Open Journal Systems

ORIGINAL CONTRIBUTIONS

Received: December 27^th 2014

Judged: March 11^th 2015

Prevalence of domestic violence in pregnant women from 20 to 35 years in a family medicine unit

Paulina Cervantes-Sánchez,^a Edna Gabriela Delgado-Quiñones,^a María Olimpia Nuño-Donlucas,^b Minerva Natalia Sahagún-Cuevas,^a Jéssica Hernández-Calderón,^a Joana Kareli Ramírez-Ramos^a

^aCurso de Especialización en Medicina Familiar, Unidad de Medicina Familiar 171

^bServicio de Ginecoobstetricia, Hospital General de Zona 89

Instituto Mexicano del Seguro Social, Zapopan, Jalisco, México

Communication with: Edna Gabriela Delgado-Quiñones

Telephone: (33) 3632 9608, extensión 31485

Email: dra.ednagdq@hotmail.com

Background: Violence against women is one of the most important health problems in recent times. In Mexico, it is reported a prevalence of 21.5 % during pregnancy; however, it seems to be underdiagnosed. The objective is to determine the prevalence of domestic violence in pregnant women from 20 to 35 years at the Unidad de Medicina Familiar (UMF) 171 of the Instituto Mexicano del Seguro Social (IMSS).

Methods: It was performed a cross-sectional descriptive study with a sample of 102 pregnant women to which we applied a sociodemographic questionnaire and the Severity of Violence Against Women Scale (ISVP).

Results: 19 women (18.6 %) suffered violence; of these, 10.8 % (n = 11) experienced physical violence, 5.9 % (n = 6) psychological violence, and 4 % (n = 4) sexual violence. We used chi squared between the variable violence and each of the sociodemographic factors: 52.6 % women (n = 10) were married (p = 0.005), 26.3 % (n = 5) had a bachelor’s degree (p = 0.074), 57.8 % (n = 11) had planned their pregnancy, 47.3 % (n = 9) were in the third trimester of pregnancy, and 78.95 % (n = 15) worked as laborers, shop-keepers or professionals (p = 0.016).

Conclusion: Among pregnant women belonging in UMF 171 of IMSS, domestic violence is a problem with a prevalence of 18.6 %.

Key words: Domestic violence; Pregnant women

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Violence is a social act and in most cases a learned behavior in a context permeated by social inequities based on gender, age, race, etc., with images of violence and physical force as the prevailing way of resolving conflicts.¹

Domestic violence is defined as any situation that causes discomfort or distress to one or more family members and comprises one or more of the following forms: insults, threats, and physical aggression.¹

Violence against women is one of the most important health problems in recent times; according to the United Nations Organization, every 18 seconds a woman is beaten in the world, while in the Estado de México 54 out of every 100 women are victims of some form of violence from their partner.²

Violence is a cause of death and disability as serious as cancer among women of reproductive age. Every 15 seconds a woman is assaulted (World Health Organization). One in three households has experienced continuous episodes of violence in the form of emotional abuse, intimidation, and sexual and physical abuse (ENVIF INEGI). It is estimated that about 50% of families suffer or have suffered from some form of violence.³

Family violence during pregnancy has a worldwide reported prevalence of 4 to 25%; in our country we found a prevalence of 15 to 32.1%, and the Instituto Nacional de Perinatología reported an incidence of 21.5%.⁴

Some studies conducted in Latin America and other world regions have shown that domestic violence is a major threat to the health and welfare of women. The Pan American Health Organization / World Health Organization (PAHO / WHO), in collaboration with the US Centers for Disease Control and Prevention (CDC) in their study "Violence against Latin American women, beyond the statistics", published in 2012, found that between 17 and 53% of respondents reported having been physically or sexually abused by their partners, and in seven of these nations the proportion was over one out of four. The investigation also showed that between 10 and 27% of women in these countries reported having suffered sexual violence at some point in their lives. This was committed by her partner or another person, and between 28 and 64% of those affected did not seek help and did not talk to anyone about the experience. According to this study, in Latin America, 40% of women are victims of physical violence, and the rate of psychological abuse in relationships is up to 50%.⁵

Partner violence brings victims and their children serious physical, psychological, sexual, and reproductive problems; moreover, the problem is reflected at the government level as it generates high economic and social costs. All this brings unwanted pregnancies, gynecological problems, induced abortions, and sexually transmitted infections, including HIV / AIDS.⁶

Moreover, pregnancy is the stage that marks the life of a woman. It represents a vital experience and to some extent her full realization as such. It is a manifestation of changes that every woman should understand and assimilate from the time her positive pregnancy test tells her her condition.⁷

The emotional state of women varies depending on the gestation period. During the first and last trimesters, levels of depression and anxiety are lower than during the second trimester. One possible explanation for this is that during the first trimester of pregnancy the status is hardly noticeable, and in most cases it is starting in the second or third month when the woman learns of her new state. Moreover, the second trimester is when the physical changes resulting from pregnancy begin to take place and the mother must accept these changes and face the new situation; that is often accompanied by responses of anxiety and depressive behaviors. Once accustomed to the new state, the responses of depression and anxiety diminish.^8,9

As to whether violence occurs during pregnancy, we found that the chances of spontaneous abortions, stillbirth, premature delivery, and low birth weight increase, which causes depression, posttraumatic stress disorder, insomnia, eating disorders, emotional distress, and suicide attempts. This results in increased rates of morbidity and mortality in children under five years (e.g., diarrheal diseases and malnutrition).6

Anxiety during pregnancy is a risk factor for preterm birth, low birth weight, and other adverse effects for the mother and newborn. In addition, it has been associated with shorter gestations with impact on neurodevelopment for the preterm child. Vrekoussis et al. suggest that adverse prenatal stimuli, such as maternal stress and anxiety, act on the embryo in development in utero, causing health problems in the short and long term (premature birth, low birth weight, and disease in adult stages ranging from neurodevelopmental disorders to metabolic syndrome).^10,11

Currently violence is already cited as a more common complication of pregnancy than hypertension, diabetes, or any other complications such as eclampsia, placenta previa, etc. Paradoxically, the reason most commonly associated with the high risk of domestic violence during pregnancy is increased stress felt by the father or partner with respect to the impending birth; this stress manifests in men as frustration directed against the mother and her unborn child.¹²

Physical violence during pregnancy increases by 2.07 times the odds of having newborns with low birth weight, regardless of comorbidity presented (95% confidence interval [CI] 1.08 to 3.95). The presence of substance abuse in pregnant women suffering from violence is found to be 5.11 times higher (95% CI 1.81 to 14.44), as well as the incidence of deaths and abdominal trauma, compared with pregnant women who do not suffer violence.¹³

From the beginning of the investigations, there have been difficulties and disagreements in the conceptualization and measurement of violence. However, various instruments have been developed to measure it. In this study we decided to use an instrument used in the Mexican population with internal consistency according to Cronbach's alpha of 0.99. The Partner Violence Severity Index (PVSI) aims to measure levels of severity for each type of partner violence in women; it assesses three types of violence (physical, psychological, and sexual) and measures the frequency of violent actions in the last 12 months.¹⁴

Methods

A cross-sectional study was conducted with non-probability sampling that included pregnant women aged 20 to 35 who attended prenatal care in the outpatient clinic, with the maternal and child nurse (MCN), and Preventive Medicine at the Unidad de Medicina Familiar 171 (UMF 171) of the Instituto Mexicano del Seguro Social (IMSS). The sample size was calculated from the total population of pregnant patients in this UMF, consisting of 1137 patients in the period from January 1 to December 31 2013. The statistical program Epi Info version 6 was used, and an average national prevalence of the rapid test of 21.5% was used, with a 99% confidence level. A total of 102 individuals were obtained. After the local research committee approved the study, we proceeded to apply surveys to pregnant women who attended prenatal care and who met the following inclusion criteria: patients aged 20 to 35 who were members of the IMSS UMF 171, who were pregnant, and who authorized their participation by informed consent in writing. 

The necessary information was obtained, which included the presence of violence, types of violence, age, marital status, occupation, education, weeks of gestation, number of pregnancies, and whether the pregnancy was planned. Once the information was collected, statistical analysis was done using SPSS, version 19. Descriptive statistics used frequencies and percentages for qualitative variables, while inferential statistics used the average in quantitative variables and Chi-squared test in qualitative variables.

Results

The results show that the ages of the 102 pregnant women who were given the sociodemographic questionnaire varied between 20 and 34 years, with a mean of 27.4 years. Of these patients, 66.7% were married (n = 68), 35.3% had a secondary education (n = 36), 39.2% were laborers (n = 40), and 51% (n = 52) were multiparous. 62.7% of the pregnant women (n = 64) were in the third trimester of pregnancy, and 68.6% of these pregnancies (n = 70) were planned.

Of the total participants given the Partner Violence Severity Index questionnaire, 18.6% (n = 19) suffered violence. Of these, 5.9% had psychological violence (n = 6), 10.8% suffered physical violence (n = 11), and sexual violence occurred in 4% (n = 4) (Table I). Of the 19 participants who suffered violence, 10 were married, six single, and three cohabiting (p = 0.005). Five of these women had undergraduate schooling, two had technical education, four high school, four participants had secondary school, three primary, and only one participant could just read and write (p = 0.074) (Table II). Of these 19 pregnant women who suffered violence, 57.8% had planned their pregnancy (n = 11) and 42.1% (n = 8) had unplanned pregnancies (p = 0.264). 47.3% of pregnant women with violence (n = 9) were in the third trimester of pregnancy. 21.05% of the pregnant women with violence (n = 4) were homemakers and 78.95% (n = 15) worked as laborers, vendors, and professionals (p = 0.016) (Table III).

Discussion

Some studies suggest that merely asking about violence, given validation and support, reduces violent incidents. This would gradually reveal the incidence of this problem in our area, which would encourage the implementation of strategies and lines of action to put an end to it.

The reviews published on domestic violence or relationship violence against women recognize the seriousness of the problem from the health perspective, and the justification includes routine inquiry about domestic violence as part of health care, even if the evidence does not motivate justification.

The lack of equity threatens the welfare and the very lives of women. It was found that 18.6 out of every 100 pregnant women by self-diagnosis were able to recognize that they suffered from domestic violence.

In the present study we observed that domestic violence is a health problem present in pregnant women 20 to 35 years enrolled in UMF 171 of IMSS. We detected a prevalence of 18.6%, similar to that recorded in other hospital settings and as published by the Instituto Nacional de Perinatología in 2006, with an incidence of 21.5%.¹⁵

In this work the most frequent type of violence was physical violence with 10.8%. These results are not compatible with that published by Fontanil et al. in 2005 in their study “Prevalencia del maltrato de pareja contra las mujeres” ("Prevalence of partner abuse against women"). In it they reported that psychological violence happens more frequently at 45.5%. Fernandez et al., in their work “Características psicopatológicas de mujeres víctimas de violencia de pareja” ("Psychopathological characteristics of female victims of intimate partner violence"), also reported that psychological abuse occurred between 20 and 75% of the 24,000 women participants.

Among the myths that society tells, children are thought to function as protectors against violence, but in everyday family life they are a major stressor element, so if we take into account the results of our work, where we find that the highest percentage of pregnant women with violence is among those who had planned their pregnancy (57.8%), compared to what Morales et al. published in 2006, where they cite that 67.3% of pregnant women who suffer violence do not plan their pregnancy,15 we might think then that this is not a protective factor against violence.  

In controversy with what Cepeda et al. published, where the prevalent schooling level among women who suffer violence was secondary,13 in this work the highest percentage of pregnant women with violence had an undergraduate degree, with 26.3%. These authors also state in their work that pregnant women homemakers were those that had the highest percentage of violence (71.2%), a risk factor that is statistically contrary in our work, since 78.95% had jobs including laborers, vendors, and professionals.

The UMF treats patients with different proportions of sociocultural levels, predominantly populations with low levels of schooling and working class with equal income, which did not allow us to study the phenomenon of violence during pregnancy in the different strata, and which prevented us from making associations to consider this as a risk factor.

We found a classic pattern of Mexican women, for only 66.67% of our patients were married and the rest were either unmarried or cohabitating, which shows a significant social and family change evolving.

Regarding the level of schooling, it is noteworthy that the largest percentage of women who suffer violence in our study had an undergraduate degree and most had jobs, with a lower percentage of full-time homemakers. These results are contrary to what we thought about how this situation could jeopardize women’s self-esteem and allow or perpetuate cycles of violence.

Domestic violence in itself is a serious problem that deserves attention, and if this is added to care for a high-risk reproductive event, not only the patient is in danger but also the health or life of the child.

The picture presented makes clear the need to consider domestic violence as an emerging public health problem because of its high prevalence and the damage caused to health. However, one must insist that domestic violence goes beyond the limits of the health field and necessarily involves the framework of human rights, as any act of violence against a person is an act that violates individual rights and guarantees. This means that strategies to address domestic violence should contemplate multidisciplinary interventions, not only from the health field. As part of this strategy, in this study pregnant women detected to have violence were referred to the social work service, where they were given support with advice regarding legal protection and self-help groups, plus a report was sent to their family physician suggesting management with psychological support and close surveillance by obstetrics.

Conclusions

Domestic violence was identified as a problem present in pregnant enrollees of UMF 171 of IMSS, with a prevalence of 18.6%.

In this paper we conclude that married pregnant women with undergraduate education who had planned their pregnancy were the most abused and suffered physical aggression.

Domestic violence is little detected and treated in primary care, since it is generally underdiagnosed and therefore all those women who have it suffer in silence, so its timely detection by applying the Partner Violence Severity Index questionnaire will make it possible to treat all patients who answer positively for violence in a timely and multidisciplinary manner, thus avoiding family inequality.

Health professionals from public and private systems who work with pregnant women must crucially be involved in the diagnosis and treatment of domestic violence in these patients. It is important to incorporate actively searching for signs and symptoms and risk factors for domestic violence into routine work. For this, training in the use of screening tools is important, such as the Partner Violence Severity Index, validated in Mexican women.

Acknowledgments

This work was possible thanks to support from the staff of the various departments of Unidad de Medicina Familiar 171 of IMSS.

References

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