens (Overstreet & Quinn, 2013). This theory aligns with our assumption that we mainly measured low-­‐level mutual violence, which is defined as temporary, survivable or reasonable and for which private attempts and informal help are used as the main resources. Fanslow and Robinson (Fanslow & Robinson, 2010) found that 63.4% of the abused women in their study did not seek help from formal services due to their perception of the violence as ‘normal or not serious’ Similar to our finding that seeking formal help was perceived as ‘unnecessary’, this perception of ‘normality’ has been shown to result in women enduring violence without any (formal) help (Lucea et al., 2013b). Couples typically do not report low-­‐level IPV as a problem in their relationship, but research has shown that they are at high risk for future relationship dissatisfaction and instability (Petch, Halford, Creedy, & Gamble, 2012; Straus, 2004). Additionally, following the model on readiness to change, we found that more than half of our participants were in the pre-­‐contemplation phase (Prochaska, Diclemente, & Norcross, 1992b), which implies that they may have been minimizing or denying the IPV. Several authors (Subramanian et al., 2012; Ramsay et al., 2009b; Zink et al., 2004) have argued that women recruited in health care settings may differ from those recruited elsewhere, since they may not yet be at the stage of identifying their relationship as abusive or ready to accept help. Relationships between intimate partners involve a wide range of activities, ranging from 237
eating, sleeping, co-­‐parenting, playing, working, making small and major decisions, to sexual activity. The fluid, liberal, and intimate nature of these interactions may make subtle violations and abuses difficult to detect and hard to understand or define. Moreover, because the actual nature, severity, and presence of violence in an intimate relationship may be constantly shifting, alternating between violence and loving contrition, acknowledging the relationship as abusive may be difficult and confusing (Liang et al., 2005). If the abuse/violence is not identified as such, it is unlikely that resources will be utilized. In addition, knowledge, attitudes, and beliefs about abuse develop within sociocultural contexts and influence how women define and respond to experiences (Lucea et al., 2013a). More specifically, the childbearing cycle strengthens the bonds between partners and their commitment to the family. For some women, pregnancy and safeguarding the child can be a catalyst to ending an abusive relationship, whereas for other women pregnancy may weaken the ability to deal or cope with the IPV and prompt them to find ways to reduce the violence or modify their own response to it (e.g. refraining from fighting back) (Lutz, 2005a; Edin, Dahlgren, Lalos, & Hogberg, 2010). There is a range of other factors, such as the type, extent and severity of IPV, which has been associated with help-­‐seeking behaviour. Some scholars have argued that women experiencing more severe violence (involving the use of deadly objects or the fear for one’s life) are more likely to seek help (Loke et al., 2012), while others, as confirmed by our results, have not found any sign of the correlation between the impact of severity of the IPV and women’s help-­‐seeking behaviour (Dufort et al., 2013). Socio-­‐demographics (including age, education, socioeconomic and marital status) and psychosocial health have also been shown to influence help-­‐seeking behaviour (Sabina, Cuevas, & Schally, 2012; Goo & Harlow, 2012; Loke et al., 2012; Kaukinen et al., 2013). Psychosocial dysfunction associated with IPV may negatively influence a woman’s help/health seeking behaviour (Goo & Harlow, 2012). In contrast, psychologically healthier individuals could be more likely or better equipped to reach out for help (Sabina et al., 2012). Therefore, the low psychosocial health scores at baseline might have had an impact on the effect of the intervention. 238
3.3.
Perceived helpfulness of the intervention The questionnaire and the interview were deemed moderately to highly helpful by respectively 37.4% and 35.1% the women who participated in the intervention. The referral card was regarded as moderately to highly helpful by 23.4%. Although we were not able to detect significant differences between the intervention and control groups, the helpfulness of the referral card seemed to be more prominent in the IG, approximating statistical significance. In contrast to McFarlane’s (McFarlane et al., 2006a) suggestion, we are unable to conclude that the simple assessment of IPV in combination with offering referrals has the potential to interrupt and prevent recurrence of IPV and associated trauma. We found that the identification of IPV, together with the distribution of a referral card (compared to a thank-­‐you card) did not result in a statistically significant difference of the measured outcomes in both arms. We hypothesize that this finding is closely related to the different organization of the health care and social services systems in Belgium and the USA, as the organizational structures and systems are strongly embedded in the countries’ own cultural contexts. Although we used a similar and validated instrument based on very specific behavioural questions (e.g. were you hit, slapped, kicked…), women might not acknowledge certain behaviour to be transgressive. The results of the intervention study shows that women do not necessarily see certain behaviour (e.g. slapping, pushing) as problematic, but rather as a normal conflict-­‐resolving tactic. Therefore, they might not feel that it is relevant to classify certain incidents as behaviour that is being assessed. It is possible that in a society with a higher tolerance for violence, such as Belgium, the victims tend to regard their experiences as less offensive or abusive. This ‘normalization of violence’ might be associated with the fact that the USA have a longer history of condemning violent behaviour compared to Belgium. Belgian women might not acknowledge certain behaviour as being transgressive and, consequently, feel hesitant to seek help. Conversely, in the USA women might be more easily prompted to find help based on a referral card. The women in our study perceived being asked about IPV as more helpful than receiving a referral card. Similarly, Chang (Chang et al., 2010) showed that screening for IPV during pregnancy can help raise awareness, and women’s interactions with health care providers may help change women’s 239
perceptions about abuse. Health psychology has demonstrated that a simple but effective means to change health-­‐related behaviour is to ask people questions about that type of behaviour (e.g. their intentions), as doing so influences the likelihood of them behaving as such (Wood, Conner, Sandberg, Godin, & Sheeran, 2014). Indeed, IPV assessment can have a therapeutic value on its own, and the process of measurement changes the very thing being measured (McFarlane et al., 2006a; Darwin, McGowan, & Edozien, 2013). As described earlier, screening for IPV is not part of the routine antenatal care in Belgium. A possible explanation for the perceived helpfulness of the questionnaire/interview is that being asked about IPV in the context of health research might have had a greater impact than anticipated in both groups (also known as the Hawthorne effect). Moreover, we cannot exclude that the study may have triggered some health professionals to pay more attention to IPV and might have increased their help-­‐providing behaviour, although we assume that this behavioural change was limited and of short duration. 3.4.
Strengths and weaknesses The recruitment took place in a balanced sample of 11 antenatal care clinics spread across Flanders (Belgium). We were able to include a sufficiently large sample of women based on a sound sample size calculation. Randomization was successful for all variables except for psychosocial health, for which we adjusted in our analysis. The number of women who failed to follow up fell within acceptable limits, and there is no evidence that the missing data would have altered the main findings in this study. However, the prevalence rates reported are most probably an underestimation since it is known that women who drop out of IPV-­‐studies are more likely to have been abused. Furthermore, the exclusion of women who were not proficient in Dutch/French/English and were not able to fill in the questionnaire in private might have created a bias. Considerable efforts were made to ensure that women were able to fill out the questionnaire or be interviewed in private, but it is conceivable that a part of our respondents were being watched by their (abusive) partners. Another potential source of bias is that the women willing to participate in the study may have been more motivated or ready to seek help or develop safety behaviour and take actions to reduce IPV, compared with the women who did not consent to participate or failed to follow up. Furthermore, almost a fourth of the women indicated not having 240
received or not recalling having received a referral card, which might have produced a biased view on the impact of the intervention. Additionally, answering questions about the helpfulness of the questionnaire/interview in a telephone interview directly with the researcher possibly stimulated social desirability bias and skewed the answers towards increased helpfulness. Lastly, we did not control for the effect of the measurement as such (measurement reactivity), which could have added some nuance to the observed impact of the perceived helpfulness of identifying IPV. 241
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Chapter 5: Conclusion and recommendations 5.1.
Prevalence The results of this research demonstrate that a substantial proportion of pregnant women attending routine antenatal care report a history of violence and/or abuse. Psychological abuse inflicted by partners is the most frequent type of violence reported. This type of abuse is often seen as ‘not serious’ or low-­‐level IPV and typically not perceived as problematic. However, couples using psychologically abusive tactics run a high risk of future relationship dissatisfaction and instability, and are at an increased risk of physical and/or sexual violence during pregnancy. Women who report violence during pregnancy are considerably more likely to experience continued IPV and a higher severity of abuse compared to women who did not experience IPV during pregnancy. Evidence increasingly shows that the consequences of psychological abuse are as serious as those of physical and sexual violence. Although our results reveal that pregnancy mostly causes a decrease in physical IPV and only to a lesser extent in psychological IPV, it remains a prevalent problem. Since not much is known about the specific reasons for this decrease, we would like to plead for more scientific and societal awareness of the “lighter” forms of IPV. Firstly, a thorough scientific debate is needed on the definitions of IPV, leading to a more precise terminology which takes the complexity of the context and mutuality into account that is particularly relevant within the perinatal period. The current methodological challenges associated with measuring IPV, primarily the lack of a sound measure and threshold for psychological abuse, represent an important obstacle for the research on violence. It is key to further develop, test and validate (psychological) abuse measures and have an in-­‐depth debate on which aspects are to be considered as transgressive and which are not. It is also paramount to identify a set of outcomes which are important to couples in IPV situations and select an appropriate means of operationalizing these outcomes in order to measure the impact of IPV-­‐related interventions. Furthermore, the existing theoretical frameworks on IPV only address partial issues of the problem. There is, however, no theory that provides an integrated framework for (pregnancy-­‐
associated) IPV and this type of theoretical framework to guide research on IPV related to pregnancy is sorely needed. Ideally, the new pregnancy-­‐related IPV theory or theories should be composed of the different levels in the socio-­‐
243
ecological model and incorporate a combination of several aspects of the existing paradigms integrating views from multiple academic disciplines, including psychology, sociology, and criminal justice. More specifically, these new IPV-­‐theories should include factors on the individual level, but all the more on the interpersonal/relationship/context level including dynamics and binding aspects which are very specific for this stage of life and can induce a lot of stress (e.g. ensuring safe passage and acceptance of the pregnancy by the partner more details, binding-­‐in to the child etc., see double binding theory). New theoretical perspectives should also address the multi-­‐layered context taking into account the influence of socio-­‐cultural rules and beliefs associated with IPV as well as with pregnancy. We believe that the differentiation between ‘intimate terrorism’ and ‘mutual violence’ (and potentially other subtypes) is a crucial factor that needs to be integrated in these new theories and serve as a basis for the development of new and more balanced measures. Elements that stem from the feminist theory, such as power and control, should also have its place in these new models, although it should be released from the one-­‐sided gendered approach. Secondly, it is crucial to raise public awareness on violent behaviour within the context of an intimate relationship. As mentioned earlier, couples often do not perceive certain (abusive) behaviour as transgressive and accept it as normal conflict-­‐resolving comportment. Nevertheless, in the long term, IPV has been shown to be harmful for the relationship and has a profound negative impact on the children. Sensitization campaigns promoting positive and non-­‐violent communication starting from early childhood can substantially contribute to reversing the normalization of violence and eliminating IPV. 5.2.
Associated factors With regard to the IPV-­‐associated factors researched in this dissertation, we first and foremost found that IPV and psychosocial health are strongly related. Due to the cross-­‐sectional nature of our study design, we are not able to make any statements on causality with regard to these associations. However, it seems reasonable to state that again a multitude of factors could have affected this interaction, and more longitudinal and in-­‐depth, qualitative analysis is necessary to shed light on the complex interactions and confounding factors that define the relationship between IPV and 244
psychosocial health. Furthermore, given the important role of psychosocial health discovered in our study, we believe that the recommendation to routinely screen for IPV during pregnancy should be broadened and that IPV should not be seen as an isolated theme. IPV research is providing increasing evidence that simultaneously addressing the multitude of risk factors related to IPV has a greater effect than addressing a single factor. Therefore, we would like to join the growing number of authors that advocate the inclusion of IPV within a broader psychosocial health assessment as a standard part of antenatal care. Routinely addressing psychosocial health in antenatal care has the potential to improve the health and well-­‐being of women and their families. Hence, we argue for giving maternal mental health a more prominent place on the research and policy agenda. A second finding concerning IPV-­‐associated factors is that the correlation between a history of abuse/violence and the mode of delivery was limited. Only sexual violence as an adult increased the risk of an elective CS among women with no prior birth experience, in particular for non-­‐obstetrical reasons. A history of abuse/violence seems to have a limited impact on the mode of delivery for women with a previous birth experience. For these multiparous women, only a history of physical violence was found to increase the risk of an emergency CS. Despite the robust methodology and the large sample size, this multi-­‐country study presumably failed to exhaustively capture the multitude of factors that interact with the association between history of abuse/violence and mode of delivery. Further longitudinal and large-­‐scale research is needed to explore this complex interaction and shed more light on the impact of abuse/violence on obstetric outcome. Furthermore, we believe that identifying a history of abuse/violence during pregnancy is an important step in providing qualitative obstetrical care and could affect the decision on mode of delivery. In this regard, the current suffering related to the abuse/violence should be taken into consideration since the psychological damage caused by violence has been shown to be affected by the way an individual interprets it, more so than the actual type and frequency of the violent experience as such. Taking current suffering into account prevents all women reporting IPV from being categorized under the same label and facilitates a more tailored approach within the context of perinatal care. 245
5.3.
Interventions The intervention part of our research demonstrated that identifying IPV in combination with handing out a referral card did not produce statistically significant differences between the intervention and control group for IPV, psychosocial health, help seeking and safety behaviour in a sample of women who recently gave birth. However, IPV did decrease with more than a third, and psychosocial health improved significantly over the study course. More than one-­‐fifth of the women sought formal help, and 70.5% sought informal help. Women reporting IPV showed significantly increased formal and informal help-­‐seeking behaviour. A third of the women took at least one safety measure. Overall, taking safety measures increased significantly when IPV was reported. The questionnaire and the interview in this study were perceived as helpful for more than a third of our sample, which was significantly higher than the perceived helpfulness of the referral card. We were, however, not able to attribute this finding to the intervention. Although the helpfulness of the referral card appears to be higher in the IG, it borderline missed statistical significance. In other words, detection of IPV can be a helpful tool in the battle against IPV, although combining identification with simply handing out a referral card may not be the best means of achieving that goal. Women may on the one hand be unaware that the behaviour constitutes abuse or on the other hand be actively seeking support for change, and therefore responses to their needs need to differ, and may require involvement of a healthcare professional rather than a list of resources (O'Doherty et al., 2015). Being asked questions on violence during and after pregnancy is perceived as more helpful than receiving a referral card. There is a large consensus among researchers and caregivers that the context of perinatal care is an ideal ‘window of opportunity’ to identify and address IPV, for it is often the only moment in the lives of many couples when there is (regular) contact with health care providers and a relationship of trust can be built. However, the implementation of screening in the current Belgian perinatal care setting is associated with substantial organizational and logistic challenges (with on average 10 minutes per antenatal consultation, a lack of privacy etc.). Moreover, many health care providers deal with numerous other barriers, such as a lack of knowledge on who to refer women/couples to, a lack of skills in how to tend to women reporting IPV, or simply being uncomfortable with the topic. In contrast, the women in our study clearly indicated willing to 246
discuss the emotional aspects of their life with the midwife. Hence, we recommend that the introduction of routine screening for IPV goes hand in hand with well-­‐considered organizational and policy changes within the perinatal care context. If all pregnant women are to be screened for violence/abuse, this should be part of a larger programme comprising sensitization efforts, training of professionals (as part of the basic training of all care professionals as well as booster sessions for perinatal care staff), a 24/7 referral plan and a care pathway that includes risk taxation. Another obstacle that needs to be tackled before routine screening can be introduced is the lack of evidence on the effectiveness of interventions. We need to shift research efforts towards testing the effectiveness of interventions for women who disclose violence/abuse. However, we should not wait for more evidence before we can take action. Screening does not seem to cause harm in the short term, although harm is only explicitly measured in only one study (O'Doherty et al., 2015). A potential way of taking a step forward is by organizing the introduction of (at least) one standard “women-­‐only” consultation with a midwife for all pregnant women. This consultation would offer one-­‐to-­‐one time with a (preferably specifically trained) midwife and is a perfect opportunity for a broad psychosocial assessment dealing with social support, recent stressors, self-­‐esteem, anxiety/depression and other mental health problems and couple relationship problems such as IPV. Since women were found to undergo and commit IPV to the same extent, we would like to emphasise the need to enquire about both perpetration and victimization behaviour in a non-­‐judgemental manner. Increasingly more research has shown that women’s IPV perpetration also has detrimental health effects, but additional research is needed to provide more clarity on these initial findings. Concerning cost-­‐effectiveness, we are unable to make any scientifically-­‐
founded statements on if screening should or should not be implemented in Belgium since there no evidence available. The limited international evidence on cost-­‐effectiveness suggest that health care programs for IPV which promote disclosure and enhance referral to care could be feasible and provide good economic value (US Preventive Task Force, 2012). For example a UK primary health care intervention-­‐package (including staff training, prompts to ask women about DV embedded in the electronic medical record, a care pathway including referral to a specialist DV agency and continuing contact from that agency), is likely to be cost saving from a societal perspective (Devine, Spencer, Eldridge, Norman, & Feder, 2012). 247
Due to the very different organisation of our health care system, we believe that a Belgian cost-­‐effectiveness study is required to provide more insight into the specific costs and benefits of the introduction of screening on all different levels. While conducting a systematic literature review and RCT on interventions addressing IPV, we came across several obstacles and will formulate some recommendations on these matters in this paragraph. Due to the lack of evidence on effective IPV interventions, additional large-­‐scale, high-­‐quality research including meta-­‐analysis is needed. Future intervention studies should also be more comprehensive in nature and simultaneously address several risk factors (such as psychosocial health, substance abuse and social support). Intervening on a single risk factor might be unsuccessful because other risk factors may persist as barriers to the desired change. We believe that comprehensive IPV interventions that concurrently address risk factors at the individual, interpersonal, societal, cultural and community levels may have higher rates of success. Interventions that involve informal networks as a fundamental component may also be more effective. However, large-­‐scale, high-­‐quality research is essential to provide further evidence about the content of these interventions and clarify which interventions should be adopted in the perinatal care context. Furthermore, future IPV interventions should include information on the typologies of IPV (intimate terrorism and mutual violence) in their assessment. Doing so will allow researchers to accurately test and compare the effects of different types of IPV victimization and perpetration among pregnant and postpartum women. Delineating these types as well as taking into account the stages of change, the help-­‐seeking strategies and the complex mutuality of IPV offers the potential to design a tailored intervention that is better adapted to the specific needs of couples experiencing IPV. If we are allowed to dream aloud, the introduction of an antenatal screening-­‐
programme (cf. supra), could go hand-­‐in-­‐hand with the introduction of a home-­‐visitation programme based on the Olds (Olds et al., 2004) and Bair-­‐
Merritt (Bair-­‐Merritt et al., 2010) trials. There is quite some evidence available that these programmes are (cost-­‐)effective and a similar programme has already been successfully implemented in the Netherlands (Mejdoubi et al., 2013b). Although the existing Belgian perinatal preventive K&G (Kind en Gezin)–programme is an excellent pathway, it will require a well-­‐coordinated approach embedded in a centralised policy-­‐framework with substantial 248
investments in training and collaboration (which will most probably be cost-­‐
effective in the long term). The K&G nurses could deliver a home-­‐visit intervention in vulnerable childbearing families. Since it has been shown that paraprofessionals can have an significant impact on psychosocial well-­‐being, the extended K&G home-­‐visits could run in parallel with a buddy-­‐programme. This is an initiative that already exists in several midwifery schools, were the senior student-­‐midwives support vulnerable families on several levels. The underneath box provides a summary of our recommendations: 1.
2.
3.
4.
5.
6.
7.
8.
9.
We call for a thorough debate on the definitions of IPV and the related terminology. We suggest further developing, testing and validating psychological abuse measures. An integrated theoretical framework on IPV related to pregnancy should be developed. Sensitization programmes raising awareness on the harmfulness of the “lighter” forms of IPV and promoting non-­‐violent communication skills could help to reduce IPV. We suggest introducing (at least) one “women-­‐only” consultation with a midwife for a comprehensive psychosocial health assessment as a standard part of antenatal care, which would include questions on abuse/violence victimization and perpetration and take current suffering into account. Additional longitudinal, large-­‐scale, in-­‐depth research and qualitative analysis is needed to explore the impact of abuse/violence on obstetric outcome and shed light on the complex interactions and confounding factors that define the relationship between IPV and psychosocial health. Future interventions should be multifaceted and address individual, interpersonal, social, and cultural aspects, distinguish between different types of violence, involve informal networks, control for measurement reactivity and include a tailored intervention (and outcome measures) adapted to the specific needs of couples experiencing IPV. More high-­‐quality research (including meta-­‐analysis) is required to provide further evidence on the content and cost-­‐effectiveness of IPV victimization and perpetration interventions and clarify which interventions should be adopted in the perinatal care context. Incorporating IPV in the medical and paramedical curricula and training (perinatal) health care professionals is a crucial step in thoroughly tackling the problem of IPV. 249
250
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Yoshihama, M. (2002). Policies and services addressing domestic violence in Japan: From non-­‐interference to incremental changes. Womens Studies International Forum, 25, 541-­‐553. Yost, N. P., Bloom, S. L., McIntire, D. D., & Leveno, K. J. (2005). A prospective observational study of domestic violence during pregnancy. Obstet.Gynecol., 106, 61-­‐65. Zink, T., Elder, N., Jacobson, J., & Klostermann, B. (2004). Medical management of intimate partner violence considering the stages of change: Precontemplation and contemplation. Annals of Family Medicine, 2, 231-­‐239. Zlotnick, C., Capezza, N. M., & Parker, D. (2011). An interpersonally based intervention for low-­‐income pregnant women with intimate partner violence: a pilot study. Archives of Womens Mental Health, 14, 55-­‐65. 287
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Annexes Annex 1: BIDENS questionnaire Annex 2: MOM study protocol Annex 3: MOM questionnaire Annex 4: Referral card Annex 5: Interview guide (first interview) Annex 6: Ethical approval BIDENS-­‐study Annex 7: Ethical approval MOM-­‐study 289
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Annex 1: BIDENS questionnaire 291
292
Master-copy English
Study number
Find a place where you can sit down in peace and quiet. Answer all questions as best you can without
thinking too much about them. If you do not find an alternative that suits you, choose the one that is
closest to what you would have wanted to answer. Both positive and negative answers are important.
This questionnaire will be read by scanner. It is therefore important that you observe the following guidelines for
filling it out:
Use a blue or black ballpoint pen.
Put a cross in the small boxes for the answer which you think suits best, like this
If you have crossed off the wrong box, you can fix this by blackening the whole box, like this █
The number-boxes have to or more boxes. When writing a single number use the box most to the right, like
this
Kindly write clearly with capital letters when writing free text
DATE FOR COMPLETING THE QUESTIONNAIRE:
Day
Month
Year
1. About your health
1.01 How do you feel your health is, generally speaking? Mark one
Very good
Rather good
Rather poor
Very poor
1.02 How many times have you visited a doctor for your own sake during the last 12 months? Mark one
0 visits
1–3 visits
4–6 visits
7 visits or more
1.03 Have you been on sick leave or not been able to engage in your daily tasks for more than 2 weeks in a row
during the past 12 months?
No
Yes
If yes, in all about
number of weeks
1.04 Have you been hospitalised during the past 12 months? Do not include childbirth.
No
Yes
If yes, in all about
number of days
1.05 Have you ever asked for help from a psychiatrist or psychologist for problems of your own? Mark one
No
Yes, previously, but not for the last 12 months
Yes, during the last year, before I got pregnant
Yes, during the last year, after I got pregnant
1.06 Do you smoke/have you smoked daily? Mark one
Yes, currently
Yes, previously
Never
1
293
1.07 How often do you consume alcohol?
Never
Sometimes
Regularly
Not since I’ve known I’m pregnant
1.08Mark your use of medication during the past year.
Not at all
Rarely
Sleeping tablets
Short period
Longer period
Regularly
Painkillers
Relaxing/anti-anxiety medication
Anti-depressives
Other medication for mental problems
1.09 Was this pregnancy planned?
No
Yes
1.10 In which week of your pregnancy are you now?
number of weeks
1.11 Are you expecting more than one child (twins or more)?
No
Yes
2. What expectations do you have about your forthcoming birth?
2. This questionnaire is about feelings and thoughts women may have at the prospect of labour and delivery.
The answers to each question appear as a scale from 0 to 5. The outermost answers (0 and 5 respectively) correspond
to the opposite extremes of a certain feeling or thought.
Please complete each question by drawing a circle around the number belonging to the answer which most closely
corresponds to how you imagine your labour and delivery will be.
Please answer how you imagine your labour and delivery will be - not the way you hope it will be.
2.01
1
2
2.02
3
4
5
6
7
How do you think your labour and delivery will turn out as a whole?
0
1
2
3
4
5
Extremely
Not at all
fantastic
fantastic
0
1
2
3
4
5
Extremely
Not at all
frightful
frightful
How do you think you will feel in general during the labour and delivery?
0
1
2
3
4
5
Extremely
Not at all
lonely
lonely
0
1
2
3
4
5
Extremely
Not at all
strong
strong
0
1
2
3
4
5
Extremely
Not at all
confident
confident
0
1
2
3
4
5
Extremely
Not at all
afraid
afraid
0
1
2
3
4
5
Extremely
Not at all
deserted
deserted
2
294
8
9
10
11
12
13
14
15
16
17
18
2.03
19
20
21
22
23
24
2.04
25
26
0
1
2
3
4
5
Extremely
Not at all
weak
weak
0
1
2
3
4
5
Extremely
Not at all
safe
safe
0
1
2
3
4
5
Extremely
Not at all
independent
independent
0
1
2
3
4
5
Extremely
Not at all
desolate
desolate
0
1
2
3
4
5
Extremely
Not at all
tense
tense
0
1
2
3
4
5
Extremely
Not at all
glad
glad
0
1
2
3
4
5
Extremely
Not at all
proud
proud
0
1
2
3
4
5
Extremely
Not at all
abandoned
abandoned
0
1
2
3
4
5
Totally
Not at all
composed
composed
0
1
2
3
4
5
Extremely
Not at all
relaxed
relaxed
0
1
2
3
4
5
Extremely
Not at all
happy
happy
What do you think you will feel during the labour and delivery?
0
1
2
3
4
5
Extreme
No panic
panic
at all
0
1
2
3
4
5
Extreme
No hopelessness
hopelessness
at all
0
1
2
3
4
5
Extreme
No longing for
longing for the child
the child at all
0
1
2
3
4
5
Extreme
No selfself-confidence
confidence at all
0
1
2
3
4
5
Extreme
No trust
trust
at all
0
1
2
3
4
5
Extreme
No pain
pain
at all
What do you think will happen when labour is most intense?
0
1
2
3
4
5
I will behave
I will not behave
extremely badly
badly at all
0
1
2
3
4
5
I will allow my
I will not allow
body to take
my body to take
total control
control at all
3
295
27
2.05
28
29
30
31
2.06
32
33
0
1
2
3
4
5
I will totally
I will not lose
lose control
control of
of myself
myself at all
How do you imagine it will feel the very moment you deliver the baby?
0
1
2
3
4
5
Extremely
Not at all
enjoyable
enjoyable
0
1
2
3
4
5
Extremely
Not at all
natural
natural
0
1
2
3
4
5
Totally
Not at all
as it should be
as it should be
0
1
2
3
4
5
Extremely
Not at all
dangerous
dangerous
Have you, during the last month, had fantasies about the labour and delivery, for example.....
... fantasies that your child will die during labour/delivery?
0
1
2
3
4
5
Never
Very often
... fantasies that your child will be injured during labour/delivery?
0
1
2
3
4
5
Never
Very often
3. About different experiences
The following questions deal with abuse in the health care system. We ask you to mark whether you have
experienced any of the following events; as a child or as an adult. If you answer yes to any of the questions 3.01–
3.03 we conclude – in this study – that you have been subject to abuse in the health care system.
3.01 Have you ever felt offended or grossly degraded while visiting health services, felt that someone put
pressure on you or did not show respect for your opinion – in such a way that you were later disturbed by or
suffered from the experience? Mark one
No
Yes, as a child (younger than 18)
Yes, as an adult (18 or older)
Yes, both as child and adult
3.02 Have you ever experienced that a ”normal” event while visiting health services suddenly became a really
terribly unpleasant experience, without you fully knowing how this could happen? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
3.03 Have you experienced anybody in the health services purposely – as you understood it – hurting you
physically or mentally, grossly violating you or using your body or your dependent relationship for his/her
own purpose? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
If you answered yes to any of the questions from 3.01–3.03, please continue with question 3.04
If you answered no to all of the questions from 3.01–3.03, please continue with question 3.06
3.04 Have you experienced any of this during the last 12 months?
No
Yes
3.05 How much are you suffering now from the consequences of the abuse in health services you have
experienced? answer by marking the number that best corresponds to how much you are suffering now
Don’t suffer
at all
0
1
2
3
4
5
6
7
8
9
10
Suffer
terribly
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3.06 Have you during the last 12 months experienced any of the following events? If yes, how would you
evaluate the experience?
If Yes
No
Yes
Not too bad
/difficult
Bad/
difficult
Very bad
/difficult
Become divorced/separated or stopped living together
Had serious problems in the relationship with your partner
Had problems or conflicts with family, friends or neighbours
Had problems at your job or the place you study at
Had financial problems
Been seriously ill or injured
Been involved in a traffic accident, fire or burglary
Someone close to you became seriously ill or injured
Lost a close relative / friend
Other:
The following questions deal with emotional abuse. We ask you to mark whether you have experienced any of the
following events, as a child or as an adult. If you answer yes to any of the questions 3.07–3.09 we conclude – in this
study – that you have been subject to emotional abuse.
3.07 Have you experienced anybody systematically and for a longer period of time trying to repress, degrade
or humiliate you? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
3.08 Have you experienced living in fear because somebody systematically and for a longer period of time has
threatened or tried to harm you or someone close to you? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
3.09 Have you experience anybody systematically and by threat or force trying to limit your contacts with
others or totally control what you may of may not do? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
If you answered yes to any of the questions from 3.07–3.09, please continue with question 3.10
If you answered no to all of the questions from 3.07–3.09, please continue with question 3.12
No
3.10 Have you experienced any of this during the last 12 months?
Yes
3.11 How much are you suffering now from the consequences of the psychological abuse you have
experienced? Answer by marking the number that best corresponds to how much you are suffering now
Don’t suffer
at all
0
1
2
3
4
5
6
7
8
9
10
Suffer
terribly
The following questions deal with physical abuse. We ask you to mark whether you have experienced any of the
following events; as a child or as an adult. If you answer yes to any of the questions 3.12–3.14 we conclude – in this
study – that you have been subject to physical abuse.
3.12 Have you experienced anybody hitting you, smacking your face or holding you firmly against your will?
Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
3.13 Have you experienced anybody hitting you with his/her fist(s) or with a hard object, kicking you, pushing
you violently, giving you a beating, thrashing you or doing anything similar to you? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
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297
3.14 Have you experienced anybody threatening your life by, for instance, trying to strangle you, showing a
knife or other weapon or by any other similar act? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
If you answered yes to any of the questions from 3.12–3.14, please continue with question 3.15
If you answered no to all of the questions from 3.12–3.14, please continue with question 3.17
3.15 Have you experienced any of this during the last 12 months?
No
Yes
3.16 How much are you suffering now from the consequences of the physical abuse you have experienced?
Answer by marking the number that best corresponds to how much you are suffering now
Don’t suffer
at all
0
1
2
3
4
5
6
7
8
9
10
Suffer
terribly
The following questions deal with sexual abuse. We ask you to mark whether you have experienced any of the
following events, as a child or as an adult. If you answer yes to any of the questions 3.17–3.20 we conclude – in this
study – that you have been subject to sexual abuse.
3.17 Has anybody against your will touched your genitals, used your body to satisfy him/herself sexually or
forced you to touch anybody else’s genitals? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
3.18 Has anybody against your will put his penis into your vagina, mouth or rectum or tried to put an object
or other part of the body into your vagina, mouth or rectum? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
3.19 Has anybody against your will touched parts of your body other than the genitals in a ”sexual way” or
forced you to touch parts of their body in a “sexual way”? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
3.20 Have you ever in any way been sexually humiliated, e.g. by being forced to watch a pornographic film, or
similar, against your will, forced to participate in a pornographic film or similar, forced to show your body
naked or forced to watch when somebody else showed his/her body naked? Mark one
No
Yes, as an adult (18 or older)
Yes, as a child (younger than 18)
Yes, both as child and adult
If you answered yes to any of the questions from 3.17–3.20, please continue with question 3.21
If you answered no to all of the questions from 3.17–3.20, please continue with question 4.01
3.21 Have you experienced any of this during the last 12 months?
No
Yes
3.22 How much are you suffering now from the consequences of the sexual abuse you have experienced?
Answer by marking the number that best corresponds to how much you are suffering now
Don’t suffer
terribly at all
0
1
2
3
4
5
6
7
8
9
Suffer
10
4. About your background
4.01How old are you?
years
4.02 What is your marital status? Mark one
Married/cohabitant
Single
Other:______________________
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298
4.03 Do you have someone, besides your husband/partner, to whom you can confide to?
No
Yes, 1–2 persons
Yes, several persons
4.04 Is your mother-tongue ……….. (the language of your country or the area of the study)?
Yes
No
If no, which is your mother-tongue? ……………………….
4.05 What education do you have? Mark one
Primary school (6-9 years)
Secondary / Grammar school (10-13 years)
College or university, less than 4 years (up to 15 years)
College or university, 4 years or more (15 years or more)
4.06 What is your main occupation? Mark one
Employed
Self-employed/freelancer
Student
Parental or pregnancy leave
Housewife
Unemployed
Social Benefit
4.07 If you received a bill for (here the correct amount for each country is written), how easy would it be to pay
that within a week?
No problem
Slightly difficult
Very difficult
5. Some more questions about your general health
5.01During the last 12 months, have you suffered from various physical ailments (e.g. stomach-ache,
headache, dizziness or muscular pain) to such an extent that you have had problems coping with your daily
life? Mark one
No
Yes, but rarely
Yes, sometimes
Yes, often
5.02During the last 12 months, have you suffered from anxiety to such an extent that you have found it hard
to cope with your daily life? Mark one
No
Yes, sometimes
Yes, but rarely
Yes, often
5.03 During the last 12 months, have you experienced unpleasant recollections intruding to disturb you
without you being able to do nothing about it? Mark one
No
Yes, sometimes
Yes, but rarely
Yes, often
5.04 During the last 12 months, have you avoided situations in order not to have unpleasant recollections or
feelings, and has that interfered with what you wanted to do? Mark one
No
Yes, sometimes
Yes, but rarely
Yes, often
5.05 During the last 12 months, have you ever felt as if your feelings were numbed for a long period? Mark one
No
Yes, sometimes
Yes, but rarely
Yes, often
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299
5.06 Read each item and mark the one which comes closest to how you have been feeling in the past week.
Yes, most of Yes, some Not very
No,
the time
times
often
never
I have felt sad or miserable
I have been anxious or worried for no good reason
I have been so unhappy that I have had difficulty sleeping
I have blamed myself unnecessarily when things went wrong
I have looked forward with enjoyment to things
5.07 Do you feel lonely?
Never
Rarely
Sometimes
Usually
Nearly all the time
6. Some more questions about your pregnancy
6.01 How do you want to give birth?
Vaginally
Probably vaginally
Probably by caesarean section
By caesarean section
6.02 Have you had counselling in connection with fear of childbirth?
No
Yes, in this pregnancy
Yes, before this pregnancy
6.03 Have you been pregnant before? (This includes pregnancies which ended in a miscarriage, abortion or stillbirth)
No Turn to question 9.01
Yes Continue below
number of children
6.04 How many children have you given birth to?
6.05 How many children are alive today?
number of children
6.06 Have you ever had a miscarriage?
No
Yes, miscarriage
If yes
number of times
6.07 Have you ever had an abortion?
No
Yes, abortion
If yes
number of times
7. About your first birth
7.01 How old were you when you gave birth to your first child? I was
7.02 Was that birth a twin/plural birth?
No
years
Yes
7.03 How did you give birth?
Normal vaginally
Planned Caesarean
Acute Caesarean
Vacuum
Forceps
Breech vaginally
7.04 How did you experience your first birth?
Purely a positive experience
Mainly a positive experience, but with negative elements
Mainly a negative experience, but with positive elements
Purely a negative experience
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300
8. About your last birth (if you’ve have given birth only once continue with question 9.01)
8.01 How old were you when you gave birth to your last child? I was
8.02 Was that birth a twin/plural birth?
No
years
Yes
8.03 How did you give birth?
Normal vaginally
Planned Caesarean
Acute Caesarean
Vacuum
Forceps
Breech vaginally
8.04 How did you experience your last birth?
Purely a positive experience
Mainly a positive experience, but with negative elements
Mainly a negative experience, but with positive elements
Purely a negative experience
9. About childbirth in general
9.01 Have you other experiences related to pregnancy and birth which are important?
No
Yes
If yes, please specify: _________________________________________________________________________
If you require more space please continue under comments.
Finally
If you have any comments to the questions we’ve asked, we would appreciate it if you wrote them on this page. If
you after completing this questionnaire feel the need to talk to someone, we advise you contact with your family
doctor, gynaecologist, midwife or the hospital at which you are planning to give birth. For questions about this study,
please contact xxxxxxxxxx Tel. XXXXX (one name and number for each country)
Comments:
Place the completed questionnaire in the enclosed envelope together with your consent
form. The postage has been paid. Thank you for taking part!
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Annex 2: MOM study protocol 303
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Study protocol MOM-study
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Page 2 of 21
Table of contents
1
2
3
4
Title of the study................................................................................. 4
Study number ..................................................................................... 4
Aim of the study ................................................................................. 4
General information............................................................................ 4
4.1 Researchers ................................................................................................................. 4
4.2 Commissioner .............................................................................................................. 4
4.3. Departments / services involved in the study ............................................................. 5
First wave ............................................................................................................................... 5
5
Introduction ....................................................................................... 5
5.1
5.2
6
Situation and problem formulation ............................................................................. 5
Literature ..................................................................................................................... 6
The study ........................................................................................... 9
6.1 Aim ............................................................................................................................... 9
6.2 Research questions ...................................................................................................... 9
6.3 Study design................................................................................................................. 9
6.3.1 First part: prevalence study (questionnaire)...................................................... 10
6.3.1.1
Study design and study population ............................................................ 10
6.3.1.2
Sample size .................................................................................................. 10
6.3.1.3
Measuring devices ...................................................................................... 11
6.3.2 Second part: randomized controlled trial (RCT) ................................................ 12
6.3.2.1
Study design and study population ............................................................ 12
6.3.2.2
Sample size .................................................................................................. 13
6.3.2.3 ........................................................................................................................... 13
6.3.2.4
Measuring instruments ............................................................................... 13
6.4 Ethical aspects ........................................................................................................... 14
6.5 The participants ......................................................................................................... 15
6.5.1 Number............................................................................................................... 15
6.3.2. Inclusion criteria ................................................................................................. 15
6.5.2 Exclusion criteria ................................................................................................ 15
6.5.3 Replacement of participants .............................................................................. 16
6.5.4 Possible advantages and risks for the test subjects. .......................................... 16
7
Procedures ....................................................................................... 17
7.1
Study process ............................................................................................................. 17
8 Randomization scheme and blinding .................................................. 19
9 Therapy preceding or during the study ............................................... 19
10 Study analysis ................................................................................... 19
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10.1
10.2
10.3
11
12
13
14
Page 3 of 21
. Study sample calculation ..................................................................................... 19
. Analysis data part 1 & 2 ....................................................................................... 19
. Statistical analysis ................................................................................................ 19
Timing and planning .......................................................................... 20
Liability insurance ............................................................................. 20
Publication policy ............................................................................. 20
Signature page.................................................................................. 21
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Page 4 of 21
Study protocol
1 Title of the study
Title study:
Partner violence and pregnancy: an intervention study in perinatal care.
Title patients: Difficult moments & feelings during pregnancy
2 Study number
MOM-2009
Ethical approval: EC 2010/093
Belgian registration number: B67020108164
Clinicaltrial registration: https://clinicaltrials.gov/ct2/show/NCT01158690?term=van+parys&rank=1
3 Aim of the study
1) Prevalence study of physical, psychological and sexual violence one year before, during and
one year after pregnancy;
2) Investigate to which degree it is possible to use an intervention (screening for partner
violence + redirecting to services providing assistance) to
a. influence the prevalence of partner violence during pregnancy and after giving birth;
b. improve psychosocial health;
c. stimulate safety behaviour;
d. stimulate help-seeking behaviour;
4 General information
4.1 Researchers
Prof. Dr. M. Temmerman (MT), Women's Clinic, Department of Urogynaecology , Prof. Dr. Hans
Verstraelen (HV), Women's Clinic, Department of Urogynaecology, Ms. A.S. Van Parys (ASVP),
Women's Clinic, Department of Urogynaecology
Vrouwenkliniek UZGent,
De Pintelaan 185 UZP 114
9000 Gent
Tel: 09/332.52.73
4.2 Commissioner
FWO Vlaanderen
Egmontstraat 5
1000 Brussels
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Page 5 of 21
4.3. Departments / services involved in the study
First wave
Hospital 1: ZNA Middelheim Antwerpen
Hospital 2: UZ Antwerpen
Hospital 3: OLV Ziekenhuis Aalst
Hospital 4: AZ Monica Deurne
Hospital 5: private practice Dr. Johan Van Wiemeersch
Hospital 6: AZ St Jan Brugge
Hospital 7: AZ Jan Palfijn
Second wave
Hospital 8: OLV Van Lourdes ziekenhuis Waregem
Hospital 9: UZ Gent Women's Clinic, Department of Urogynaecology UGent (scientific
coordination of the study)
Hospital 10: AZ Groeninge Kortrijk
Hospital 11: Virga Jesse Hasselt
Hospital 12: ZOL Genk
5 Introduction
5.1 Situation and problem formulation
Partner violence has been widely described as an extensive and worldwide problem with important
societal and clinical implications (Humphreys et al., 2011; Tailieu et al., 2010; Gazmararian et al.,
2010; Macy et al., 2007; Bailey & Daugherty, 2007; Tilley & Brackley, 2004; Jasinski, 2004; Espinosa &
Osborne, 2002; McFarlane, et al., 2000). We define partner violence as the collection of all
behaviours, actions and attitudes, or the threat of, of one of the partners or former partners who
possible or effectively harms the other partner in a physical, psychological or sexual way (Roelens et
al., 2008; Werkgroep Partnergeweld, 2006; WHO, 2002; Saltzman et al., 2002). More specifically, the
perinatal period (defined as: up to one year before pregnancy, during pregnancy or up to one year
after pregnancy) is a period when the vulnerability of the female partner increases because the
violence threatens both the maternal and the foetal / neonatal wellbeing (Silverman et al., 2006;
Janssen et al., 2003).
Prevalence rates of violence in the period around pregnancy and giving birth vary according to the
applied definitions, research methodology and study population, but most studies mention 3 - 8%
(Humphreys et al., 2011; Tailieu et al., 2010; Gazmararian et al., 2010; Sanchez et al., 2007; Silverman
et al., 2006; Jasinski, 2004; Espinosa & Osborne, 2002). On the basis of a representative sample of
pregnant women in East-Flanders, we reported earlier that 3,4% of the 537 participating pregnant
women indicated that they have been a victim of partner violence during and/or in the year
preceding pregnancy (Roelens et al., 2008). Our colleagues from Brussels (Jeanjot et al., 2008)
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published comparable rates: 11% of women who had recently given birth, had been a victim of
domestic violence during pregnancy, of which more than half of the cases were partner violence.
Women who are exposed to violence during the perinatal period are unmistakably more at risk of a
late start of prenatal care, a low birth weight, preterm labour and giving birth, foetal / neonatal
complications (e.g. intra-uterine growth retardation) and maternal complications (e.g. preeclampsia,
postnatal depression, etc.) (Humphreys et al., 2011; Tailieu et al., 2010; Gazmararian et al., 2010;
Bailey & Daugherty, 2007; Macy et al., 2007; Sanchez et al., 2007; Silverman et al., 2006; Boy &
Salihu, 2004; Tilley & Brackley, 2004; Jasinski, 2004; Janssen et al., 2003; Espinosa & Osborne, 2002;
McFarlane, et al., 2000).
The lack of representative, large-scale and monitored intervention studies about partner violence
before, during and after pregnancy causes a lack of knowledge about treatment of the phenomenon.
The combination of societal taboos, the denial of violence towards pregnant women, the complexity
of the topic and the limited research data, point towards an urgent need for a scientific guide for
perinatal care provision.
Perinatal care forms an ideal window of opportunity to identifying, guiding and redirecting women
experiencing violence as pregnancy is often the only moment when women are regularly in touch
with caregivers (Espinosa & Osborne, 2002; Mc Farlane et al., 2000). Various authoritative instances
in Great Britain and America (among which American College of Obstetricians and Gynaecologists,
American Academy of Paediatrics, American College of Emergency Physicians, American Academy for
Family Physicians, Centres for Disease Control) therefore advice systematic screening for violence
during pregnancy. Gradually an increasing amount of research proves that it is safe and/or effective
to screen for violence during pregnancy (Katoaka et al., 2010, Bailey et al., 2010, Bunn et al., 2009,
Houry et al, 2008 McFarlane, Parker & Moran, 2007; Cherniak et al., 2005; Department of Health,
2005). In contrast to countries such as Great Britain, the Netherlands and the United States, partner
violence is not routinely screened for in Belgium. What is more, in Flanders 69,5% of the 249
questioned gynaecologists rejected the proposition to screen routinely (Roelens et al., 2006). The
most important barriers in Belgium are, just like in our neighbouring countries, a lack of time, fear of
insulting patients and deficient knowledge of the redirection possibilities. As opposed to what
caregivers expected, Belgian women also seem to have few issues with caregivers routinely asking
questions about (partner) violence (Furniss, 2007; Renker & Tonkin, 2006; Roelens et al., 2006;
Misnky-Kelly, 2005, Bacchus, Mezey & Bewley, 2002).
5.2 Literature
Bacchus, L, et al. (2007) A theory-based evaluation of a multi-agency domestic violence service at
Guy’s & St Thomas’ NHS Foundation Trust. London: King’s College London.
Bailey, A. & Daugherty, R. (2007). Intimate partner violence during pregnancy: incidence and
associated health behaviours in a rural population. Matern Child Health J, 11, 495-503.
Bailey, B. (2010). Partner violence during pregnancy: prevalence, effects, screening, and
management. International Journal of Women’s Health, 2, 183-197.
Boy, A. & Salihu, H. (2004). Intimate partner violence and birth outcomes: a systematic review. Int J
Infertil, 49, 159-163.
Bunn, M. (2009). Domestic violence screening in pregnancy. Hawaii Medical Journal, 58, 240-242
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Cherniak, D. et al. (2005). Intimate partner violence consensus statement. SOGC clinical practice
guidelines n° 157, Society of Obstetricians and gynaecologists of Canada.
Department of gender and women’s health family and community health world health organisation
(2001). Ethical en safety recommendations for research on domestic violence against
women. WHO, Geneva.
Department of Health (2005). Responding to domestic abuse. Department of Health, London
Espinosa, L. & Osborne, K. (2002). Domestic violence during pregnancy: implications for practice.
Journal of Midwifery & Women’s Health, 47, 305-317.
Edwards P. et al. (2002) Increasing response rates to postal questionnaires: systematic review. BMJ,
324: 1183-1185.
Furniss, K. (2007). Nurses and barriers to screening for intimate partner violence. American Journal of
Maternal Child Nursing, 32, 238-243.
Humphreys, J. et al. (2011). Increasing Discussions of Intimate Partner Violence in Prenatal Care
Using Video Doctor Plus Provider Cueing: A Randomized, Controlled Trial. Women’s Health
Issues, 21, 136-144.
Houry, D. et al. (2008). Does screening in the emergency department hurt of help victims of intimate
partner violence?. Annals of Emergency Medicine, 51, 433-442.
Janssen, P. et al.. (2003). Intimate partner violence and adverse pregnancy outcomes: a populationbased study. Am. J. Obstet. Gynecol.,188, 1341-1347.
Jasinski, J. (2004). Pregnancy and domestic violence: a review of the literature. Trauma, Violence &
Abuse, 5, 47-64.
Jeanjot, I., Barlow, P. & Rozenberg, S. (2008). Domestic violence during pregnancy : survey of patients
and health care providers. J Womans Health, 17, 557-567.
Liebschutz, J. et al. (2008). Disclosing intimate partner violence to health care clinicians. BMC Public
Health, 8, 229-237.
Kataoka, Y. et al (2010). Self-administered questionnaire versus interview as a screening method for
intimate partner violence in the prenatal setting in Japan: A randomized controlled trial. BMC
Pregnancy and Childbirth, 10:84
Macy, R. et al. (2007). Partner violence among women before, during and after pregnancy multiple
opportunities for intervention. Women’s Health Issues, 17, 209-299.
McFarlane, J. Parker, B. & Moran, B.(2007). Abuse during pregnancy, a protocol for prevention and
intervention, 3rd edition. March of Dimes, New York.
McFarlane, J., Soeken, K. & Wiist, W. (2000). An evaluation of interventions to decrease intimate
partner violence to pregnant women. Public Health Nursing, 17, 443-451.
Misnky-Kelly, D. et al. (2005). We’ve had training, now what? Qualitative analysis of barriers to
domestic violence screening and referral in a health care setting. Journal of interpersonal
violence. 20, 1288-1309.
Ramsay, J. et al.. (2007). Should health professionals screen women for domestic violence?
Systematic review. BMJ, 325, 314-318.
Renker, P. & Tonkin, P. (2006). Women’s views on prenatal violence screening. Obstetrics and
gynaecology, 107, 348-354.
Roelens, K., Verstraelen, H., Van Egmond, K. & Temmerman, M. (2008). Disclosure and healthseeking behaviour following intimate partner violence before and during pregnancy in
Flanders, Belgium: a survey surveillance study. Eur. J. Obstet. Gynaecol.,137, 37-42.
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Roelens, K., Verstraelen, H., Van Egmond, K. & Temmerman, M. (2006). A knowledge, attitudes, and
practice survey among obstetrician-gynaecologists on intimate partner violence in Flanders,
Belgium. BMC Public Health, 6, 237-247.
Silverman, J. et al. (2006). Intimate partner violence victimization prior to and during pregnancy
among women residing in 26 U.S. states: associations with maternal and neonatal health.
Am. J. Obstet. Gynecol., 195, 140-8.
Taillieu, T. et al (2010). Violence against pregnant women: Prevalence, patterns, risk factors, theories,
and directions for future research. Aggression and violent behavior, 15, 14-35.
Tilley, D. & Brackerley, M. (2004); Violent lives of women: critical points for intervention – phase I
focus groups. Perspectives in Psychiatric Care, 40, 157-166.
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6 The study
6.1 Aim
The first objective of this study is a large-scale prevalence study of physical, psychological and sexual
violence one year before, during and one year after pregnancy. Furthermore, we want to examine if
there are safe and / or effective ways to tackle partner violence and all its negative consequences
within the perinatal care setting. Consequently, our second objective is to investigate to what extent
it is possible to decrease the prevalence of partner violence and reduce the negative effects of
partner violence on the pregnancy by an intervention (screening for partner violence and redirecting
to care provision for partner violence using a resource card).
6.2 Research questions
•
•
•
•
•
•
•
•
•
What is the prevalence of psychological, physical and sexual violence one year before, during
and one year after pregnancy in a large pregnant population (N=2000)?
How does intimate partner violence (IPV) evolve during pregnancy (increases, decreases,
stays the same)?
What is the psychosocial health status (anxiety, depression, self-esteem, mastery and stress)
of pregnant women (with or without violence experiences)?
o Are these problems related to experiencing violence?
How satisfied are pregnant women with the care they receive from midwives and/or
gynaecologists?
o Are women with psychosocial health problems and/or experiences of violence, less
satisfied with perinatal care?
What is the impact of an intervention (screening for violence during pregnancy in
combination with handing out a resource card) on the evolution of IPV?
What is the psychosocial health status of women in the intervention group compared to the
control group after the intervention?
What is the impact of the intervention on help-seeking behaviour in both groups?
o Do women in the intervention group seek more help than women in the comparison
group?
o What is the role ‘the stage of change’ in help-seeking behaviour?
What are triggers that stimulate women to find help?
o What role does the pregnancy play in this?
How does the intervention influence safety behaviour (McFarlane & Parker 1994) in both
groups?
6.3 Study design
The study is designed in 2 phases: a prevalence study and a randomized, single blind intervention
study with 2 parts. In the prevalence study, 2000 pregnant women will be recruited via prenatal
consultations in 15 hospitals. Based on this questionnaire, a number of victims of partner violence
will be selected to take part in a randomized controlled trial (RCT). We strive to interview 150
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victims of partner violence during pregnancy and up to one year before pregnancy. The group of
victims is randomized into an intervention and a control group. The Intervention Group (IG) will
receive a resource card with on the one side contact data of care providers for partner violence and
on the other side tips to improve the safety of women and possible child(ren). The Control Group
(CG) will not receive a resource card but instead a thank-you note and follow the standard prenatal
care process (on the information letter we include the phone number of tele-onthaal, which
participants can contact 24/7 should they require help).
Because there are no randomized screenings for partner violence in Belgium and the study
population is not routinely identified, the recruiting of the research population is also part of the
intervention.
6.3.1 First part: prevalence study (questionnaire)
6.3.1.1
Study design and study population
The study population will be recruited via prenatal consultations in 15 selected hospitals in Flanders.
We opt for recruiting simultaneously in various hospitals during the short period of 6 months to keep
the motivation with regard to study participation of both caregivers and patients as high as possible.
We plan to recruit for 1,5 years in total, which means 9 months in the first wave and 9 months in the
second wave.
The hospitals will be selected on the basis of capacity of the obstetrics department. The number of
women that should be recruited per hospital varies according to the capacity of the participating
hospitals. As it is impossible to obtain exact data 1 of the number of women that is yearly followed up
prenatally in Belgium, we are forced to estimate the capacity based on the number of births per
hospital. We assume that most women give birth in the hospital where they were followed up
prenatally (also in the private practices of the doctors). The number of births will more likely be an
underestimation of the number of women who are followed up prenatally because a small
percentage of women eventually gives birth in a different hospital (move, emergency birth, ...).
6.3.1.2 Sample size
The sample size of the prevalence study is based on the calculation of the sample of the randomized
controlled test. In other words, to gain a sufficiently large sample size for the randomly controlled
study, we originally aimed to reach 4000 women (calculation cf. sample size randomized controlled
test) twice during pregnancy, once between 20 and 22 weeks and once between 32 and 34 weeks of
pregnancy.
A couple of months after the start of the study, it became clear that recruiting took a lot longer than
planned because filling in the questionnaire was linked to a specific pregnancy duration. In
consultation with the members of the doctoral supervision committee [prof. dr. Temmerman (UG),
dr. Verstraelen (UG), dr. Roelens (UG) en prof. dr. Fred Louckx (VUB)], it was decided to drop the
strict pregnancy duration and have a participant fill in one questionnaire at any moment during the
pregnancy. Should a woman be willing to fill in a second one, that is possible provided that an
interval of 4 weeks is respected. By this methodological adjustment, we hope to reach more women
who could be considered for the RCT.
1
The RIZIV only offers data on the district level and not on the level of separate hospitals.
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As suggested by a number of doctors in the participating centres (ZNA Middelheim Antwerpen, UZ
Antwerpen, OLV Hospital Aalst, private practice dr. Van Wiemeersch, Jan Palfijn Gent and AZ St. Jan
Brugge), it was decided to recruit via the maternity and the MIC (department of Maternal Intensive
Care) of the aforementioned hospitals, in parallel with the prenatal consultation. All pregnant
women who are admitted to maternity and/or MIC are asked by the midwife if they are willing to fill
in a questionnaire. Of course the same ethical conditions hold with regard to filling in the
questionnaire as for the prenatal consultations. Because of the organisational difficulties and the
underestimation of prevalence of violence in the population (+/- 20% instead of 8.4%), the intended
sample size has been readjusted to 2000 women.
Because we plan to recruit 2000 women in +/- 15 hospitals, we can presume that every participating
hospital includes a minimum of 270 women within a period of 9 months (because of the large lost-tofollow-up in the second phase, see infra). The participating hospitals with many births (> 2000 / year)
will presumably include more than 270 women and the hospitals with less births (1000 - 2000 / year)
probably less than 270, with the ultimate goal of recruiting a total of 2000 women for the prevalence
study.
6.3.1.3 Measuring devices
The prevalence study is based on a written questionnaire. This questionnaire contains questions
about demographic aspects (age, civil status and level of education), psychosocial status (fear,
depression, self-confidence and stress), physical violence, sexual violence, psychological abuse and
satisfaction about the perinatal care provision.
The questions about physical and sexual violence probe for the existence and evolution of violence
throughout life, during the pregnancy and one year before the pregnancy. We ask if the violence has
been committed by the (former) partner, a family member or a stranger. We also determine the
frequency and investigate if the violence has changed in severity and / or frequency since the
beginning of the pregnancy. These elements will be measured by means of a translated and adjusted
version of the AAS (Abuse Assessment Screen, Soeken et al. in Campbell., 1998). This instrument is
internationally the most widely used and validated instrument with regard to detection of violence in
an obstetric population. As the authors of the AAS have informed us that to date no validated Dutch
and French versions exists, the instrument has been translated into both languages and back. There
was intensive communication with the authors of the AAS about the translation and adjustment of
the instrument. We investigate by means of a pre-test if the Dutch and French version reach similar
results as the original instruments.
As the AAS only pays limited attention to psychological abuse, we have added 7 items to measure
psychological abuse since the beginning of the pregnancy and one year before the pregnancy. These
items are based on translated and adjusted questions of the “WHO multi-country study on women’s
health and domestic violence against women questionnaire “(Garcia Moreno, et al., 2005)”.
To measure the psychosocial health status, we have received permission to use the ‘abbreviated
psychosocial scale’ by Goldenberg et al. (1997). This scale was extended and validated in a
population of pregnant victims of domestic abuse (Neggers et al., 2006; 2004). The ‘abbreviated
psychosocial scale’ comprised the following scales: Speilberger Trait Anxiety Scale, Center for
Epdimiologic Studies Scale, Rosenberg Self-Esteem Scale, Pearlin Mastery Scale and Schar Subjective
Stress Scale. The questions concerning the satisfaction measurement of perinatal care is based on a
translated and adjusted version of the ‘patient satisfaction scale’ by Plichta et al. (1996).
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The questionnaire will be filled in once during pregnancy. Because women can choose to fill in the
questionnaire anonymously (should they wish not to participate in the second phase of the study), a
code (first two letter of the first name, first two letters of the last name, the month and the year of
the date of birth) will be used.
The women who agree to participate and are eligible for the second part of the study (RCT) will fill in
their contact data on the questionnaire and be contacted later. The questionnaires of the women
who do not agree to participate in the second part will be used to determine the prevalence of
partner violence, the psychosocial status and the satisfaction with regard to perinatal care.
6.3.2 Second part: randomized controlled trial (RCT)
6.3.2.1 Study design and study population
The second part of the study is a randomized controlled trial (RCT), in which the identified victims
from the first part will be randomized in a single blind way into an intervention group and a control
group.
The victims of violence who included their contact data in the questionnaire (first part), will get an
opaque envelope from the midwife/doctor/secretary during their postpartum appointment (about 6
weeks after giving birth). The envelope of the intervention group contains a financial incentive and
the resource card. This resource card has the size of a bank card and lists on the one side contact
data of care provision and on the other side tips to improve the safety of pregnant women and
child(ren). These safety tips were selected and compiled in close collaboration with (inter)national
researchers and caregivers in the field of partner violence. The envelope of the control group also
contains a financial incentive and a note (same format and layout as the resource card) that thanks
them for their cooperation.
The thank-you note is added to the envelope of the control group so the caregivers and researcher
cannot feel the difference between the envelopes of the intervention and control group. That way
blinding is guaranteed as best as possible. We provide a financial incentive to maximize the response
rate in this second part, as this has clearly been shown to have a positive effect (Edwards et al.,
2002). The envelopes will be numbered using the "random digit" procedure. In this procedure, the
computer randomly assigns a study number to the envelopes, thus dividing the research population
into an intervention and a control group. The numbering of the "random digit" procedure will be
executed by a person who is not linked to the study. This person will also keep the key to the
identification of the control and intervention group. As the victims will receive either a resource card
or a thank-you note, it is not possible to fully blind the participants.
The caregivers and the reception staff that participate in the study will receive limited information
from the researcher about guiding and redirecting of these patients. However, it is not intended to
provide the caregivers for this study with extra support as the caregivers do not know who is a victim
and who is not. Because of the attention given to the study, caregivers might give more
consideration to the issue. This can possibly influence the result and will be taken into account when
processing the data. Due to the expected barriers of caregivers such as a lack of time, knowledge and
skills to deal with partner violence during pregnancy (Jeanjot et al., 2008; Roelens et al., 2006), we
presume that a written screening for violence on such a scale will already be quite the challenge.
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Therefore, we presume that few caregivers will provide extra support and that the influence on the
results will be minimal.
6.3.2.2 Sample size
To enable thorough statistical analyses, we strive for a minimum of 150 victims, which means 75
victims in the intervention group and 75 victims in the control group. These minima are based on a
similar intervention study by McFarlane et al. (2006), which clarified that 52 victims of the
intervention group have to be included to register a significant effect (decrease of the number of
violence episodes by the intervention, namely the provision of a resource card) with 80% statistical
power. To balance out a possible 'lost-to-follow-up', we provide about 20 extra participants for each
group. The study of Roelens et al. (2008) revealed that 3,4% of pregnant women had been victim of
physical and/or sexual violence during and/or one year before pregnancy. This study screened only
once for violence in a written form (also by means of an earlier version of the AAS). Gazmararian et
al. (1996) reported that the prevalence of partner violence during pregnancy increases with 5% when
screening takes place more than once of which a minimum of one screening during the third
trimester (≥ 27 weeks). Consequently, we originally expected a prevalence of 8,4% (3,4 + 5%) of
partner violence one year before and/or during pregnancy if we screened for partner violence once
during the first or second trimester of the pregnancy and once during the third trimester. We noticed
with regards to that 8,4% it seems like a large number compared to the prevalence of 3,4% reported
by Roelens et al. (2008), but we have to take into account that psychological abuse was not included
in that study.
Based on a prevalence of 8,4%, it was necessary to disperse 8000 questionnaires in Dutch, French
and English among 4000 women (2 questionnaires per woman) in the original study design.
Presumably, about 300 victims would be detected in this group during the perinatal period. Given the
delicate nature of the study topic, we expect that only about 150 women out of the 300 would be
willing to participate in the second part of the study.
During the first months of recruiting, it became clear that the percentage of women that (according
to our definitions) indicated experience with partner violence, clearly was higher than 8,4%. Of the
686 women that were recruited in the first wave, about 20% indicated that they have had experience
with physical, psychological and/or sexual partner violence. As a consequence, the total number of
women to recruit could be readjusted from 4000 to 2000. The number in the intervention and
control group, however, has stayed the same.
6.3.2.3 Measuring instruments
After the women have received the resource card or thank-you card during the postpartum check-up
6 weeks after giving birth, a researcher will conduct two semi-structured phone interviews of all
participants in the intervention group and control group. These interviews will take place respectively
6 months and 12 months after having received the envelope. Measuring will take place at 2
moments to check the effect of the intervention over time. For safety reasons, it will always be
checked if the women can talk freely, and if not she will be called back at a later time. The interview
will only take place when the victim and the researcher both deemed the situation safe.
The researcher will write down the quantitative and qualitative data during the interviews, which will
be later put into SPSS.
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The following variables will be asked for and measured during the interview:
• Date of birth;
• Partner relationship(s);
• Family structure;
• Mother tongue;
• Number of pregnancies / miscarriages / abortions;
• Planned pregnancy;
• Psychosocial status (fear, depression, self-confidence, stress and control);
• General health;
• Use of alcohol / tobacco and/or drugs;
• Partner violence;
• Readiness to change;
• Safety conduct;
• Help-seeking behaviour;
• Social support
6.4 Ethical aspects
Due to the complex and delicate topic of this study, a number of ethical measures have to be taken
into account to guarantee the safety of the participants, caregivers and researcher.
The information letter clearly mentions that concrete care provision with regard to partner violence
is not part of the aim of the study. The phone number of ‘tele-onthaal’ will be clearly mentioned on
the information letter so that all women who want to seek help whether due to this study or not, will
be able to get it 24/7. The information letter will also state that anonymity towards the caregiver will
be lifted should the researcher estimate that the safety risks are too high. This risk estimation will
happen every time when the participants and the researcher are in contact.
Concerning the first part of the study (questionnaire), a couple of conditions have to be met as well.
The questionnaires will be filled in in the hospital when the woman is alone (with the exception of
children younger than 2 years old) and when a caregiver is around should the woman wish for
further assistance.
Upon completion of the second and last interview, the researcher will offer the women of the control
group to still get the resource card that the intervention group has already received.
We also take specific measures into account for pregnant minors who wish to participate in the
study. Because of the delicate nature of the questionnaire, it does not seem to be a good idea to
have parents or guardians sign the consent form. As they are possibly involved in the violence, this
could provoke a rise in violence prevalence. Therefore, a member of the psychosocial staff of the
hospital will be contacted to have a short conversation with the minor. This staff member will decide
if the minor is fit to fill in the questionnaire. If the minor is deemed mature enough, the staff member
will sign the form of consent together with the minor. During the interview with the minor, a
psychologist will be present at all times to act as the "lawyer" of the minor.
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6.5 The participants
6.5.1 Number
Based on a prevalence of +/- 20% (calculation of percentage cf. sample size RCT), +/- 2000 women
will have to be screened for partner violence during pregnancy to detect +/- 300 victims of partner
violence one year before and/or during pregnancy. Consequently, 150 victims (75 for each group) are
required to mark a significant effect of the resource card with 80% power (part 2).
6.3.2. Inclusion criteria
Part 1:
• Dutch-, French- or English-speaking (mastering the language sufficiently to fill in a
questionnaire autonomously);
• Mentally competent;
• Pregnant.
Part 2:
• Dutch-, French- or English-speaking (mastering the language sufficiently to be
interviewed);
• Mentally competent;
• Victim of partner violence based on the questionnaire part 1;
• Contact data filled in on the questionnaire and agreed in written form via the form of
consent to being interviewed (2 months and 6 months post-intervention);
• Contactable via phone;
• Situation deemed safe enough to be interviewed.
6.5.2 Exclusion criteria
Part 1:
• Not sufficiently mastering Dutch, French or English to fill in the questionnaire
autonomously;
• Mentally incompetent;
• Not pregnant.
Part 2
• Not sufficiently mastering Dutch, French or English to be interviewed;
• Positive screening result for violence committed by other offenders than the (former)
partner;
• Denial of partner violence, despite a positive screening result for partner violence based
on the questionnaire of part 1;
• No written permission via informed consent;
• Refusal of participation in interview(s), despite formal permission via informed consent;
• No (readable) or incomplete contact data of participant;
• Not reachable via phone or problems with hearing;
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• Situation deemed too dangerous.
6.5.3 Replacement of participants
If we have insufficient data at our disposal for a participant in the second part of the study (RCT), she
will be replaced by a participant of whom we do have the full data at our disposal.
6.5.4 Possible advantages and risks for the test subjects.
Expected advantages are possibly a decrease of the number of violence episodes, an increase of
help-seeking and safety behaviour and an improvement of the psychosocial status. Should the
researchers estimate that the safety of the participant is threatened because of the study, she will be
excluded. Existing and validated instruments for risk taxation (e.g. Danger Assessment Screen,
Campbell et al. 2003) will be used if deemed necessary.
There are probably no risks connected to study participation.
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7 Procedures
7.1 Study process
Participants
Questionnaire pregnancy
Partner violence
Intervention group
Interview 6 months
Interview 12 months
Lost-to-follow-up
Control group
Interview 2 months
Interview 6 months
Lost-to-follow-up
Exclusion
No partner violence
Prevalence study
Exclusion
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7.2.1. Part 1 (questionnaire)
Step 1: identification of potential participants by caregiver(s) and/or reception personnel and short
introduction of the study
• Check if sticker(s) is/are already applied to the file (in case of an electronic patient file, the
sticker procedure is digitalised)
o If not:
if she is pregnant, mentally competent and sufficiently proficient in
Dutch/French/English → questionnaire;
if she is not pregnant, mentally competent or sufficiently proficient in
Dutch/French/English → exclusion;
o If so:
sticker: on file (this avoids that the woman unnecessarily is asked to
participate several times)
• Short oral explanation of the study: “Study about difficult moments & feelings during
pregnancy. We know that feelings influence the pregnancy. We want to improve
understanding of experiences and feelings and search ways to improve care."
Step 2: inclusion of participants
• Hand over the envelope Dutch/French/English (+ apply sticker on the file);
• Participants fill in informed consent and questionnaire by participants;
• Deposit closed envelope with informed consent and questionnaire in box;
Step 3: collected informed consent files and questionnaires
• Monthly sending / picking up of content of box;
• Scanning of questionnaires and identification of victims of partner violence (for part 2);
• Creation of database with contact data of victims and assigning of study numbers.
7.2.2. Part 2
Step 4: Randomisation
• Randomize victims of partner violence into intervention and control group via “random
digit” procedure after receiving the questionnaire;
Step 5: Intervention
• Find out the moment of postpartum consultation for participants part 2;
• Hand over envelope (with resource card or thank-you note) to midwife / secretary for
postpartum check-up;
Step 6: Interviews
• 6 months after handing over envelope, interview 1 with intervention and control group;
•
12 months after handing over envelope, interview 2 with intervention and control group
Study protocol “Partner violence and pregnancy, an intervention study in perinatal care”
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Page 19 of 21
8 Randomization scheme and blinding
With inclusion into the second part of the study, each participant gets a unique identification / study
number that has previously been assigned to one of the 2 groups via a random digit calculator. The
participants will receive a resource card or a thank-you card and thus not be able to be completely
blinded for the intervention. The researcher is blinded and will not be able to identify which
participant belongs to which group provided that two measures are installed. First of all, the
envelopes of the control group and of the intervention group contain cards of the same shape, so
that the difference cannot be felt. Secondly, someone who is not involved in the study will number
the envelopes. The caregiver(s) and/or reception staff also do not know who belongs to the
intervention or control group, but do not play a part in the continuation of the study.
After all data are known and centralised in a database, the blinding is lifted at the end of the study
for further analysis. At that moment, the participants of the control group will be offered to still
obtain the resource card. The database that enables linking the study numbers to the identity of the
women will be destroyed upon completion of the study.
9 Therapy preceding or during the study
No specific conditions.
10 Study analysis
10.1 . Study sample calculation
Based on a prevalence of +/- 20%, it will be necessary to screen +/- 2000 women for partner violence
during pregnancy (part 1) and to detect +/- 300 victims of partner violence one year before and/or
during pregnancy. Hence, 150 victims (75 in each group) are necessary to mark a significant effect (α
= 0.05) of the resource card with 80% power (part 2).
10.2 . Analysis data part 1 & 2
Dra. An-Sofie Van Parys
Prof Dr. Hans Verstraelen
(with the support of Dr. Ellen Deschepper at the cell Biostatistics, UG)
10.3 . Statistical analysis
We will measure the prevalence of partner violence, the psychosocial status and the satisfaction
regarding the perinatal care provision. We also study the correlation of partner violence with the
psychosocial status and the satisfaction regarding the perinatal care provision. We also investigate
whether the absolute and relative risk reduction is significant for the comparison of the intervention
group and the control group based on the chi² test (variables see supra). SPSS will be used for the
quantitative data analysis.
Study protocol “Partner violence and pregnancy, an intervention study in perinatal care”
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11 Timing and planning
See Microsoft Project Sheet
12 Liability insurance
UGent Policy – Fault liability.
13 Publication policy
The data obtained by this study can be published in a suitable scientific journal. In this case, the
patients' privacy will be respected at all times.
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14 Signature page
Researcher:
Name:
Prof. dr. Marleen Temmerman
Title:
promotor
Date and signature:
________________________________________________
Researcher:
Name:
Prof. dr. Hans Verstraelen
Title:
copromotor
Date and signature:
________________________________________________
Researcher:
Name:
Ms. An-Sofie Van Parys
Title:
doctoranda
Date and signature:
________________________________________________
Study protocol “Partner violence and pregnancy, an intervention study in perinatal care”
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326
Annex 3: MOM questionnaire 327
328
| Women’s Clinic, Ghent University 0P3, De Pintelaan 185, 9000 Gent
QUESTIONNAIRE
DIFFICULT MOMENTS AND FEELINGS
DURING PREGNANCY
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INSTRUCTIONS FOR COMPLETING THE QUESTIONNAIRE
This questionnaire forms part of a study at Ghent University on difficult moments and feelings during pregnancy. It is known that feelings affect
pregnancy. This study is conducted in order to understand how your feelings affect your pregnancy and thereby improve health care. We would
like to ask you to complete the exact same questionnaire at 20-22 weeks of your pregnancy and at 32-34 weeks. It will take approximately 10
minutes to complete the questionnaire.
In order to link these two questionnaires and still guarantee your anonymity as much as possible, we kindly ask you to fill out the following code
in capital letters: the first two letters of your first name, the first two letters of your family name, and the month and year of your
date of birth.
Complete:
/
For example::
Marie Smith, born in August 1978 becomes:
MA
/
/
SM
/
/
08
/
19
1978
Not just the pregnancy, but also the period after childbirth can be accompanied by difficult moments and conflicting feelings. That is why we would
like to study the experiences and emotions of a number of women who completed the questionnaires during their pregnancy at two different
moments after childbirth. If you are willing to help us out with this, we will contact you for two telephone interviews, one month and five months
after childbirth. During these interviews, we intend to map your experiences and feelings in more detail and explore ways to take better care of
women. The interviews will take approximately one hour. Your participation is essential to improve perinatal care! Therefore we will offer you a
gift voucher of 20€ if you are willing to be interviewed twice. We would like you to fill out your data below in capital letters, so that we are able
to contact you.
ALL INFORMATION FROM THIS QUESTIONNAIRE WILL BE TREATED AS STRICTLY CONFIDENTIAL. YOUR GYNAECOLOGIST, MIDWIFE
OR ANYONE ELSE WILL NOT BE INFORMED OF THE CONTENTS OF THIS QUESTIONNAIRE.
Name and familyname:
Land line/cell phone no.:
E-mail:
How do you proceed?
STEP 1: Read the information guide on pages 11 & 12 and sign the Informed Consent Form on page 13 ;
STEP 2: Complete the entire questionnaire;
STEP 3: Tear off the final page: you can take the blue copy of the Informed Consent Form [page 15] home as proof of your participation in this
study;
STEP 4: Put the questionnaire in the envelope provided and seal it;
STEP 5: Put the envelope in the box.
THANK YOU IN ADVANCE FOR YOUR PARTICIPATION IN THIS STUDY!
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QUESTIONNAIRE
As this questionnaire will be scanned in, it is important to pay strict attention to the following elements:
• Completely colour the option that is applicable to you as follows ‘ O ’ . In some questions, it is possible to colour multiple options;
• If you made a mistake, cross out the incorrect answer as follows: ‘ O ’ and then colour the correct one;
• Please write clearly when filling out a text or a number.
1.
2.
3.
4.
Date at which this questionnaire was completed:
How many weeks are you pregnant at this moment:
How old are you?
What is your marital status?
O
Married
O
.......... / .......... / 20 ..........
.......... weeks
.......... years old
Living together
Divorced or Separated
O
Single
O
5. What is the highest certificate or degree that you have achieved?
O
None
O
Non-university higher education
O
Primary education
O
University higher education
O
Secondary education
6. How did you feel most of the time DURING THE PAST 2 WEEKS?
There are no ‘right’ or ‘wrong’ answers, colour the option that reflects best how YOU felt during the past 2 weeks.
Never
Rarely
Sometimes
Often
Almost
always
a. I feel pleasant
O
O
O
O
O
b. In general, I tend to be very tense and nervous
O
O
O
O
O
c. I feel lonely
O
O
O
O
O
d. I am happy
O
O
O
O
O
e. I have crying spells
O
O
O
O
O
f. I feel secure
O
O
O
O
O
3
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Never
Rarely
Sometimes
Often
Almost
always
g. I have difficulty ‘shaking off the blues’ even with help
from my family or friends
O
O
O
O
O
h. All in all, I am inclined to feel that I am a failure
O
O
O
O
O
i. I am calm, cool and collected
O
O
O
O
O
j. Unimportant thoughts often run through my mind and
bother me
O
O
O
O
O
k. I feel fearful
O
O
O
O
O
l. I take disappointments so keenly that I can not put
them out of my mind
O
O
O
O
O
m. There is a great amount of nervous strain connected
with my daily activities
O
O
O
O
O
n. I feel hopeful about the future
O
O
O
O
O
o. I feel depressed
O
O
O
O
O
p. I feel sad
O
O
O
O
O
q. I am content (satisfied)
O
O
O
O
O
r. I take a positive attitude toward myself
O
O
O
O
O
s. I lack self-confidence
O
O
O
O
O
7. How did you feel most of the time DURING THE PAST 2 WEEKS?
There are no ‘right’ or ‘wrong’ answers, colour the option that reflects best how YOU felt during the past 2 weeks.
Strongly
disagree
Somewhat
disagree
Undecided
Somewhat
agree
Strongly
agree
a. I am easily bothered by things that did not use to
bother me
O
O
O
O
O
b. I have little control over the things that happen to
me
O
O
O
O
O
c. There is little I can do to change many of the
important things in my life
O
O
O
O
O
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Strongly
disagree
Somewhat
disagree
Undecided
Somewhat
agree
Strongly
agree
d. I feel that I do not have much to be proud of
O
O
O
O
O
e. I am able to do things as well as most other people
O
O
O
O
O
f. I often feel helpless in dealing with the problems
of life
O
O
O
O
O
g. I feel that I have a number of good qualities
O
O
O
O
O
h. I feel that I am a person of worth, at least on an
equal plane with other people
O
O
O
O
O
i. There is really no way I can solve some of the
problems I have
O
O
O
O
O
8. Have you ever been emotionally or physically abused by your partner or someone important to you?
Yes
O
No
O
9. DURING THE 12 MONTHS PRIOR TO YOUR PREGNANCY, were you hit, slapped, kicked or otherwise physically hurt by
someone?
Yes
O
No → go to question 10.
O
a. Who? Colour all options that apply.
O
Spouse
O
Partner
O
Family member
O
Ex-spouse
O
Ex-partner
O
Stranger
O
Other
b. How often? [during the 12 months prior to your pregnancy]
Rarely
O
O
Occasionally
O
Often
O
Very often
10. SINCE YOU BECAME PREGNANT, have you been hit, slapped, kicked or otherwise physically hurt by someone?
O
Yes
O
No → go to question 11.
5
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a. Who? Colour all options that apply.
O
Spouse
O
Partner
O
Family member
O
Ex-spouse
O
Ex-partner
O
Stranger
O
Other
b. How often? [during the 12 months prior to your pregnancy]
Rarely
O
Occasionally
O
O
Often
O
Very often
c. In terms of its severity and/or frequency, has this behaviour:
Increased
O
O
Decreased
O
Remained unchanged
11. DURING THE 12 MONTHS PRIOR TO YOUR PREGNANCY, did anyone force you to have sexual activities?
Yes
O
No → go to question 12.
O
a. Who? Colour all options that apply.
O
Spouse
O
Partner
O
Family member
O
Ex-spouse
O
Ex-partner
O
Stranger
O
Other
b. How often? [since you became pregnant]
Rarely
O
O
Occasionally
O
Often
O
Very often
12. SINCE YOU BECAME PREGNANT, has anyone forced you to have sexual activities?
O
Yes
O
No → go to question 13.
6
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a. Who? Colour all options that apply.
O
Spouse
O
Partner
O
Family member
O
Ex-spouse
O
Ex-partner
O
Stranger
O
Other
b. How often? [since you became pregnant]
Rarely
O
Occasionally
O
O
Often
O
Very often
c. In terms of its severity and/or frequency, has this behaviour:
Increased
O
O
Decreased
O
Remained unchanged
13. Are you afraid of your partner or anyone you listed above?
Yes
O
O
No
14. If you did not have a partner in the 12 months prior to your pregnancy, nor since you became pregnant → go to question 16.
When you think about your current or last partner, did he/she in the 12 MONTHS PRIOR TO YOUR PREGNANCY:
a. Try to restrict your contact with male/female friends and/or family?
O
Never
O
Rarely
O
Occasionally
O
Often
O
Very often
O
Occasionally
O
Often
O
Very often
O
Occasionally
O
Often
O
Very often
O
Often
O
Very often
b. Insist on knowing where you are at all times?
O
Never
O
Rarely
c. Ignore you and treat you indifferently?
O
Never
O
Rarely
d. Insult you, criticize you, or react in a despising manner to what you do or say?
O
Never
O
Rarely
Occasionally
O
7
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e. Belittle or humiliate you in front of other people?
O
Never
O
Rarely
Occasionally
O
O
Often
O
Very often
f. Do things to scare or intimidate you on purpose? [e.g. smashing things, threatening to kill you or to commit suicide]
O
Never
O
Rarely
O
Occasionally
O
Often
O
Very often
O
Occasionally
O
Often
O
Very often
g. Threaten to hurt you or someone you care about?
O
Never
O
Rarely
15. When you think about your current or last partner, has he/she SINCE YOU BECAME PREGNANT:
a. Tried to restrict your contact with male/female friends and/or family?
O
Never
O
Rarely
O
Occasionally
O
Often
O
Very often
O
Occasionally
O
Often
O
Very often
O
Occasionally
O
Often
O
Very often
b. Insisted on knowing where you are at all times?
O
Never
O
Rarely
c. Ignored you and treated you indifferently?
O
Never
O
Rarely
d. Insulted you, criticized you, or reacted in a despising manner to what you do or say?
O
Never
O
Rarely
O
Occasionally
O
Often
O
Very often
Occasionally
O
Often
O
Very often
e. Belittled or humiliated you in front of other people?
O
Never
O
Rarely
O
f. Done things to scare or intimidate you on purpose? [e.g. smashing things, threatening to kill you or to commit suicide]
O
Never
O
Rarely
Occasionally
O
O
Often
O
Very often
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g. Threatened to hurt you or someone you care about?
Never
O
O
Rarely
Occasionally
O
Often
O
O
Very often
h. If you answered any of the above questions from ‘a’ to ‘g’ with ‘Rarely’, ‘Occasionally’, ‘Often’ or ‘very often’, has this behavior
SINCE THE BEGINNING OF YOUR PREGNANCY, in terms of severity and/or frequency:
Increased
O
O
Decreased
O
Remained unchanged
16. Did someone else than your current or last partner, behave in more than one of the abovementioned ways?
(see ‘15.a’ to ‘15.g’)
Yes
O
O
No → go to question 17.
a. Who? Colour all options that apply.
O
Family member
O
Stranger
O
Other
b. When?
O
during the 12 months prior to your pregnancy
O
since you became pregnant
O
both during the 12 months prior to your pregnancy and since you became pregnant
17. How would you rate the CARE provided by your MIDWIFE in the following areas? [If you did not receive any care from a midwife,
colour the option ‘Not applicable’. If you have been treated by several midwives during your pregnancy, we are referring to the midwife of
your last prenatal check-up]
Insufficient
Sufficient
Good
Excellent
Not
applicable
a. Provides you with good health care overall
O
O
O
O
O
b. Is knowledgeable and competent to follow up on your
pregnancy
O
O
O
O
O
c. Personally spends enough time with you
O
O
O
O
O
d. Makes a special effort to get you to explain your
symptoms and complaints completely
O
O
O
O
O
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Insufficient
Sufficient
Good
Excellent
Not
applicable
e. Answers your questions honestly and completely
O
O
O
O
O
f. Makes sure you understand what you are being told
O
O
O
O
O
18. How would you rate the CARE provided by your GYNAECOLOGIST in the following areas? [If you did not receive any care from a
gynaecologist, colour the option ‘Not applicable’. If you have been treated by several gynaecologists during your pregnancy, we are referring
to the gynaecologist of your last prenatal check-up]
Insufficient
Sufficient
Good
Excellent
Not
applicable
a. Provides you with good health care overall
O
O
O
O
O
b. Is knowledgeable and competent to follow up on your
pregnancy
O
O
O
O
O
c. Personally spends enough time with you
O
O
O
O
O
d. Makes a special effort to get you to explain your
symptoms and complaints completely
O
O
O
O
O
e. Answers your questions honestly and completely
O
O
O
O
O
f. Makes sure you understand what you are being told
O
O
O
O
O
THANK YOU VERY MUCH FOR YOUR PARTICIPATION IN THIS STUDY! IF YOU HAVE ANY FURTHER
QUESTIONS, PLEASE DO NOT HESTITATE TO CONTACT
An-Sofie Van Parys
Women’s Clinic, Ghent University 0P3, De Pintelaan 185, 9000 Gent
Tel:
09/332.53.72 (direct line)
Email: [email protected]
DO NOT FORGET TO SIGN PAGE 13 & 15
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INFORMATION GUIDE FOR PARTICIPANTS
1. Study title:
Difficult moments and feelings during pregnancy.
2. Aims of the study:
This questionnaire forms part of a study at the Ghent University on difficult moments and feelings during pregnancy. It is known that feelings
have an impact on pregnancy. This study is conducted in order to understand how your feelings affect you pregnancy and to provide better
care.
3. Description of the study:
Please turn to the “Instructions for completing the questionnaire” on the page 2.
4. What is expected of the participant?
Your full cooperation with the researcher and strict compliance with her instructions are extremely relevant for the successful completion
of the study. We would like to ask you to complete a short questionnaire on the spot at two different times (between the 20th - 22nd and
32nd - 34th weeks of your pregnancy). If you are willing to participate in the second part of this study, you may also be phoned twice for an
interview. This study is not intended to provide care. Your gynaecologist, midwife or anyone else will not be informed of the contents of your
questionnaire.
If you would nonetheless like to talk to someone or require support, feel free to contact:
• “Tele-onthaal” (Support Hotline): dial 106 or 107;
• The prenatal care providers (gynaecologist, midwife, nurse) and the social services of the hospital.
5. Participation and termination:
Any participation in this study is voluntary and cannot be considered as providing an immediate therapeutic advantage. Your participation
may contribute to better care for women who are pregnant or who have only just delivered. You have the right to refuse to participate and
can withdraw from the study at any time, without needing to provide an explanation and without any consequences for your continued
relationship and/treatment with the researcher or doctor in charge. Your participation in this study will be terminated if the researcher deems
this to be in your interest. You can also be withdrawn prematurely from this study if you decide not to follow the procedures properly or if you
fail to respect the items described. If you do decide to participate, you are requested to sign the Informed Consent Form.
6. Procedures:
6.1. Procedure:
You will be briefed on this study by a care provider or a receptionist at the hospital where go for your prenatal care. If you are willing to
participate, you will receive an envelope with this informative guide (including the informed consent form) and the questionnaire. If you
remain interested after having read this, please sign the Informed Consent Form.
As mentioned before, you will be requested to complete a short questionnaire in the hospital at the different phases of your pregnancy
(once between 20th - 24th week and once between the 32nd - 34th week). Please deposit the completed questionnaire and the signed
Informed Consent Form in a sealed envelope in the box provided. You may keep a copy of the Informed Consent Form at the end of this
package as proof of your participation.
If you are selected to participate in the second part of the study, you will receive an envelope from the researcher during the first prenatal
consultation after the second questionnaire. The researcher will then contact you for a telephone interview at approximately one
month and five months after your delivery. We can offer you a gift voucher of 20€ if you are willing to be interviewed twice on the
telephone.
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6.2. Research proceedings:
Phase 1:
Questionnaire between the 20th - 22nd week and between the 32nd -34th week;
Phase 2:
The envelope is handed over to you;
Interview 1 and 5 months after your delivery.
7. Risks and advantages:
You have the right to enquire about the possible and/or known risks and disadvantages of this study at all times. You will be informed if any
data might be revealed in the course of this study that could affect your willingness to continue to participate. You will receive appropriate
treatment should you still experience any repercussions as a result of your contribution. This study has been approved by an independent
Medical Ethics Commission at Ghent University Hospital and will be carried out according to the international guidelines for good clinical
practice (ICH/GCP) and the Helsinki Declaration for the protection of participations in clinical research. Under no circumstances should you
consider the approval by the Medical Ethics Commission as an incentive to participate.
8. Costs:
Your participation in this study carries no extra costs for you.
9. Compensation:
If you are selected and willing to be interviewed, you will receive a gift voucher with a value of 20€.
10. Confidentiality:
In compliance with the Belgian laws of the 8th of December 1992 and the 22nd of August 2002, your right to privacy will be respected and
you will be granted access to all the gathered data. Any erroneous information can be corrected at your request. Direct access to the files is
granted to representatives of the organization commissioning this research project, auditors, the Medical Ethics Committee and authorized
governmental agencies, in order to verify the research procedures and/or the data, without infringing your confidentiality. This is only permitted
within the boundaries that are defined by applicable law. You are expressing your consent with this procedure by signing the Informed Consent
Form after a short briefing. If you agree to participate in this study, your personal and medical data will be collected and coded (in this process
it will still be possible to link that information to your personal file). Any reports in which you are identified will not be publicly available. Your
identity will remain confidential if the study’s results are published.
11. Injury as a result of participation in this study:
The researchers foresee a compensation and/or medical treatment should you suffer any harm and/or injury as a result of participation in this
study. A zero liability insurance policy has been signed for that purpose in compliance with the law regarding experiments with human test
subjects of the 7th of May 2004. In this event, your data will be passed on to the insurance company.
12. Contacts:
Feel free to contact the following persons at any time during the study should you experience any harm or if you would like to receive additional
information regarding the research project or your rights and duties:
An-Sofie Van Parys
Midwife, sexologist and PhD student,
Women’s Clinic, Ghent University
Tel: 09/332.53.72
Email: [email protected]
Dr. Hans Verstraelen
M.D. and scientific associate,
Women’s Clinic, Ghent University
Tel: 09/332.37.96
Prof. dr. Marleen Temmerman
Gynaecologist and Head of Department,
Women’s Clinic, Ghent University
Tel: 09/332.37.96
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INFORMED CONSENT FORM
I,
hereby declare that I have read the “Information guide for participants in experiments”
including pages 11 and 12 and that I have received a copy of this document (see page 15). I agree with its contents and also agree to participate
in this study.
I have received a copy of this signed and dated “Informed Consent Form”. I have been briefed on the nature, the aim, the length and the foreseen
effects of this study and on what is expected of me. The possible risks and advantages of the study have been explained to me. I have had the
opportunity and sufficient time to ask questions about this study, and I have received a satisfactory answer to all my questions.
I hereby agree to fully cooperate with the supervising researcher. I will inform him/her if I experience any unexpected or unusual symptoms.
I have been informed about the existence of a liability insurance policy should I suffer any harm that can be ascribed to the research procedures.
I am aware that this study has been approved by an independent Medical Ethics Commission at the Ghent University Hospital and that it will be
conducted according to the guidelines for good clinical practice (ICH/GCP) and the Declaration of Helsinki for the protection of human research
subjects. However, this approval did not influence my decision in any way to participate in this study.
I can withdraw from the study at any time without having to provide a reason for this decision and without jeopardizing my continued relationship
with the researcher.
I have been duly informed that both my personal data and the data related to my health, race and sex life will be processed and stored for at least
20 years. I consent to this process and am aware that I have the right to access these data. I understand that my access to these data can be
postponed until after the study has been completed, since these data are processed for medical-scientific purposes. I will contact the supervising
researcher responsible for processing should I wish to access my data.
I understand that auditors, representatives of the organization commissioning the researcher, or authorized governmental agencies might want to
inspect my data to inspect the gathered information. I give my permission for such inspections, even if this means that my data might be passed
on to a country outside the European Union. My privacy will still be respected at all times.
I am willing to take part in this study on a voluntary basis
.
Name of the person
Date:
Signature:
I have explained the nature, the aim and the predicted effects of the study to the abovementioned volunteer.
The volunteer agreed to take part by signing with his/her personal and duly dated autograph.
Name of the person who provided the explanation
Date:
Signature:
13
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An-Sofie Van Parys
Midwife, sexologist and PhD student
Women’s Clinic, Ghent University 0P3, De Pintelaan 185, 9000 Gent
Tel: 09/332.53.72 (direct line)
Email: [email protected]
mom_vragenlijst_def_ENG.indd 14
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342
COPY INFORMED CONSENT FORM
I,
hereby declare that I have read the “Information guide for participants in experiments”
including pages 11 and 12 and that I have received a copy of this document (see page 15). I agree with its contents and also agree to
participate in this study.
I have received a copy of this signed and dated “Informed Consent Form”. I have been briefed on the nature, the aim, the length and the
foreseen effects of this study and on what is expected of me. The possible risks and advantages of the study have been explained to me. I
have had the opportunity and sufficient time to ask questions about this study, and I have received a satisfactory answer to all my questions.
I hereby agree to fully cooperate with the supervising researcher. I will inform him/her if I experience any unexpected or unusual symptoms.
I have been informed about the existence of a liability insurance policy should I suffer any harm that can be ascribed to the research
procedures.
I am aware that this study has been approved by an independent Medical Ethics Commission at the Ghent University Hospital and that it will
be conducted according to the guidelines for good clinical practice (ICH/GCP) and the Declaration of Helsinki for the protection of human
research subjects. However, this approval did not influence my decision in any way to participate in this study.
I can withdraw from the study at any time without having to provide a reason for this decision and without jeopardizing my continued
relationship with the researcher.
I have been duly informed that both my personal data and the data related to my health, race and sex life will be processed and stored for at
least 20 years. I consent to this process and am aware that I have the right to access these data. I understand that my access to these data
can be postponed until after the study has been completed, since these data are processed for medical-scientific purposes. I will contact the
supervising researcher responsible for processing should I wish to access my data.
I understand that auditors, representatives of the organization commissioning the researcher, or authorized governmental agencies might
want to inspect my data to inspect the gathered information. I give my permission for such inspections, even if this means that my data might
be passed on to a country outside the European Union. My privacy will still be respected at all times.
I am willing to take part in this study on a voluntary basis.
The volunteer’s name:
Date:
Signature:
I have explained the nature, the aim and the predicted effects of the study to the abovementioned volunteer.
The volunteer agreed to take part by signing with his/her personal and duly dated autograph.
Name of the person who provided the explanation:
Date:
Signature:
15
mom_vragenlijst_def_ENG.indd 15
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343
An-Sofie Van Parys
Midwife, sexologist and PhD student
Women’s Clinic, Ghent University 0P3, De Pintelaan 185, 9000 Gent
Tel: 09/332.53.72 (direct line)
Email: [email protected]
mom_vragenlijst_def_ENG.indd 16
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344
Annex 4: Referral card 345
346
FIND HELP, YOU ARE NOT ALONE
Centre for social work (Centrum Algemeen Welzijnswerk)
T: 078/150.300 [normal rate]
www.caw.be
Support hotline [24h/24h] (Télé-onthaal)
T: 106 or 107
www.tele-onthaal.be
Police [24h/24h]
T: 101 of 112
www.police.be
Your family physician or find a family physician on www.goldenpages.be
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347
SAFETY MEASURES/TIPS
• Make sure you always carry some money, so you are able to telephone, take the
bus or a taxi in case of an emergency.
• Hide a bag containing extra clothing, a spare set of house and car keys, copies of
important documents [social security card, drivers licence, ID card, bankcard, …] in
an easily accessible and safe place.
• Establish a code with your neighbors, family or any other person that is important
to you [e.g. switching lights on and off], so they can call the police if you need help.
• Remove objects that can be used as a weapon.
You are not the only one in this difficult situation…
Ensure your own safety and the safety of your children.
mom_naamk_ENG_ok.indd 2
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348
Annex 5: Interview guide (first interview) 349
350
INTERVIEW 1
CASE number:
Study number:
ENGLISH Interview scheme 10-12 months
Good morning/afternoon/evening Ms …
My name is An-Sofie Van Parys. I am the midwife who is coordinating the study in which you took
part in--------------------------------------(some time ago) in ------------------------------------------------------. During
your pregnancy you filled in a questionnaire (about difficult times and feelings) and agreed to give
an interview. That is why I am calling you now; the interview will last about 20 min.
Is this a good time for you?
o If NO: when could I call you back?
o If YES: ↓
Are you alone right now?
o If NO: When could I call you back, because it is very important for the study that you
are alone [to avoid that you are distracted and I can ask some questions in private]?
[Refuse emphatically if woman wants to continue in presence of other person(s): standard study protocol is
that all women have to be alone, so answers are comparable]
o If YES: should your (ex)partner or anyone else enter the room at any time, you can
just hang up and I will call you back later [as it is important for the purpose of the
study that you are alone] ↓ [I am the midwife of hospital ---------------------------------------------- and we are
calling up everyone a few months after they have given birth to see how they are doing]. You seem to be very
concerned over your wife and that is admirable, but would it be possible to talk to her over the phone?” It seems
a bad time to call’
With this interview, we want to better understand your experiences and feelings and look for better
ways to help pregnant women.
I will be asking a number of explicit questions, which may be difficult to answer. Be aware that you
are not obliged to respond and that you can stop at any time.
Everything you tell me is strictly confidential. This means that your name will not appear anywhere
and everything will be processed entirely anonymously.
The idea is not for this to become a therapeutic or counselling session. If you were to need such a
session after our talk, I would like to refer you to a local care worker. [CAW 078/150,300,
www.caw.be, tele-onthaal 106/107]
Do you have any questions before we start?
Interview 1 (10-12 months after receipt of envelope), English version
351
page 1
INTERVIEW 1
CASE number:
Study number:
DEMOGRAPHICS
OK, then we’ll start the interview with some general questions
D1
What is your date of birth? (day / month / year)
D2
Are you currently in a (partner) relationship?
D
2a
If YES: how long have you been together?
D
2b
Have you had one or more (other) (ex)partners in the past 2 and 0 No
a half years?
D
2c
How long were you together for?
/
/
0 No
1 Yes
years
months
1 Yes
1)
2)
3)
D3
Who is currently part of your family? (children + adults)?
D
3a
How old is your child / are your children?
D4
What is your mother tongue?
months
years
months
years
months
years
Total number:
years
years
years
-
Interview 1 (10-12 months after receipt of envelope), English version
352
page 2
INTERVIEW 1
CASE number:
Study number:
OBSTETRIC HISTORY
O1
How many times have you been pregnant, i.e. including
miscarriages and abortions?
O2
How many miscarriages have you had?
O3
How many abortions have you had?
O4
Are you pregnant at the moment?
O5
When did you give birth most recently?
O6
Was this pregnancy planned?
times
0 No
1 Yes
/
/
0 No
1 Yes
PSYCHOSOCIAL STATUS (TRAIT ANXIETY, SELF-ESTEEM, MASTERY,
DEPRESSION, SUBJECTIVE STRESS)
The next questions deal with how you have generally felt in the PAST 2 WEEKS. There are no
“right” or “wrong” answers, just give the answer that best reflects HOW OFTEN you felt this way
in the LAST 2 WEEKS. I will read out the possible answers a number of times and then you can
just give the answer yourself.
Almost
always
5
Ofte
n
4
Sometime
s
3
Rarel
y
2
Neve
r
1
P
1
Did you feel [during the last 2
weeks] pleasant
(2; anx)
P
2
In general [during the last 2
weeks] were you very tense
and nervous (6; str)
1
2
3
4
5
P
3
Have you [during the last 2
weeks] felt lonely (1; dep)
1
2
3
4
5
P
4
Have you been [during the last
2 weeks] happy (2; anx)
5
4
3
2
1
P
5
Did you have [during the last 2
weeks] crying spells (1; dep)
1
2
3
4
5
P
6
Have you [during the last 2 5
weeks] felt secure (2; anx)
4
3
2
1
Interview 1 (10-12 months after receipt of envelope), English version
353
page 3
INTERVIEW 1
CASE number:
Study number:
Almost
always
1
Ofte
n
2
Sometime
s
3
Rarel
y
4
Neve
r
5
P
7
Did you find it difficult [during
the last 2 weeks] to ‘shake off
the blues’, even with the help of
family or friends (1; dep)
P
8
All in all, did you [during the last
2 weeks] tend to feel like a
failure (4; est)
1
2
3
4
5
P
9
Have you been [during the last
2 weeks], calm and collected
(2, anx)
5
4
3
2
1
P
10
Did you often [during the last 2
weeks] have unimportant
thoughts running through your
mind, which bothered you (5;
anx)
1
2
3
4
5
P
11
Did you feel [during the last 2
weeks] fearful (1; dep)
1
2
3
4
5
P
12
Did you experience
disappointments [during the
last 2 weeks] so strongly that
you could not get them out of
your mind (5; anx)
1
2
3
4
5
P
13
Was there [during the last 2
weeks] a lot of nervous strain
connected to your daily
activities (6, str)
1
2
3
4
5
P
14
Did you [during the last 2
weeks] feel hopeful about the
future (2; dep)
5
4
3
2
1
P
15
Did you [during the last 2
weeks] feel depressed (1; dep)
1
2
3
4
5
P
16
Did you [during the last 2
weeks] feel sad (1; dep)
1
2
3
4
5
P
17
Were you [during the last 2
weeks] satisfied (content) (2;
anx)
5
4
3
2
1
Interview 1 (10-12 months after receipt of envelope), English version
354
page 4
INTERVIEW 1
P
18
P
19
CASE number:
Did you [during the last 2
weeks] take a positive attitude
towards yourself (3; EST)
Did you [during the last 2
weeks] have a lack of selfconfidence (5; anx)
Study number:
Almost
always
5
Ofte
n
4
Sometime
s
3
Rarel
y
2
Neve
r
1
1
2
3
4
5
I am now going to read a few statements. Please indicate to which extent you agree.
(Are you still OK, madam? We have come a long way already!)
Completel
y
agree
1
Rathe
r
agree
Rather
disagre
e
2
I do
not
kno
w
3
4
Completely
disagre
e
5
P
2
0
Were you [during the last 2
weeks] easily bothered by things
that did not use to bother you (1;
dep)
P
2
1
Did you have [during the last 2
weeks] little control over the
things happening to you (4; mst)
1
2
3
4
5
P
2
2
There is little you can [during the
last 2 weeks] change about
many of the important things in
your life (4; mst)
1
2
3
4
5
P
2
3
Did you [during the last 2 weeks]
have the feeling you do not have
much to be proud of (4, est)
1
2
3
4
5
P
2
4
Have you [during the last 2
weeks] been able to do things
as well as most other people (3;
est)
5
4
3
2
1
P
2
5
Did you [during the last 2 weeks]
often feel helpless to deal with
life’s problems (4; mst)
1
2
3
4
5
Interview 1 (10-12 months after receipt of envelope), English version
355
page 5
INTERVIEW 1
P
2
6
CASE number:
Did you [during the last 2 weeks]
have the feeling that you have a
number of good qualities (3; est)
P
2
7
Did you [during the last 2 weeks]
have the feeling that you were a
person of value, at least as
valuable as other people (3, est)
P
2
8
Was there [during the last 2
weeks] really no way of solving
some of your problems (4; mst)
Caution: question phrased
negatively!
Study number:
5
4
3
2
1
Completel
y
agree
5
Rathe
r
agree
Rather
disagre
e
4
I do
not
kno
w
3
2
Completely
disagre
e
1
1
2
3
4
5
General health (Stivoro, Fragerströmtest, Questions Sabine Hellemans, McFarlane)
Now we’ll proceed with a number of questions about your health:
G1
Compared to other people 1
your age, would you say your Excellent
physical health over the last
6 months has been…
2
Very good
3
Good
4
Reasonable
5
Bad
G2
Compared to other people 1
your age, would you say your Excellent
mental health over the last 6
months has been…
2
Very good
3
Good
4
Reasonable
5
Bad
G3
Have you ever smoked?
0
No, never smoked
G
3a
Are you currently smoking?
0
No
G.
How long ago did you quit 1
smoking?
1 week
ago
1
Yes
1
Yes, now and again
(at least 1
cigarette/week, but
not daily)
2
3
Less than Less than 6
1 month
months ago
ago
Interview 1 (10-12 months after receipt of envelope), English version
356
2
Yes, at least 1
cigarette/day
4
Less than 1
year ago
5
More than
1 year ago
page 6
INTERVIEW 1
CASE number:
Study number:
G4
How often do you drink 1
Never
alcohol?
2
Not
during
pregnan
cy
G5
Have you taken sleeping
pills, tranquilizers, antidepressants or anti-anxiety
drugs in the last 12 months?
1
Never
2
3
Not during Sometimes
pregnancy
G6
1
Have you used drugs such
as cannabis, amphetamines, Never
ecstasy or cocaine in the last
12 months?
2
3
Not during Sometimes
pregnancy
3
Occasio
nally, <
1/month
4
5
one to once
or
three x twice/week
per
month
6
(almost)
every
day
4
5
Regularly, but Regularl
not anymore
y
and
now as
well
4
5
Regularly, but Regularl
not anymore
y
and
now as
well
We are now over halfway the interview… Is everything still OK?
(ex)partner violence (CTS2S)
The next questions deal with your relationship with your (ex)partner [in case of various
(ex)partners in the last 2.5 years: I am referring to the relationship that was most difficult to you (in
the past 2.5 years)]. All people in a relationship have disagreements and argue and all couples
have their own way of resolving those arguments.
In the next few questions, I will list what could happen during those arguments. Please indicate
HOW MANY TIMES this type of things occurred between you and your (ex)partner IN THE LAST 6
MONTHS. The figure you provide does not have to be entirely accurate. It is not easy to remember
all of these things, so an approximate figure is more than sufficient.
PG1 You explained your side, or
suggested a compromise,
in an argument with your
(ex)partner
How often has this happened in the last 6 months?
1
2
3
4
5
6
7
1 x 2 x 3 -5 x 6 - 10 x 11 - 20 x > 20 x Not in
8
Never
the last 6
months,
but
before
PG2 Your (ex)partner clarified
1
his/her side, or suggested a 1 x
compromise, in an
argument with you
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
7
> 20 x Not in
8
Never
the last 6
months,
but
before
PG3 You insulted your
(ex)partner, or swore,
shouted or screamed at
him/her
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
7
> 20 x Not in
the last 6
months,
Interview 1 (10-12 months after receipt of envelope), English version
357
page 7
8
Never
INTERVIEW 1
CASE number:
Study number:
but
before
PG4 Your (ex)partner insulted
you, or swore, shouted or
screamed at you
How often has this happened in the last 6 months?
1
2
3
4
5
6
7
1 x 2 x 3 -5 x 6 - 10 x 11 - 20 x > 20 x Not in
8
Never
the last 6
months,
but
before
PG5 You had a sprain, bruise or
small cut or felt pain the
next day after a fight with
your (ex)partner
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
7
> 20 x Not in
8
Never
the last 6
months,
but
before
PG6 Your (ex)partner had
sustained a sprain, bruise
or small cut or felt pain the
next day after a fight with
you
1
1x
PG7 You showed respect for, or
showed that you cared for
your (ex)partner’s feelings
about an issue you
disagreed on
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
7
> 20 x Not in
8
Never
the last 6
months,
but
before
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
7
> 20 x Not in
8
Never
the last 6
months,
but
before
PG8 Your (ex)partner showed
respect for, or showed that
he/she cared for your
feelings about an issue you
disagreed on
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
7
> 20 x Not in
8
Never
the last 6
months,
but
before
PG9 You pushed, jabbed or
slapped your (ex)partner
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
7
> 20 x Not in
8
Never
the last 6
months,
but
before
PG
10
Your (ex)partner pushed,
jabbed or slapped you
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
7
> 20 x Not in
the last 6
months,
but
before
Interview 1 (10-12 months after receipt of envelope), English version
358
page 8
8
Never
INTERVIEW 1
PG
11
CASE number:
You punched or kicked your
(ex)partner or you beat
him/her up
Study number:
How often has this happened in the last 6 months?
1
2
3
4
5
6
7
1 x 2 x 3 -5 x 6 - 10 x 11 - 20 x > 20 x Not in
8
Never
the last 6
months,
but
before
PG
12
Your (ex)partner punched
or kicked you (ex)partner or
beat you up
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
> 20 x
7
Not in
8
Never
the last 6
months,
but
before
PG
13
You destroyed something
belonging to your
(ex)partner or threatened to
hit him/her
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
> 20 x
7
Not in
8
Never
the last 6
months,
but
before
PG
14
Your (ex)partner destroyed
something belonging to you
or threatened to hit you
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
> 20 x
7
Not in
8
Never
the last 6
months,
but
before
PG
15
You went to a doctor or
needed to see a doctor
because you had been in a
fight with your (ex)partner
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
> 20 x
7
Not in
8
Never
the last 6
months,
but
before
PG
16
Your (ex)partner went to a
doctor because or needed
to see a doctor he/she had
been in a fight with you
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
> 20 x
7
Not in
8
Never
the last 6
months,
but
before
PG
17
You used force (like hitting,
holding down or using a
weapon) to make your
(ex)partner have sex with
you
1
1x
2
2x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
> 20 x
7
Not in
the last 6
months,
but
before
Interview 1 (10-12 months after receipt of envelope), English version
359
page 9
8
Never
INTERVIEW 1
PG
18
CASE number:
Your (ex)partner used force
(like hitting, holding down or
using a weapon) to make
you have sex with him/her
Study number:
How often has this happened in the last 6 months?
1
2
3
4
5
6
7
1 x 2 x 3 -5 x 6 - 10 x 11 - 20 x > 20 x Not in
8
Never
the last 6
months,
but
before
PG
19
PG
20
You insisted on sex when
1
your (ex)partner did not
1x
want to / or insisted that you
had sex without a condom
(without using physical
force)
2
2x
Your (ex)partner insisted on
sex when you did not want
to / or insisted that you had
sex without a condom
(without using physical
force)
2
2x
1
1x
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
> 20 x
7
Not in
8
Never
the last 6
months,
but
before
3
3 -5 x
4
6 - 10 x
5
11 - 20 x
6
> 20 x
7
Not in
8
Never
the last 6
months,
but
before
Readiness to change (Hegarty et al., 2008; Frasier et al., 2001)
RTC
1
Have you thought about making any changes to 0
your current situation (concerning your relationship) No
within the next 6 months?
1
Yes
RTC
2
Have you thought about making any changes [to 0
your current situation concerning your relationship] No
within the next 30 days?
1
Yes
Are you still OK? We have come a long way, we need max 5 minutes.
Safety promoting behaviour (Safety promoting behavior checklist, McFarlane et al., 2004)
Sometimes, arguments get out of hand and you need to do certain things to feel safer. That is what
the following questions are about.
VG
1
Have you (in the past 6 months) made sure that you had a small 0
amount of money on you to make a call, take the bus or taxi in No
case of emergency?
Interview 1 (10-12 months after receipt of envelope), English version
360
1
Yes
page 10
INTERVIEW 1
CASE number:
Study number:
VG
2
Have you (in the past 6 months) prepared an emergency bag 0
with clothes, spare house and/or car keys, copies of important No
documents (social security card, birth certificate, driving license,
ID card, bank card …) and stored it in a safe location
1
Yes
VG
3
Have you (in the last 6 months) agreed on a code (e.g. switching 0
lights on and off) with neighbours, relatives or someone else so No
they know that they have to call the police when you need help.
1
Yes
VG
4
Have you (in the last 6 months) removed objects that could be
used as a weapon
1
Yes
0
No
It may seem odd that I am asking these questions, but we advise you to do these things if
you do not feel safe, of course you are not obliged to do this…
Help-seeking behaviour (Community agencies use, questionnaire McFarlane et al. 2006;
Fanslow et al., 2010 p 939)
The following questions are about the help you sought for your problems with your (ex)partner.
Have you, in the last 6 months, because of your problems with your (ex)partner, contacted one or
more of the following services?
If so, how many times and how helpful did you find these services/this service to deal your problems
with your (ex)partner?
1= very helpful, 2= somewhat helpful, 3= not helpful, 4= made things worse
Service
No
H
G
1
H
G
2
Centrum voor Algemeen
Welzijnswerk (CAW)
0↓
Ye
s
1→
Number
times
of To which extent
were you helped
1
2
3
Centrum geestelijke
gezondheidszorg
(Mental Health Centre)
0↓
1→
1
2
3
4
H
G
3
H
G
4
H
G
5
Vluchthuis
0↓
(Women’s shelter, safe house)
1→
1
2
3
4
Hospital Social Services
0↓
1→
1
2
3
4
Tele-onthaal
(telephone hotline)
Over-the-phone assistance
0↓
1→
1
2
3
4
Interview 1 (10-12 months after receipt of envelope), English version
361
page 11
4
INTERVIEW 1
H
G
6
H
G
7
H
G
8
H
G
9
H
G
10
H
G
11
CASE number:
Study number:
Self-help group
0↓
1→
1
Service
No
Police
0↓
Ye
s
1→
Legal services (legal aid,
lawyer, court, …)
0↓
1→
1
2
3
4
Other: …………………….
0↓
1→
1
2
3
4
Number
times
2
3
of To which extent
were you helped
1
2
3
4
4
If YES to one item HB 1 -9:
What was the immediate cause/reason to contact that service/those services? I will
read out a number of possible reasons:
1 I could not take it anymore
2 (Ex) (ex)partner threatened or tried to kill me
3 Severely injured by (ex)partner
4 Afraid that (ex)partner would kill me
5 Children are suffering because of the situation
6 Children were beaten or threatened
7 Under the influence of family and/or friends
8 Pregnancy/baby
9 Other: …………………………………………………………………..
If NO to all items HB 1 - 9 :
Why did you not contact one or more of these services? I will read out a number of
possible reasons:
1 the situation/(ex)partner violence is normal or not serious (enough)
2 I am ashamed or embarrassed about the (ex)partner violence
Interview 1 (10-12 months after receipt of envelope), English version
362
page 12
INTERVIEW 1
H
G
12
H
G
13
CASE number:
Study number:
3 I am afraid of the consequences
4 I need to solve this myself/alone
5 I am afraid of losing the children
6 Those services cannot help me anyway
7 Other: …………………………………………………………………..
Did you, (outside of the services just mentioned), talk 0
to someone about your problems with your No
(ex)partner?
1
Yes
IF SO, to whom?
1 Family
2 Friend (male or female)
3 Acquaintance
4 Neighbour
5 Co-worker
6 Family doctor
7 Gynaecologist
8 Midwife
9 ER doctor
10 ER nurse
11 Psychologist
12 Psychiatrist
13 Social worker
14 Other: …………………….
Social support (questionnaire Wendy K&G and/or BIDENS question)
Well, this brings us almost to the last questions of the interview.
SS
1
Do you have someone, apart from your (ex)partner, to really 0
confide in?
No
1
2
Yes, 1 or Yes, >2
2
persons
persons
If you need to, who could you turn to for each of the following things?
SS
2
SS
3
SS
4
Noone
(ex)partner
Parents
Brothers/
Sisters
Parents
in-law
Neighbours
Coworkers
Friends
Others
specify
Talking about personal
problems or intimate
matters
Advice and counsel
1
2
3
4
5
6
7
8
9
1
2
3
4
5
6
7
8
9
Help with practical matters
(odd jobs, transport,
housekeeping)
1
2
3
4
5
6
7
8
9
Interview 1 (10-12 months after receipt of envelope), English version
363
page 13
INTERVIEW 1
SS
5
SS
6
SS
7
CASE number:
Study number:
Financial support
1
2
3
4
5
6
7
8
9
Having fun or relaxing
together
Having a nice chat
1
2
3
4
5
6
7
8
9
1
2
3
4
5
6
7
8
9
Controle interventie
1= very helpful, 2= somewhat helpful, 3= not helpful, 4= made things worse
2
I do not
remember
I1
During your consultation after your delivery, did you receive 0
an envelope regarding this study, containing a plastic card No
and gift voucher?
1
Yes
I2
To which extent did this card help you to deal with the 1
problems involving your (ex) partner?
2
3
4
I3
To which extent did filling in the questionnaire help you to 1
deal with the problems involving your (ex) partner?
2
3
4
I4
To which extent did this interview help you to deal with the 1
problems involving your (ex) partner?
2
3
4
Conclude
As a last point, I would like to know what your gynaecologist or midwife could do to help
you with your problems with your (ex)partner? What would have helped you during your
pregnancy?
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Interview 1 (10-12 months after receipt of envelope), English version
364
page 14
INTERVIEW 1
CASE number:
Study number:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………….
Are there any other important things you would like to tell me?
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….
Do you need to talk to a professional care worker?
(CAW 078/150 300, www.caw.be, tele-onthaal 106/107)
CAW1
Gave number
No
0
Yes
1
Well, this concludes this first interview.
If you remember, the study consists of 2 interviews. In other words, we will call you again in 6
months to do the follow-up interview
Again, thank you very much for your time and participation in the study.
Respondent in intervention group (referral card):
Respondent in control group (thank you card):
Interview 1 (10-12 months after receipt of envelope), English version
365
page 15
366
Annex 6: Ethical approval BIDENS-­‐study 367
368
369
370
371
372
373
374
Annex 7: Ethical approval MOM-­‐study 375
376
377
378
379
Intimate Partner Violence and Pregnancy, an Intervention Study in Perinatal Care
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