The results of this study showed that maternal-fetal attachment in pregnant Iranian and Afghan pregnant women was more than average. Also, maternal-fetal attachment and all its dimensions were significantly higher in Afghan pregnant women than in Iranian pregnant women. Results of several studies on Iranian pregnant women showed that maternal-fetal attachment in pregnant women was more than average [1–3, 26]. Also, the results of various studies on pregnant women in Korea, Africa, Turkey, and the USA showed that the maternal-fetal attachment was also above average, all of which were in line with the present study [4, 7, 8, 27]. But O'Malley et al. (2018) in Ireland showed that the rate of maternal-fetal attachment in Irish pregnant women was moderate [28]. This inconsistency may be due to the low sample size, differences in research methodology, and cultural differences. Based on the above studies, it can be concluded that maternal-fetal attachment rate among pregnant women (either in Iran or in different countries) is favorable. Maternal attachment to the fetus during pregnancy affects the formation and development of a safe and healthy child attachment [9]. With increased maternal attachment to the fetus, mothers are more likely to engage in health behaviors during pregnancy such as stopping smoking and alcohol, proper nutrition, exercise, continued antenatal care, tendency to recognize the fetus, and attending birth preparation classes, as well as increasing breastfeeding rates. All of these behaviors lead to a satisfactory pregnancy outcome and improve maternal-fetal health [10]. Therefore, it is necessary to consider various factors that may affect maternal-fetal attachment when caring for pregnant women. For example, in the present study, pregnant women with non-Iranian spouses had higher maternal-fetal attachment scores than those with Iranian spouses, and Afghan women’s age, spouse age, marital length, and unwanted pregnancy influenced maternal-fetal attachment rate. In other words, the higher the age of pregnant women, their spouses and duration of marriage, the lower the maternal-fetal attachment score and the severity of these relationships was moderate. Also, the maternal-fetal attachment score of Afghan women with unwanted pregnancy was higher than that of Afghan pregnant women with wanted pregnancy. In the studies, older age [1, 3, 28], low gestational age [3, 10], low education [3, 10, 28], low education-related jobs such as agriculture [1, 3, 10], dissatisfaction with fetus gender [3], complications of current pregnancy [3], and unwanted pregnancy [10] reduce maternal-fetal attachment and antenatal education [4], number of pregnancies [1, 3, 10], and breastfeeding experience [4] increases the maternal-fetal attachment. These studies were inconsistent with the present study. But among the above variables, age was in line with Afghan women. No study was found to investigate maternal-fetal attachment in Afghan women.
The results of this study showed that the level of domestic violence was low in Iranian and Afghan pregnant women. Besides, verbal and emotional-psychological abuses in Iranian pregnant women were significantly higher than that of Afghan pregnant women, while sexual abuse in Afghan pregnant women was significantly higher than that in Iranian pregnant women. There was also no difference between the two groups in physical abuse, financial abuse, and total score of domestic violence. The Cengiz et al. (2013) study in Turkey, the Boru Bifftu et al. (2017) study in northwest Ethiopia, as well as the results of two studies in 2016 and 2019 in Nepal were consistent with the present study and showed that the level of domestic violence against pregnant women was low in these regions [15, 16, 20, 29]. But the Yohannes et al. (2019) study in southeastern Ethiopia and the Fekadu et al. (2018) study in northwest Ethiopia found that the rate of domestic violence against pregnant women was high in these regions [17, 30]. These studies were inconsistent with the present study. Differences in sample size, cultural differences in different countries and communities, differences in education level, inaccessibility to accurate information about marital relationship, and differences in data collection questionnaires can lead to inconsistencies amongst studies. Studies conducted on Iranian pregnant women showed that domestic violence was high in these women [13, 14, 31]. These studies were also inconsistent with the present study. Reasons for such inconsistency can be differences in sample size, research method, differences in questionnaires used to measure the domestic violence rate, and cultural differences in respondents' willingness to disclose their marital experiences. In this study, despite the trust-building, it should be noted that since domestic violence is related to the privacy of one's life, the women under investigation might either have denied the violence or have not stated it correctly for some reasons. The results of the studies showed that the most common type of violence was sexual one and then psychological and emotional violence [14, 17, 20, 29] which were in line with the present study. But Yohannes et al.'s (2019) study in southeastern Ethiopia was not consistent with the present study which showed that physical violence had the highest rate of violence among pregnant women [30]. Also, the results of Hassan et al. (2013) study showed that physical violence and psychological violence were the most common types of violence in this study. This study was inconsistent with the present study regarding physical violence [13]. Kamali et al. (2015) study found that the most common type of violence was related to the physical, psychological, and sexual violence, respectively. This study investigated violence in urban and rural pregnant women. Violence was high in both communities, but physical, psychological, and sexual violence on rural pregnant women was higher than that on urban pregnant women [30]. Domestic violence during pregnancy increases the risk of miscarriage, vaginal bleeding, cesarean section, low birth weight and delayed growth in the uterus [13–15]. Therefore, it is necessary to take into account various factors that may affect domestic violence when taking care of pregnant women. For example, in the present study, variables such as age, spouse’s age, marital duration, housing status, fetus gender, wanted pregnancy, number of children, and history of physical illness in the afghan women influenced the rate of domestic violence. In other words, the higher the age of pregnant women, their spouses and the duration of marriage, the higher the score of domestic violence. Pregnant women with a personal house, women whose fetus gender was unknown, unwanted pregnancy, women with more than two children, and women with physical illness reported more violence than other Afghan women. In other studies, age [14, 31], spouse’s age [31], education [13, 16, 31], economic status [13, 31], spouse’s addiction (smoking and alcohol) [13, 14, 30, 31], number of pregnancies and children [13, 31], duration of marriage [14, 31], experience of previous marriage [14], unwanted pregnancy [16] and spouse’s occupation [13, 30] influenced the rate of violence against pregnant women. These studies were inconsistent with the population of Iranian pregnant women but consistent with Afghan pregnant women in terms of age, spouse’s age, number of children, duration of marriage, and unwanted pregnancy. It should be noted that no study has examined the rate of domestic violence against pregnant Afghan women. Also, in searches of databases, we were unable to find a valid and up-to-date study on violence against Afghan women. The only case was the statistics published by European Union in 2017 showing that the violence against Afghan women was high. Of the 3778 registered cases of violence per year, 231 cases were homicides, 1003 were assaults, and 38 were rapes [32]. In Afghan society, women's decision-making has been limited, and their vulnerability to violence increased due to the wrong cultural traditions such as early marriage, exchange marriage, and marriage with conditional bride pricing. Also according to the culture dominating the country, domestic violence must be resolved in the family and remained a private matter in the family environment. Partner’s violence is not disclosed due to fear of losing family honor. 89% of Afghan women express satisfaction with their husbands in the health centers while being violated. Also, 50% of women believe that their husbands have the right to beat them in the case of disobedience [33].
The results of this study showed that the higher the domestic violence and the dimensions of verbal, emotional-psychological, and financial abuses in Iranian pregnant women, the lower the maternal-fetal attachment. The higher the verbal, physical, emotional-psychological, and financial abuses in pregnant Afghan women, the lower the maternal-fetal attachment, while the higher the sexual abuse, the higher the maternal-fetal attachment and all its dimensions. The results of the studies by Almeida et al. (2013) in Portugal and Ghaffari et al. (2018) in Iran showed that the higher the domestic violence and physical abuse, the lower the maternal-fetal attachment in pregnant women [21, 23]. This study was not consistent with Iranian pregnant women, but it was consistent with Afghan women. Differences in research method, cultural differences, socioeconomic characteristics and method of data collection, different individual and social characteristics in two populations in two different cities, low number of samples under study and impact of mental states of samples on responses can cause such differences in the results of studies. Ghodrati et al. (2017) in their study concluded that there was a significant relationship between maternal-fetal attachment and social violence, but there was no relationship between maternal-fetal attachment and psychological, physical, financial, and sexual violence [22]. This study was inconsistent with the present study. The reasons for inconsistency include differences in sample size, cultural differences between individuals in two different cities, differences in data collection questionnaires, and selection of 24- to 35-week gestational age for samples. From the above studies, it can be concluded that violence against pregnant women reduces maternal-fetal attachment. Women who are victims of domestic violence have a negative attitude toward pregnancy and their fetus. It is recommended to reduce and control violence, conduct family and marital counseling to increase maternal attachment to the fetus and improve motherhood process in these women [21, 23]. The results of this study showed that the higher the sexual violence, the higher the maternal attachment to fetus in afghan pregnant women. To justify this result, one might point to a systematic study conducted by Vogel in 2013, in which 75% of women believed that sex, whether with consent or not, was a woman's duty [33]. However, further research is needed on the Afghan pregnant women population and the cultures dominating this community to justify the results of this study properly.