Background
Domestic violence (DV) during pregnancy is not simply a severe public health issue that jeopardizes maternal and foetal health, [
1‐
8] but also a violation human rights [
6] and according to the Swedish penal code a criminal act [
9]. The World Health Organization (WHO) has reported that more than 90 % of the abused pregnant women are abused by the biological father of the child the woman was carrying [
10]. There is a large variation in the prevalence of reported violence, which can be explained by differences in the material, definitions and methodologies used, as well as the context [
11‐
14]. However, longitudinal studies that shows the incidence of DV during pregnancy are rare. Further there is a lack of evidence about potential risk factors that are associated with the incidence of DV during pregnancy.
A meta-analysis of 92 independent studies completed in 23 countries (Sweden included) published in 2013, revealed an average prevalence of DV during pregnancy of 19.8 % where 28.4 % of these were characterised as emotionally based, 13.8 % as physical violence and 8.0 % were sexual abuse [
14]. The overall prevalence of DV during pregnancy in developed countries was reported as 13.3 % in comparison to 27.7 % in the less developed countries [
14]. In Sweden the prevalence of abuse during pregnancy has previously been reported as 1.0 % DV during early pregnancy (mean 12.8 week, SD 5.11) [
11], 1.3 % perpetrated by a close acquaintance or relative during or shortly after pregnancy [
12], and 4.3–14.5 %, depending on the severity of the violence, was perpetrated by a current or ex-partner [
13].
In a meta-analysis of 55 independent studies, the strongest predictor for DV among pregnant women disclosed as having a history of violence [
14]. In addition, it has been reported in a study from six countries in northern Europe that a history of abuse is common among pregnant women [
15] which was also revealed in our earlier study [
11]. Other identified risk factors for DV among pregnant women are being single, having a lower standard of education as well as low socioeconomic status, an unintended pregnancy and when the perpetrator of the abuse misused alcohol [
14]. Another systematic review and meta-analysis showed that high levels of anxiety, symptoms of perinatal depression and posttraumatic stress disorder (PTSD) were significantly associated with the experience of DV during a woman’s lifetime, including while pregnant [
7].
The health and well-being of a mother-to-be is also reflected in the offspring’s health and the pregnancy outcome. A systematic review of 30 studies, disclosed that pregnant women exposed to DV are almost 1.5 times more likely to have a preterm baby as well as delivering a low-birth-weight baby [
8]. Abuse of pregnant women indirectly affects (i.e. increased risk of various psychological and physical health problems) or directly (i.e. abrupt trauma to the stomach) the morbidity and mortality of both the mother and the offspring [
1‐
5].
An absolute condition for a pregnant woman surviving the abuse is that it is identified early in order to get adequate help in the form of support and care. A Cochrane review supports the fact that disclosure of violence increases significantly, when the question of exposure to violence is addressed, especially at Antenatal Care (ANC) [
16]. In late 2014, The National Board of Health and Welfare in Sweden recommended that all women received by a midwife at an ANC should be asked about any experience of violence they had [
17]. However, it can vary locally from county to county as to how and to what extent this sensitive matter is addressed. It is the Healthcare providers’ responsibility to develop procedures for how and when the issue of violence is to be discussed with the mother-to-be. As well as to develop procedures for the staff to follow when they detect a woman who has been exposed to violence. Further, it is also the health care provider’s responsibility to ensure that the staff are working in accordance with these procedures. Today, there are not only public, but also private clinics for pregnant women in Sweden. In the year 2014, almost 80 % of all pregnant women in Sweden were asked by their midwife, at their ANC, if they had any experience of violence [
18]. Obstacles to early recognition of the problems of violence can be the lack of local guidelines as well as lack of professional support and overall, the problem of the midwives themselves if they lack knowledge or confidence [
19]. Added to this is also the fear of the possible reaction of the perpetrator (ibid). Also, it is fundamental to have prepared strategies to follow up and refer a survivor of violence to help in order to get positive effects for the pregnant woman and her child’s health and to decrease or eliminate the violence [
16].
The literature appears to be inconsistent across cultures concerning whether pregnancy is a time of protection or risk to be exposed to DV [
20]. In our previous report which is the first part of this whole project, the recruitment of pregnant women was undertaken at 17 ANC’s, both public and privately driven [
11]. All violence-exposed women also reported a history of violence regardless of type or level of abuse. There was a seven-fold risk for having several symptoms of depression if exposed to violence (ibid). As there is a shortage of reports about the incidence of DV during pregnancy and related risk factors, there was a need to explore this subject area to get a better picture of the magnitude of this problem.
The aim was to explore the prevalence and incidence of domestic violence among pregnant women in the southwestern region of Scania in Sweden, as well as their experience of a history of violence. In addition, to explore the association between domestic violence during pregnancy and possible risk factors.
Results
The response rate for QII was 78.8 % (
n = 1527) of the total cohort (
n = 1939) of women who were recruited in
early pregnancy during gestational week 13 (mean 12.84, SD 4.11, min 4-max 35) and had completed QI. QII was answered during
late pregnancy or during gestational week 34 (mean 33.9 week, SD 2.2, min 25-max 42). Both QI and QII were completed by 77.8 % (
n = 1509) of the participants and 44.3 % (
n = 668) of them reported a lifetime experience of abuse irrespective of type, severity or perpetrator. Also, 5.1 % (
n = 77) reported some experience of abuse during the past year i.e. during pregnancy as well as some months before the pregnancy being known (Table
1).
Table 1
Type and severity of lifetime abuse: in Questionnaire I, Questionnaire II, Questionnaire I and II
Lifetime experience of abusec
| 761 (39.5) | 562 (36.8) | 668 (44.3) |
Any abuse during the past year | 84 (4.3) | 38 (2.5) | 77 (5.1) |
Lifetime of emotional abuse | 374 (19.5) | 257 (16.8) | 335 (22.2) |
Mild
| 307 (16.1) | 221 (14.5) | 291 (19.3) |
Moderate
| 187 (9.8) | 123 (8.1) | 175/11.6) |
Severe
| 203 (10.6) | 135 (8.8) | 192 (12.7) |
Any emotional abuse during the past year | 61 (3.1) | 28 (1.8) | 56 (3.7) |
Lifetime of physical abuse | 561 (29.3) | 417 (27.3) | 514 (34.1) |
Mild
| 529 (28.0) | 399 (26.1) | 493 (33.5) |
Moderate
| 203 (10.7) | 171 (11.2) | 214 (14.5) |
Severe
| 127 (6.7) | 89 (5.8) | 118 (8.0) |
Any physical abuse during the past year | 36 (1.9) | 13 (0.9) | 31 (13.0) |
Lifetime of sexual abuse | 302 (15.7) | 218 (14.3) | 265 (17.8) |
Mild
d
| 49 (2.6) | 37 (2.4) | 52 (3.6) |
Mild
e
| 208 (11.0) | 169 (11.1) | 217 (14.9) |
Moderate
| 212 (10.9) | 166 (10.9) | 199 (13.5) |
Severe
| 144 (7.4) | 94 (6.2) | 118 (8.0) |
Any sexual abuse during past year | 2 (0.1) | 5 (0.3) | 5 (0.3) |
Prevalence and incidence of DV during pregnancy
Table
2 shows the prevalence and incidence of DV during pregnancy. The prevalence of DV during pregnancy (solely) irrespective of type or severity was reported to be 2.0 % (
n = 29). The incidence of DV during pregnancy was 7.3 new cases per 1000 pregnant women and there were 11 new women who reported DV during pregnancy. In QI 1.0 % (
n = 18) of the participant women reported DV in
early pregnancy and in QII there were 1.1 % (
n = 17) of the women who reported that during
late pregnancy they were exposed to DV (Table
2). Of the 18 women reporting DV during pregnancy in QI, 12 of them did not report DV during pregnancy in QII. This can be explained as follows; three had miscarriages/abortion, one moved from the catchment area, four did not fill-in the QII and four did not report any DV during pregnancy in QII (this information is exclusively presented in the text).
Table 2
Self-reported prevalence and incidence of DV during pregnancy
a
Total cohort | 1939 (100) | 1527 (100) | 1939 (100) | 1509 (100) |
In the analysis | 1928 (99.4) | 1497 (98.0) | 1467 (75.7) | 1497 (99.2) |
Missing
c
| 11 (0.6) | 30 (2.0) | 472 (24.3) | 12 (0.8) |
Emotional abuse | 15 (0.8) | 13 (0.9) | 24 (1.6) | 9 (6.0) |
Physical abuse | 7 (0.4) | 8 (0.5) | 11 (0.7) | 3 (2.0) |
Sexual abuse | 2 (0.1) | 2 (0.1) | 2 (0.1) | 0 (0.0) |
Total of any type of abuse | 18 (1.0) | 17 (1.1) | 29 (2.0) | 11 (7.3) |
Association between possible risk factors and exposure to DV during pregnancy
The strongest risk factor for DV being reported during late pregnancy was
a history of violence whereby all of the women (
n = 17) who had disclosed exposure to DV during pregnancy had also reported ‘a history of violence’ (
p < 0.001). Women with
a low educational status were 3.1 times more likely to report being exposed to DV during pregnancy (
p = 0.016). Women living
Single/living apart were 17.9 times more likely to report exposure to DV during pregnancy (
p < 0.001). Further, women in a situation of
financial distress were 3.7 times more likely to be exposed to DV during pregnancy (
p = 0.014). Also, women with
an unintended pregnancy were 2.8 times more likely to be exposed to DV during pregnancy (
p = 0.040). Those who reported
lack of sleep during the last year, to such an extent that they had problems coping with their daily life, were 9.6 times more likely to be exposed to DV during pregnancy (
p < 0.001). Women having an EDS score ≥13 indicating the presence of several symptoms of depression were 15.8 times more likely to be exposed to DV during pregnancy (
p < 0.001). Lastly, women having a low score on the SOC-scale, indicating an inability to use their own resources to maintain and improve their health in stressful situations were 9.9 more likely to be exposed to DV during pregnancy (
p < 0.001) (Table
3).
Table 3
Association between possible risk factors and DV during late pregnancy (N = 1509)
History of violencea
| 668 (44.3) | 17 (2.6) | - | <0.001 |
Age ≥35 | 269 (18.1) | 2 (0.8) | 0.6 (0.1–2.7) | NS |
Multiparae | 760 (54.3) | 11 (1.5) | 1.9 (0.6–5.4) | NS |
Low educational status | 481 (31.9) | 10 (2.1) | 3.1 (1.2–8.2) | 0.016 |
Unemployed | 74 (4.9) | 2 (2.9) | 2.7 (0.6–12.2) | NS |
Foreign language | 357 (23.7) | 6 (1.7) | 1.8 (0.7–4.9) | NS |
Single/living apart | 50 (3.3) | 6 (12.2) | 17.9 (6.4–50) | <0.001 |
Financial distress | 705 (46.7) | 13 (1.9) | 3.7 (1.2–11.5) | 0.014 |
Alcohol consumption | 330 (22.1) | 4 (1.2) | 1.1 (0.4–3.4) | NS |
Smoking/using wet tobacco | 300 (20.1) | 5 (1.7) | 1.7 (0.6–4.8) | NS |
Overweight/obese | 378 (26.0) | 7 (1.9) | 2.0 (0.8–5.3) | NS |
Unintended pregnancy | 246 (16.5) | 6 (2.4) | 2.8 (1.01–7.5) | 0.040 |
Miscarriage/abortion | 91 (6.2) | 2 (2.2) | 2.1 (0.5–9.1) | NS |
Self-reported poor health | 67 (4.6) | 1 (1.5) | 1.4 (0.2–10.7) | NS |
Lack of sleep | 107 (7.2) | 7 (6.7) | 9.6 (3.6–25.8) | <0.001 |
EDS ≥13 | 115 (8.2) | 9 (8.0) | 15.8 (5.8–43.4) | <0.001 |
SOC Low score | 364 (25.4) | 13 (3.7) | 9.9 (3.2–30.7) | <0.001 |
Table
4. Here, the resulting outcomes in Table
3 were checked for the following variables; single/living apart, EDS ≥13, low SOC score, lack of sleep, financial distress, low educational status, unintended pregnancy and age. Single/living apart remained significant (
p = 0.002) and had 8.4 times risk associated with DV during pregnancy, EDS scores ≥13 and lack of sleep had 3.8 times the risk respectively (
p = 0.04,
p = 0.03).
Table 4
Association between possible risk factors and exposure to DV during pregnancy in late pregnancy (n = 17)
Single/living apart a
| 18.0 (6.4–51.0) | 9.2 (2.9–29.6) | 7.9 (2.4–25.5) | 8.4 (2.5–28.0) | 8.5 (2.4–29.8) | 7.2 (2.0–26.2) | 8.2 (2.1–32.0) | 8.4 (2.2–32.6) |
EDS ≥13 b
| | 9.9 (3.3–29.4) | 5.4 (1.7–17.5) | 3.5 (1.0–12.6) | 3.5 (1.0–12.7) | 3.6 (1.0–12.7) | 3.7 (1.0–13.2) | 3.8 (1.1–13.6) |
Low score SOC c
| | | 3.8 (1.0–13.6) | 3.4 (0.9–12.3) | 3.4 (0.9–12.7) | 3.2 (0.9–12.0) | 3.3 (0.9–12.2) | 3.3 (0.9–12.3) |
Lack of sleep d
| | | | 3.8 (1.1–12.5) | 3.8 (1.1–12.6) | 4.0 (1.2–13.2) | 3.9 (1.2–13.3) | 3.8 (1.1–12.9) |
Financial distress e
| | | | | 1.0 (0.3–3.7) | 0.8 (0.2–3.2) | 0.8 (0.2–3.2) | 0.8 (0.2–3.2) |
Low educational status f
| | | | | | 2.0 (0.6–6.4) | 2.2 (0.7–7.2) | 2.2 (0.6–7.1) |
Unintended pregnancy g
| | | | | | | 0.7 (0.2–2.7) | 0.8 (0.2–2.8) |
Age h
| | | | | | | | 1.2 (0.2–6.0) |
Discussion
The present study showed the prevalence of DV as being 2 % in women during their current pregnancy (solely). This means that at least 180 pregnant women in the catchment area are exposed to DV during pregnancy annually (calculated on 9000 births in the catchment area or at one university hospital with two delivery apartments). This results in a twofold prevalence when compared with our earlier study [
11] were the women answered QI in early pregnancy. This can indicate that DV during pregnancy is not only a continuum of pre-existing DV [
10,
11], but likely to increase over time [
29], which is also in accordance with the normalizing process (where the violence has become a natural part of the relationship) [
30] and noted in an earlier study by Finnbogadóttir et al. [
31]. However the true prevalence can be difficult to determine of many reasons, as for example fear concerning abuse escalation if the perpetrator would be made aware through disclosure [
32], as well as any sense of shame over the situation the violence-exposed woman finds herself in [
19,
31,
33‐
35]. In addition, in our prior study [
11] it was indicated that the prevalence of DV during early pregnancy might be underestimated due to reported higher prevalence of lifetime physical abuse performed by an actual partner as well as due to selection or non-respondent bias. In the current study there is also an indication that the prevalence of DV might be underestimated due to that 5.1 % of the pregnant women reported experience of some abuse over the past year. This involves experience of abuse perpetrated some months prenatal as well as during pregnancy. This is also in agreement with earlier research from countries in northern Europe where the same questions from the same instrument NorAQ had been used; Norway 5 % [
36] and 3.7 % respectively [
15], Iceland 3.3 %, Belgium 3.0 %, Denmark 3.3 %, Estonia 6.5 % and Sweden 3.0 % (ibid). In the present study the prevalence of DV during pregnancy appears to be realistically perceived in a global perspective, because the prevalence in developed countries compared to less developed countries (more violence-tolerant societies) has shown to be lower [
14,
37]. Still, the true prevalence is difficult to estimate but can approach the prevalence level indicated in reality studies performed in different contexts from different countries.
In addition, the present study showed the incidence of DV during pregnancy to be 7.3 new cases per 1000 pregnant women or at least 65 new violence-exposed pregnant women annually (calculated on 9000 births). It has been suggested that the pregnancy per se can trigger violence [
38,
39] as well as that the violence during pregnancy may be only a continuum of previous violence [
10,
11]. This was also supported by the current study, where all of the women who were exposed to DV during pregnancy also reported a history of violence. However, the literature is inconsistent regarding this point, but it has been pointed out that cultural factors may be important determinators [
37]. Corresponding, studies have shown that repeated questioning about the experience of violence increases the possibility that the violence-exposed woman admits her vulnerability [
12,
40]. The complexity of the topic and the pre-existing strain in the relationship, as well as new demands made during pregnancy, may also explain new cases of abuse during pregnancy. Further, in many cases the survivor wants the relationship to work [
31,
41] and therby does not disclose the ongoing abuse. Correspondingly, violence-exposed pregnant women are prone to stay in a dysfunctional relationship in order to protect their unborn baby and are not willing to leave the relationship for reasons of abuse, and also if their self-esteem and self-respect has been lost and they experience that they feel drained of their energy [
31]. Altogether this is extremly important information for every caregiver when meeting the violence exposed pregnant women and can guide them in how their actions/practises to help and support should be planned for each individual woman.
History of violence was separately, the strongest risk factor for being exposed for DV during pregnancy. This is congruent with previous research [
11,
14]. Further, our data suggests that a history of violence is a common occurrence among pregnant women since more than four out of ten (44.3 %) women in the study had experienced a history of violence. This is also verified by earlier research [
11,
15]. Indeed women with a history of violence in their relationship may be at increased risk for DV during pregnancy [
11,
14] therefore it’s of utmost importance to approach the matter with the pregnant women at the ANC’s as well as to have the possibility to give the survivor first line support. This is in accordance with the WHO’s clinical guidelines from 2013 as well as the national recommendations in Sweden [
17]. Furthermore, when a midwife or obstetrician discovers a violence-exposed pregnant woman in Sweden they are obliged to report their findings to the social services if there are other children in the family and/or in order to protect the unborn baby [
42‐
44]. There can be a reluctance among women to disclose their current situation regarding DV due to their fear that their other children might be taken away from them. In our former study, this misapprehension was clearly pointed out by one of the interviewed midwives who had experience of an immigrant woman who thought the authorities would take her other children away from her if the violence was revealed [
19]. However, in the same study the midwives also expressed their fear of retaliation against themselves or their families if they should report suspected DV to the authorities if the perpetrator was known to have shown very aggressive behaviour (ibid). Therefore, it’s extremely important to have a clear and safe plan of action for the violence-exposed pregnant women as well as for all of the health care personnel at the ANC’s.
The present study also revealed the following strong predictors for pregnant women to be exposed to DV during pregnancy on the grounds of their being; ‘single/living apart’ which is supported by earlier research [
14] as well as the ‘presence of several depressive symptoms’ which is correspondingly supported by systematic review and meta-analysis [
7]. Having a ‘lack of sleep’, which is also supported by earlier studies [
11,
31]. Lack of sleep is one of the signs for PTSD as well as depression [
45]. To be single/living apart as well as suffering from a lack of sleep during the last year to such an extent that the pregnant woman has problems coping with her daily life should be an alarm signal to the midwife and other health care providers indicating strong predictors for DV during pregnancy. Moreover, the presence of several depressive symptoms detected in early pregnancy [
11], as well as in late pregnancy, [
7] can also indicate that the woman is exposed to DV during pregnancy. Hypothetically, a pregnant violence-exposed woman who reports herself as being single/living apart and exposed to DV may have recently left the abusive relationship during pregnancy. Another possible scenario is that the perpetrator she has already left stalks her and will not leave her alone.
Strength and weakness in the study
The current cohort study with its longitudinal design based on prospectively collected data allowed the comparison of violence exposed and non-violence exposed pregnant women during the same time-period, which is considered as a strength for the study as well as offering the possibility to explore both prevalence and incidence of violence. Further, using validated instruments in the questionnaires [
21‐
23,
25,
46,
47] where the main instrument was previously used in a multicounty study, [
48] and also validated within a Swedish population, [
22] is also considered as a strength. Initially, power calculation was performed and the number of participants was slightly underpowered with 1939 instead of 2000. The results might potentially be biased due to selection. This is because the recruitment took more time than expected due to a high work load among the recruiting midwives and therefore the selection became nonconsecutive, but random. However, we do not find any reason to believe that systematic selection bias occurred. The strength of the current study is the sample size in QI (
n = 1939) and the satisfactory number of answers of 78.8 % in QII. The fact is, only 1.5 % of those (
n = 1550) who received the QII constitutes an internal drop-out (Fig.
1). However, due to an administration failure the recruiters (the midwives) failed to give the second questionnaire to 239 participants (12.3 %) which may reflect how strained their working situation was during the participant recruiting period. Therefore, unfortunately the prevalence and incidence of DV during pregnancy may be underestimated. The results from the study are also limited to those who fulfilled the inclusion criteria ≥18 years, registered at an ANC when pregnant, and who understood and could write Swedish or English.
Abbreviations
AAS, abuse assessment screen; ANC, antenatal care; AUDIT, alcohol use disorders identification test; BMI, body mass index; CI, confidence intervals; DV, domestic violence; EDS, Edinburgh depression scale; EPDS, Edinburgh postnatal depression scale; NorAQ, NorVold abuse questionnaire; QI, questionnaire I; QII, questionnaire II; OR, odds ratios; SOC-13, sense of coherence scale-short form; WHO, World Health Organization
Acknowledgements
The authors would like to thank all the midwives who carried out the recruitment and made it possible for us to fulfill the study. Special thanks to Mathias Grahn for his excellent statistical support.
NorAQ was developed by NorVold, a research network established in 1997 to explore the prevalence of violence against women and its effects on women’s health. The NorVold research network was supported by grants from the Nordic Council of Ministers. Principal investigators are Barbro Wijma, Berit Schei. Coordinator: Katarina Swahnberg. Local investigators are: Denmark: Katrine Sidenius, Malene Hilden, Finland: Erja Halmesmäki, Ulla Pikkarinen, Iceland: Tora Steingrimsdottir, Norway: Berit Schei, Hildegunn Stoum-Hinsverk, Kristin Offerdal, Sweden: Barbro Wijma, Katarina Swahnberg.