30 | International Journal of Childbirth Education | Volume 28 Number 3 July 2013
Domestic Violence and
Pregnancy: A Literature Review by Tanya Menezes Cooper, MA MFT-I Abstract: The World Health Organization (WHO), along with other health organi- zations, has declared the prevalence of domestic violence to be a serious global health concern needing more attention to promote healthier outcomes for mothers and children following birth. Even with the encouragement of the WHO, and with the convenience of private health treatment rooms, few health providers have conducted assessments for domestic violence. Finally, this article addresses the important role childbirth educators can play in assessing and educating expectant parents about the implications of domes- tic violence and pregnancy, and provides information for the process. Keywords: domestic violence, pregnancy, abuse, childbirth educators Introduction Pregnancy is a time of new life and of new beginnings for two people in a relationship. When domestic violence is an added factor, then pregnancy can be a further complica- tion for the woman carrying a child. Health care providers, including childbirth educators in contact with the prospec- tive mother, have the opportunity to assess mothers for the possibility of domestic violence occurring in their relation- ship. These may be the only opportunities a mother has of safely voicing the dilemma she and her unborn child are in. It may also lead to her only chance of escaping her or her unborn childs death sentence. Pregnant women and their unborn infants are vulnerable populations who should be treated as such, yet some reports show that death rates among pregnant women have escalated in recent years (Cle- ments, Holt, Hasson, & Fay-Hillier, 2011). Background Information on Domestic Violence Domestic violence, also termed intimate partner violence (IPV), has existed since the dawn of man. Its oc- currence is more acceptable in some countries than it is in others. Domestic violence is commonly described as the occurrence or threat of physical, verbal, or sexual abuse, as well as emotional and psychological abuse by a spouse or intimate partner (McMahon & Armstrong, 2012). Domestic violence occurs before, during and after pregnancy but has been observed to occur more often during the vulnerable time of pregnancy (Adesina, Oyugbo, & Olubukola, 2011; OReilly, 2007). During pregnancy, domestic violence can become particularly dangerous and devastating, causing premature birth, serious injury or death to the baby, while also causing detriment to the mothers mental and physical health (Keeling, 2012; Manzolli et al., 2009; OReilly, 2007; Oweis, Gharaibeh, & Alhourani, 2009). According to Sarkar (2008), the World Health Orga- nization (WHO) claimed that 15 countries reported the prevalence of domestic violence within their countries was 15% to 71%. Additionally, in North Africa and the Middle East domestic violence is widely accepted, and in Egypt and Jordan, 90% of ever-married women consider wife-beating as acceptable (Sarkar, 2008). More than 40% of Nigerian women have experienced domestic violence (Sarkar, 2008). In the United States, 24% of heterosexual couples reported domestic violence (Sarkar, 2008). Taiwan and the UK report- ed prevalence rates of 6.9% and 29%, respectively (Sarkar, 2008; Keeling, 2012). These statistics are in consideration of overall physical abuse within a relationship, regardless of whether or not the couple is experiencing a pregnancy at the time. continued on next page Volume 28 Number 3 July 2013 | International Journal of Childbirth Education | 31 Domestic violence has been observed to occur more often during the vulnerable time of pregnancy Prevalence of Domestic Violence and Pregnancy Domestic violence during pregnancy happens to women of varying ages, cultures, and socio-economic status; how- ever, it has been determined through various studies, that women of lower socio-economic status tend to experience domestic violence during pregnancy more often (Bravemann et al., 2010; Keeling, 2012; OReilly, 2007). There are two different associations commonly recog- nized when discussing domestic violence and pregnancy. One association is that of the occurrence of domestic violence during pregnancy, while the other is the occurrence of sexual assault by a spouse or intimate partner that results in pregnancy (Sarkar, 2008). Both circumstances can be devastating for a woman who nds herself in either situation. Commonly, the abuse continues throughout the pregnancy and the woman remains in danger (Sarkar, 2008). In Pakistan, 44% of women report regular physical abuse during marriage, with 23% reporting physical abuse during pregnancy (Sarkar, 2008). In a study conducted in Brazil by Manzolli et al. (2009), 43.4% of women receiving primary prenatal care reported having experienced domestic violence, with 18.9% claiming abuse during their current pregnancy. In the same study, a postpartum survey indicated that 33.8% of women experienced domestic violence during their previous pregnancy (Manzolli et al., 2009). Developing countries report that 4% to 29% of women experience do- mestic violence during pregnancy, while developed countries report that 1% to 20% of women experience domestic vio- lence in pregnancy (Oweis, Gharaibeh, & Alhourani, 2009). The WHO, the CDC, and Healthy People 2020 have all declared domestic violence as a leading health concern and cause for traumatic death to mothers and their unborn infants (Clements et al., 2011). In a recent study, Clements et al. (2011) stated that 77% of pregnant mothers who were murdered died in the rst trimester of their pregnancy. The number one cause of death to a mother during pregnancy is homicide (Clements et al., 2011). There were further reports of battering to pregnant women, kicking and striking of their abdomen, breasts, and genitals, choking, slapping and sexual assault (Clements et al., 2011). The injuries are often detrimental even when death is not imminent. It is important to acknowledge that spousal and partner inicted violence is not the only violence that occurs during a womans pregnancy. Some women also must contend with assault from other members of their family, such as older children in the home, parents living in the home, and in-laws (Raj et al., 2011). Abuse by in-laws, particularly mothers- in-law is common in some Asian countries and in Muslim cultures such as India (Raj et al., 2011). In Mumbai, 26.3% of the sample population reported experiencing abuse from in- laws. The abuse usually consists of economic abuse, such as withholding money, verbal and physical abuse, and neglect, such as withholding food (Raj et al., 2011). It is accepted within these particular cultures and is usually indicative of partner inicted violence as well (Raj et al., 2011). Women often feel there is little or nothing they can do when domestic violence occurs during pregnancy, except to tolerate it (Libuku, Small, & Wilkinson, 2008). Some women stay in abusive relationships because they have no source of income, have no place to go, or they feel it is best for their child (Libuku et al., 2008). They also may choose to stay continued on next page Domestic Violence and Pregnancy: A Literature Review continued from previous page 32 | International Journal of Childbirth Education | Volume 28 Number 3 July 2013 because they have low self-esteem, or have a fear for their safety if they try to leave (Libuku et al., 2008). For some women, during pregnancy is their rst experience with being assaulted by their spouse or partner (McMahon & Arm- strong, 2012). Still other women will actually have a reprieve from the usual domestic violence in their relationship during pregnancy (McMahon & Armstrong, 2012). Implications of Domestic Violence during Pregnancy Women abused during pregnancy may experience many complications. Some of the reported complications are high blood pressure, premature rupture of the membranes, pre- mature birth, preeclampsia, edema, urinary tract and bladder infections, vaginal bleeding, placenta previa, excessive vomiting, dehydration, or homicide (Cook & Bewley, 2008; Lazzenbatt & Greer, 2009). There are also implications related to the child being carried in the womb, besides the dangers associated with the mother. An unborn child subjected to domestic violence is at risk of being miscarried, born preterm, born under-weight or smaller than normal, or born under-developed (Lazzenbatt & Greer, 2009). A child is also at risk of dying soon after birth due to complications of the birthing processes incurred because of domestic violence, such as placenta previa (Laz- zenbatt & Greer, 2009). Risk Factors for Domestic Violence Some known risk factors for domestic violence are low socio-economic status, cultural beliefs, and substance abuse by the mother, the partner or both (McMahon & Armstrong, 2012). Additional risk factors include the pregnant mother having sex with multiple partners, negative or volatile family dynamics, nancial difculties within the family, and low social support (McMahon & Armstrong, 2012). These dif- culties are seen as risk factors only, not as excuses. Signs and Symptoms of Domestic Violence Signs and symptoms of domestic violence are sometimes obvious and at other times not so obvious. In cases when it is not as obvious, it may take screening and assessment procedures to bring the signs and symptoms or the actual oc- currences of domestic violence to the surface. The most com- monly recognized signs and symptoms of domestic violence can be excessive bruising, especially a combination of new and old bruises, low weight gain by the mother, noticeable anxiety, depression, low self-esteem, and negative self-image (McMahon & Armstrong, 2012). During assessment, a woman may express a lack of safety, or a fear of upsetting her spouse or partner (McMahon & Armstrong, 2012). How Assessment Can Play a Role Though during pregnancy and immediately postpartum are especially vulnerable times for mothers and their infants to experience domestic violence (OReilly, 2007), this is also a particularly advantageous time for health care profession- als, including childbirth educators, to assess and address the problem with the mother, because this is a time in which they will likely come in contact the most often. Assessments must be culturally sensitive, yet address the problem of domestic violence by spouses or partners, as well as other family members (McMahon & Armstrong, 2012). It is equally important to remember that a person may need to be as- sessed regularly for their own safety, as some women are not ready to seek help at rst but may be prepared as violence escalates or the pregnancy advances (Clements et al., 2011; McMahon & Armstrong, 2012). continued on next page Domestic Violence and Pregnancy: A Literature Review continued from previous page T i f f a n y
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P h o t o g r a p h y Volume 28 Number 3 July 2013 | International Journal of Childbirth Education | 33 There are barriers to assessment. Some social workers and healthcare providers, including doctors, do not feel they have time to conduct the assessment and make appropriate referrals, or wish to make either the mother or her part- ner uncomfortable by bringing up the subject of domestic violence (Clements et al., 2011; McMahon & Armstrong, 2012). Providers, such as childbirth educators, may also fear they will alienate the mother or partner if they bring up the subject or make a violent situation worse for the mother (Clements et al., 2011). With these concerns in mind, it is more important than ever for childbirth educators to take an active role in assessing and educating new parents about the dangers of domestic violence for both the mother and the unborn child. The Role of Childbirth Educators Women enduring domestic violence are often in denial, believing the violence will not get worse or that it will end once the child is born (Libuku et al., 2008). Through as- sessment, group education, and private conversations with participants, educators have an opportunity to present the facts about what pregnant victims of domestic violence are at risk of experiencing. Discussing the dangers and the resourc- es associated with domestic violence may help to empower a woman in a domestic violence situation to take steps to make a change. It is vitally important for childbirth educators to be in a position of giving the complete truth to mothers regard- ing the possible implications of being in a domestic violence situation during pregnancy. Homicide is the number one cause of death to pregnant mothers and their unborn chil- dren; more than auto collisions or suicide (Clements et al., 2011). Childbirth educators are in a position to discuss the prevalence of domestic violence during pregnancy with new parents, without placing judgment on those parents, giving them the opportunity to reach out for assistance. Childbirth educators can also offer resources to the mother regardless of the fathers knowledge or willingness to participate in a solution. The childbirth educator may be the only person a pregnant victim of domestic violence comes in contact with that can assess for the abuse and take actions to resolve it. References Adesina, O., Oyugbo, I., & Olubukola, A. (2011). Prevalence and pattern of violence in pregnancy in Ibadan, South-west Nigeria. Journal of Obstetrics and Gynaecology, 31(3), 232-236. doi: 10.3109/01443615.2010.547954 Bravemann, P., Marchi, K., Egerter, S., Kim, S., Metzler, M., Stancil, T., & Libert, M. (2010). Poverty, near-poverty, and hardship around the timeof pregnancy. Maternal & Child Health Journal, 14, 20-35. doi: 10.1007/s10995- 008-0427-0 Clements, P. T., Holt, K. E., Hasson, C. M., & Fay-Hillier, T. (2011). Enhanc- ing assessment of interpersonal violence (IPV) pregnancy-related homicide risk within nursing curricula. Journal of Forensic Nursing, 7(2011), 195-202. doi: 10.1111/j.1939-3938.2011.01119.x Cook, J., & Bewley, S. (2008). Domestic violence against women in their childbearing years: A review of the literature. Journal of the Royal Society of Medicine, 101, 353-363. doi: 10.1258/jrsm.2008.080002 Keeling, J. (2012). Exploring womens experiences of domestic violence: In- jury, impact and infant feeding. British Journal of Midwifery, 20(12), 843-848. Lazzenbatt, A., & Greer, J. (2009). Safeguarding and protecting children in maternity services: Implications for practice. Child Care in Practice, 15(4), 313-326. doi: 10.1080/13575270903101241 Libuku, E., Small, L. F., & Wilkinson, W. (2008). Exposure to domestic vio- lence during pregnancy: Perceptions and coping mechanisms of a vulnerable group. Health SA Gesondheid, 13(2), 3-13. Manzolli, P., Nunes, M. A., Schmidt, M. I., Pinheiro, A. P., Soares, R. M., Giacomello, A., ... Ferri, C. P. (2009). Violence and depressive symptoms during pregnancy: A primary care study in Brazil. Social Psychiatric Epidemi- ology, 45, 983-988. doi: 10.1007/s00127-009-0145-y McMahon, S., & Armstrong, D. Y. (2012). Intimate partner violence during pregnancy: Best practices for social workers. Health & Social Work, 9-17. doi: 10.1093/hsw/hls004 Oweis, A., Gharaibeh, M., & Alhourani, R. (2009). Prevalence of violence during pregnancy: Findings from a Jordanian survey. Maternal and Child Health Journal, 14, 437-445. doi: 10.1007/s10995-009-0465-2 OReilly, R. (2007). Domestic violence against women in their childbearing years: A review of the literature. Contemporary Nurse, 25, 13-21. Raj, A., Sabarwa, S., Decker, M. R., Nair, S., Jethva, M., Krishnan, S., ... Silverman, J. G. (2011). Abuse from in-laws during pregnancy and post- partum: Qualitative and quantitative ndings from low-income mothers of infants in Mumbai, India. Maternal & Child Health Journal, 15, 700-712. doi: 10.1007/s10995-010-0651-2 Sarkar, N. N. (2008). The impact of intimate partner violence on womens reproductive health and pregnancy outcome. Journal of Obstetrics and Gynae- cology, 28(3), 266-271. doi: 10.1080/01443610802042415 Tanya has a masters degree in counseling psychology and is a registered marriage and family therapist intern in the state of California. She is currently earning a PhD in Health Psychology at Walden University with an emphasis on child and adolescent health. Tanya enjoys working with children of all ages in improv- ing their physical and psychological health while employed as a clinician/quality improvement coordinator in her county of residence. 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