Background
Intimate partner violence (IPV) is defined as behavior by an intimate partner that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors [
1]. The World Health Organization stated that violence against women is a major global public health problem and human rights concern. The study by the WHO [
2] in ten different countries reported that 13%-61% of women had been abused by their intimate male partners. IPV is also a serious social problem in Japan. The Gender Equality Bureau Cabinet Office [
3] in Japan conducted a national survey and found 15% of women experienced physical violence, 12% of women were assaulted psychologically by male partners and 7% of women experienced coercive sexual intercourse. In addition, the rate of IPV victims has not changed for over ten years since the government survey started in 1999. It is urgent that solutions be developed to eliminate violence against women in all countries.
Moreover, IPV towards pregnant women is a serious concern that the world faces. A systematic review indicated that prevalence of IPV during pregnancy ranged from 0.9% to 20.1% [
4]. Research on Japanese pregnant women that applied the Index of Spouse Abuse (ISA) [
5] found that 5% of women experienced IPV during pregnancy, and another survey showed that 1% of pregnant women had experienced physical intimate partner violence [
2]. IPV threatens several aspects of health among pregnant women. These include not only physical injuries [
6] but also psychological impairment such as postpartum depression [
7], posttraumatic stress disorder [
8,
9], bonding disorders [
10] and suicidality [
11]. Violence during pregnancy can result in pregnancy complications such as hypertension, vaginal and cervical bleeding, placental problems, severe nausea, and kidney infection [
12]. In addition IPV during pregnancy affects the fetus and neonates, such as low birth weight, preterm delivery and neonatal death [
13‐
15]. It may cause life-threatening results or the death of the mother and child [
13,
15,
16].
In Japan, the Act on the Prevention of Spousal Violence and the Protection of Victims was promulgated in April 2001 in recognition of the high IPV prevalence and its adverse social and health outcomes in Japan [
17]. This was the first law to indicate explicitly that spousal violence was a criminal act and the perpetrator must be punished by the criminal code. It also prescribed that prefectures establish and authorize at least one or more spousal violence counseling and support centers to take a central role in the support system for IPV victims in Japan. As a result of the Act, the number of institutions such as shelters, women’s counseling centers and IPV counseling centers increased. By 2001, more than 180 spousal violence counseling and support centers had been established in Japan. Counseling by these centers in 2007 numbered 62,078, about double the number in 2002 [
18]. This indicates that given the opportunity, women in Japan seek help and receive support about IPV and that support has been expanding.
A systematic review concluded that there was evidence that IPV screening increased identification of women experiencing IPV, however, there was insufficient evidence of an effect for other outcomes such as recurrence of IPV or health measures [
19]. Recently some evidence from antenatal care settings suggested that advocacy and empowerment interventions that followed IPV screening provided results in improved mental health outcomes of women [
20,
21]. Based on this, WHO guidelines recommended IPV screening for women during their antenatal care [
1]. In Japan, the Act on the Prevention of Spousal Violence and the Protection of Victims also stipulated the role of medical professionals for early detection and consultation. However, a survey of four prefectures in metropolitan areas found that IPV screening is still not widespread, with only 5% of institutions conducting IPV screening [
22]. The common barriers to conducting IPV screening at health care settings have been reported as time limitations [
23,
24], lack of confidence in screening [
24,
25], difficulty to establish rapport [
24], unease or fear about angering patients or causing emotional discomfort [
26]. In a questionnaire survey of women in Japan who had experienced IPV screening, most women replied that it was not unpleasant [
27,
28], but these were only a few questionnaire items answerable in yes/no format, to elicit the extent of satisfaction and with no psychometric controls applied. No other information was garnered about their experience.
Accordingly, this study aimed to conduct semi-structured interviews with postpartum women who received IPV screening during pregnancy to investigate women’s experiences of reading and completing the IPV screening questionnaire.
Results
Demographic characteristics of participants
Of the 48 women meeting the inclusion criteria during the study period and invited to participate in this study, agreement was received from 43 women (89.5%). The five not participating had been transferred to another hospital. After this information was provided and written informed consent was obtained data was collected. The valid response rate for the Violence Against Women Screen (VAWS) was 100%. All 43 women were then interviewed during their postpartum stay in the hospital.
Table
1 displays the demographic characteristics of participants. The majority (65.1%), of participants were in their thirties. Slightly over half were multiparas and the majority had vaginal births. All were married and most resided with their husbands. Family composition was nuclear family for 31 women (72.1%). Slightly over one-third of the participants were considered ‘housewives’ and the remainder worked full or part time. Most had graduated from high school and some had higher education. The couple’s annual income was between ‘$21,000-and $40,000 for half of the participants and between $41,000 and $61,000 or more’ for almost the other half. No one was receiving welfare payments. The participants’ spouses were generally in their thirties (67.4%) and most were employed (90.6%). One man (2.3%) was suspended from duty, and 3 men (7.0%) were unemployed.
Table 1
Demographic characteristics of participants and their partner (N = 43)
Participants |
Age (year) |
<20 | 1 (2.3) |
20–29 | 14 (32.6) |
30< | 28 (65.1) |
Marital status |
Married | 43 (100) |
Divorce history |
Wife | 3 (7.0) |
Husband | 1 (2.3) |
Living with partner |
Cohabitated | 40 (93.0) |
Separated | 3 (7.0) |
Family structure |
Nuclear families | 31 (72.1) |
Extended families | 12 (27.9) |
Educational background |
Junior high school graduate | 4 (9.3) |
High school graduate | 10 (23.3) |
Junior college graduate | 17 (39.5) |
University graduate / Graduate school | 12 (27.9) |
Employment status |
House duty | 15 (34.9) |
Full-time | 16 (37.2) |
Part-time | 10 (23.3) |
Others | 2 (4.7) |
Annual income (dollar) |
<200,000 | 2 (4.7) |
200,000–400,000 | 22 (51.2) |
400,000–600,000 | 9 (20.9) |
600,000≦ | 9 (20.9) |
Missing | 1 (2.3) |
Parity |
Primipara | 19 (44.2) |
Multipara | 24 (55.8) |
Partner of participants |
Age (year) |
20–29 | 9 (20.9) |
30–39 | 29 (67.4) |
40< | 5 (11.6) |
Employment status |
Full-time | 38 (88.4) |
Part-time | 0 (0) |
Suspension from work | 1 (2.3) |
Unemployment | 3 (7.0) |
Others | 1 (2.3) |
Results of IPV screening in pregnancy
Table
2 indicates the frequency of responses for each question of VAWS during pregnancy. A total 37.2% of participants responded “sometimes” for the question “Is it difficult to settle by talking arguments between you and your partner?”, and 14% of participants responded “sometimes” for “feel frightened by their partner” and “Has your partner screamed and /or yelled at you?” “Sometimes” was answered by 4.7% for the question of “hit the wall or thrown object”. One woman responded “sometimes” for sexual violence, and also one woman responded “sometimes” for physical violence. There were 8 women (18.6%) who screened positive for IPV during pregnancy; in other words their VAWS score exceeded the cut-off of 2 points or greater and one was referred to the counseling center.
Table 2
Frequency of each question of VAWS during pregnancy
1. Is it difficult to settle by talking arguments between you and your partner? | 0 (0) | 16 (37.2) | 27 (62.8) |
2. Do you feel frightened by what he does or said? | 0 (0) | 6 (14.0) | 37 (86.0) |
3. Has your partner screamed and/or yelled at you? | 0 (0) | 6 (14.0) | 37 (86.0) |
4. Has your partner ever hit the wall or thrown objects? | 0 (0) | 2 (4.7) | 41 (95.3) |
5. Has your partner ever forced you to have sex? | 0 (0) | 1 (2.3) | 42 (97.7) |
6. Has your partner ever pulled your arm, pushed, slapped you? | 0 (0) | 1 (2.3) | 42 (97.7) |
7. Has your partner ever hit or kicked you? | 0 (0) | 0 (0) | 43 (100) |
Women’s experiences of IPV screening
As a result of in-depth interviews, women’s experiences regarding IPV screening during pregnancy using the VAWS questionnaire were categorized into three themes: necessity, acceptability and optimality. The first theme ‘necessity’ included benefits for women through IPV screening. Three categories supported ‘necessity’: redefining the relationship, promoting IPV awareness, and opportunity to initiate support. The second theme was focused on women’s ‘acceptability’ of IPV screening, especially the VAWS questionnaire, and contained three categories: comfortable, quickly completed and difficulty. The third theme, ‘optimality’ referred to IPV screening during pregnancy that had appropriate timing for both women screening positive or negative. These three themes are discussed next in more detail.
Necessity
Participants talked about the necessity of IPV screening for all women during pregnancy. There were three categories under this theme: ‘redefining the relationship’, ‘promoting IPV awareness’ and ‘opportunity to initiate support’ which all indicated benefits of IPV screening for not only potential victims but also all pregnant women.
(1)
‘Redefining the relationship’
There were 13 (30.2%) participants who discussed ‘redefining the relationship’. For example they expressed opinions such as, ‘It caused me to think about my relationship with my partner’. Participants were able to review their relationship with their partner and realized there were many positive attributes. There were also women who said that they felt the importance of support from their partner during pregnancy and child rearing. Of particular note was that this category included women who had screened positive on the VAWS during pregnancy. A few women (4.7%) said that IPV screening ‘provided an opportunity to discuss their relationship with their partner’. They had told their partner about the IPV screening, and used it as an opening to discuss their relationship.
‘Once again, I start to take a look at our relationship, and think how to create a good relationship between me and my husband.’
‘I thought about it (the relationship between us two), remembering the way of talking with my husband, times when we have had an argument by doing IPV screening,
(2)
‘Promoting IPV awareness’
There were seven women (16.3%) in the category ‘promoting IPV awareness’ due to IPV screening. These women said as a result of IPV screening, they understood that IPV was a serious social problem and that there was a large number of women troubled by violence and felt sympathy with them, They said ‘I became aware again about IPV’; ‘Women are burdened by troubles such as DV’.
‘From my opinion as a pregnant woman, women must never be subjected to it (violence). I have not experienced such violence, but if there are such women, they really are to be pitied. Question items (of VAWS) make me aware of it (violence) ’.
(3)
‘Opportunity to initiate support’
Three women (7%) said that IPV screening ‘provides an opportunity to receive support for women subjected to IPV’. In this category, the women indicated that IPV screening made disclosure easier and provided an opportunity to talk, and was linked to being able to get support. The participants said that particularly for women who had no one to consult with, this sort of opportunity was necessary.
‘If there are mothers worried by violence, it would be good if they can be provided support after giving birth. For women with no one to consult, it is an opportunity to talk about it’
Acceptability
Acceptability of using the VAWS questionnaire emerged from women’s experiences. There were three categories supporting acceptability: ‘comfortable’, ‘quickly completed’ and ‘difficulty’.
Most of the women, 42 women (97.7%), described some aspect of ‘comfortable’. In this category, a common expression was ‘it was not unpleasant’ or ‘I wasn’t particularly concerned’. This means women in general accepted being questioned about IPV and about the expressions used for the questionnaire items. Most women did not feel uncomfortable about IPV screening, and among the 8 women who were positive for IPV screening during pregnancy, 7 women replied ‘It was not unpleasant’.
‘Midwife promised that privacy was protected, so it wasn’t unpleasant’.
‘I haven’t experienced this problem, so I wasn’t concerned and uncomfortable. But I don’t know. Women who experienced violence would be concerned, I am not sure. I don’t feel uncomfortable for the questions (of IPV screening).’
There were 30 women (69.8%) who thought the VAWS screening tool was easy to read and answer. Participants commented: ‘There were no questions difficult to understand’, ‘I think it was easy to answer’. The VAWS is a 7-item screening tool and each item is short and simple; therefore women understood and found there were no items that were difficult to understand. Additionally, 40 women (93.0%) thought the IPV screening could be completed quickly, so it was ‘just right’ or ‘appropriate’. However, three women thought it was ‘a lot’.
‘There were no questions where I didn’t understand the intention of the question’
‘The same types of questions are repeated. If asking these questions at a pregnancy checkup, fewer questions are better’
There were only 2 women (4.7%) who replied that ‘There was a question difficult to answer’. One of the reasons was that the contents of screening questions query about topics that are private especially regarding sexual violence. This woman screened negative in the VAWS test before pregnancy and during pregnancy. One woman responded that she did not feel discomfort about the questions, but thought that if her partner saw her answers he would feel uncomfortable, so they were difficult to answer. That woman screened positive in the VAWS test before pregnancy and during pregnancy.
‘There was a question difficult to answer a bit. That is about sexual violence. Because it is private matter. I can answer it, but I feel like difficult to answer’
‘I didn’t feel uncomfortable. But I feel the question is private. I answered yes to the question “Does your partner hit the wall or scream when he is angry”. If my husband looked at this answer, he would feel uncomfortable. I am afraid so.’
Optimality
The majority of the women (95.3%) thought that conducting IPV screening at the prenatal check-up was optimal. Those 41 women gave positive responses such as ‘I think it’s good’, and ‘I would not mind it’. On the other hand, 2 women gave negative responses such as, ‘It is not necessary’, and ‘I don’t think it is much good’. The reason for this was IPV is not an illness, so it is not necessary to deal with it at a hospital.
‘I think it’s good. It is helpful for women who have experienced violence’
‘I don’t think it is much good. Because IPV is different from an illness, so it is not necessary to deal with it at a hospital. There are other places to help women like shelters’.
In addition, when participants were asked whether they would consult with health care providers about IPV, only 8 women (18.6%) replied ‘Yes’. Reasons given for replying ‘Yes’ were ‘They seem close at hand’, ‘I want to consult a third party’, and ‘I can accept it if it is the opinion of a specialist’. Four women (9.3%) replied ‘I can’t say’. Reasons for replying ‘I can’t say’ were ‘I don’t know’, ‘It depends on the details’, and ‘It depends on the situation’. The majority, 31 women (72.1%), replied ‘No’. Reasons for replying ‘No’ were: ‘It is difficult to talk’, ‘I would talk with friends or family first’, ‘I would consult an IPV specialist’, ‘It would be a problem if my partner was informed of the fact that I consulted’, and ‘I don’t connect nurses with consultation about violence’.