Design
The conventional content analysis approach was used to design this qualitative study to get deeper insight into pregnant women's experiences of perinatal domestic violence (27).
Participants And Setting
The study was accomplished in Mashhad, the second most populous city in Iran from September 2019 to August 2021. Urban health centers, obstetrics and gynecology departments of referral hospitals, midwifery counseling centers, forensic medicine center, and provincial social welfare center were used as the study settings.
Purposive sampling based on the maximum variation of mothers' age, occupation status, education level, number of children, wanted or unwanted pregnancy, gestational age and HITS domestic violence positive screening score (11–20) was used to select the participants (28). The inclusion criteria were pregnant or postpartum women with the experience of positive perinatal domestic violence. Exclusion criterion were substance abuse and physical and mental illnesses that prevent women from participation in the study.
Individual semi-structured in depth interviews were conducted on 14 women who experienced domestic violence during pregnancy and until one year postpartum period (29–32) and 11 women who were specialist in different related disciplines comprising of reproductive health, midwifery, psychology, forensic medicine, social working, law, sociology. Participants' profiles are shown in Tables 1 and 2.
Table 1
The profile of women participated in the study
participant | Age of woman/ husband | Education of woman /husband | Woman's job | Husband's job | Gestational age | HITS score* |
1 | 37/ 53 | 8years/ 8 years | House wife | Retired | 37w | 16 |
2 | 22/ 29 | 7 years/ diploma | House wife | factory worker | 39w | 12 |
3 | 29/ 30 | 7 years/ diploma | House wife | Unemployed | 40w | 11 |
4 | 19/ 30 | Diploma/ Associate Degree | House wife | factory worker | 35w | 17 |
5 | 25/ 25 | Illiterate/ 6years | House wife | factory worker | 10 hours postpartum | 12 |
6 | 41/ 47 | Diploma/ 6 years | House wife | Sales Manager | 45 days postpartum | 16 |
7 | 36/ 31 | Diploma/ 6 years | House wife | Driver | 17w | 18 |
8 | 24/ 28 | Diploma/ diploma | House wife | Factory worker | 20w | 14 |
9 | 28/ 26 | Diploma/ 6 years | Employed | Private business | 8w | 20 |
10 | 36/ 35 | Doctorate/ master degree | Factory production manager | Factory production manager | 1 year after birth | 12 |
11 | 36/ 40 | Master degree/ diploma | Engineer | Self employed | 1 year after birth | 12 |
12 | 26/ 31 | Master degree/ doctorate | University teacher | Doctor | 39w | 12 |
13 | 36/ 40 | Both Bachler degree | Employer | Self employed | 1 year after birth | 12 |
14 | 25/30 | Both Bachler degree | House wife | employee | 1 year after birth | 18 |
* The HITS scale is a paper-and-pencil instrument that was comprised of the following four items: “How often does your partner: physically hurt you, insult you or talk down to you, threaten you with harm, and scream or curse at you?” Patients responded to each of these items with a 5-point frequency format: never, rarely, sometimes, fairly often, and frequently. Score values could range from a minimum of 4 to a maximum of 20 (28). |
Table 2
The profile of the key informants
Participant | Age | Education | Field of study | Work experience (years) | Job position |
15 | 48 | Bachelor’s degree | Midwifery education | 23 | Responsible midwife of health base |
16 | 35 | Bachelor degree | Counseling | 12 | Social Emergency Supervisor |
17 | 52 | Master’s degree | Sociology | 25 | Expert in charge of social welfare in the province |
18 | 45 | Master's degree | Counseling | 10 | Consultant voice and In-person counseling center supervisor |
19 | 50 | Specialty in Medicine | Forensic medicine | 15 | Forensic expert |
20 | 48 | Master’s degree | Midwifery education | 26 | Responsible midwife, Midwife of the maternity clinic |
21 | 35 | Doctor of Philosophy | health psychology | 10 | Psychiatrist of the Comprehensive Health Center |
22 | 38 | Master’s degree | Criminal Law and Criminology | 15 | Lawyer and women's activist |
23 | 37 | Doctor of Philosophy | Reproductive health | 14 | University Assistant Professor |
24 | 47 | Bachelor’s degree | Social work | 23 | Hospital social worker |
25 | 48 | Master’s degree | Maternal and child health | 25 | Director of the midwifery department, University instructor |
Data Collection
The data were collected through semi-structured in depth interviews by the first author with adequate experience of qualitative study and 24 years working experience in the field of reproductive health and midwifery education. All of the interviews were conducted in a separate room and suitable time for the participants to ensure their privacy and confidentiality. Due to the participant's approval, the interviews were audio recorded and observational notes were taken. Data saturation was achieved following 23 interviews. For data saturation assurance, two further interviews were done, which resulted in no new data. The interviews lasted between 45 and 90 minutes.
An interview guide with open ended questions was used to explore the exclusive needs of abused pregnant women as follows: "please elaborate any needs of abused pregnant women that you feel?", "what do you expect of health care system to provide for abused pregnant women?" and followed by probes to attain the additional information and descriptions.
Data analysis
Conventional content analysis was used to answer the research question. The data were analyzed simultaneous during data collection according to the Graneheim and Lundman approach which allows the researchers to examine individual experiences and shows conflicting opinions and unsolved issues regarding meaning and use of concepts, procedures and interpretation via MAXQDA software (version 10, VERBI Software, Berlin, Germany) (25, 33, 34). After each interview the first researcher listened to it several times to get a general understanding of the content and then transcribed the interview verbatim and read it repeatedly to gain a deeper understanding of the data. The text of each interview was divided into meaning units. The meaning units were then condensed, summarized and coded. Codes were compared according to the similarities and differences and categorized into subcategories and categories and finally the theme developed.
Ethical Consideration
According to the Helsinki Declaration, the participants were fully informed about the purpose and benefits of the study as well as their voluntary participation (35). They were reassured that they can withdraw from the study any time without prejudice. Written informed consent was obtained from all the participants and illiterate's legal guardian. If any of the questions caused distress for the participants, the interview was stopped and after a while, and by the participant’s permission, it was continued. The participants' privacy and the confidentiality of data were maintained. At the end of the interviews, necessary information about the existing supportive services for abused women was given to the participants. The study was approved by the Local Research Ethics Committee of Mashhad University of Medical Sciences and the Ethics Code was IR.MUMS.NURSE.REC.1398.026.
Trustworthiness
Guba and Lincoln's criteria containing credibility, dependability, confirmability and transferability were used to confirm the rigor and the trustworthiness of the data (36). To maintain the credibility of the results, three expert supervisors reviewed and confirmed the processes of data collection, data analyzing and interpreting the results. Similarly purposive sampling with maximum variation and appropriate participants and key informants were used. For dependability, the correctness of data analysis were confirmed by independent skilled researchers in qualitative research. For confirmability, some of the transcripts, along with the codes and categories were provided to the main supervisor as well as two other faculty members outside the field of the study, who were skilled in qualitative research and the process of analysis was confirmed. For transferability, the study characteristics such as the context of the research, participants, process of data collection and data analysis were explained in detail for further evaluation. For improvement of reporting the study, SRQR (Standards for Reporting Qualitative Research) criteria were used appropriately (37).
Findings
The abused women's age were between 19 to 41 years and 30 years old in average. Domestic violence screening score (HITS score) ranged from 11 to 20. Educational levels of abused women's ranged from illiterate to doctor of philosophy degrees. Key informants were specialist in midwifery education, reproductive health, maternal and child health, counseling, forensic medicine, health psychology, sociology, law, and social work.
In the present study 1479 codes, 14 subcategories, 3 categories, and 1 main theme emerged from data analysis. The "family and society empowerment" as the main theme was comprised of three categories including "need to empower couples to reduce domestic violence during pregnancy", "demand for improved health care services", and "need to strengthen inter sectoral, legal and social supports". A more detailed presentation of the results including three main themes and related categories, are presented in Table 3.
Table 3
Abused pregnant women's exclusive needs
Sub categories | Categories | Theme |
Need to enhance couples’ awareness | Need to empower couples to reduce domestic violence during pregnancy | Family and society empowerment |
Necessity of improving couples' life skills | | |
Enabling women’s economic empowerment | | |
Demand for preserving individual values | | |
Health care system informational and skills empowerment | Demand for improved health care services | |
Professional ethics requirements | | |
Service demand for psychological care | | |
Need to maternity care improvement | | |
Investing for health care infrastructures | | |
Empowering the health education system | | |
Provision and strengthening inter-sectoral support | Need to strengthen inter sectoral, legal and social supports | |
Reform the educational system | | |
Reform and implementation of women's protection laws | | |
Need to receive social support | | |
Main Theme. Family And Society Empowerment
The main theme that emerged from the data analysis was family and society empowerment that implied the necessity of family, health system, legal, social and inter sectoral empowerment to reduce domestic violence during pregnancy.
Category 1. Need To Empower Couples To Reduce Domestic Violence During Pregnancy
Empowering couples as promoting couple's information, improving couples' life skills, economic empowerment, and preserving individual values could reduce violence during pregnancy.
1.1. Need to enhance couples' awareness
Enhancing couples’ awareness about individual rights, violence definition and different types of domestic violence along with promoting their awareness about pregnancy, childbirth, hormonal changes, physical and psychological changes following pregnancy and childbirth, and maternal and child care provide their empowerment and reduces violence. The following quotes reflected the importance of couples' awareness:
"I do not know anything about violence and my related rights, I should know about them." (Participant 12)
"…men should be trained about maternal changes during pregnancy, they should know about maternal physical, mental and sexual changes..." (Participant 10)
1.2. Necessity of improving couples' life skills
Learning life skills is one of the most important needs of couples to reduce domestic violence. Improving couples' life skills such as anger control, interpersonal communication, self-care, problem solving, decision making, stress reduction, empathy, creative thinking, self-awareness, and critical thinking decreases perinatal violence. One participant stated about the importance of learning life skills:
"I need to know about life skills such as anger management and problem solving. We must learn more about life skills." (Participant 11)
1.3. Enabling women’s economic empowerment
Learning self-employment skills, learning income-generating skills and couple career's advancement reduce economic dependence of the mother on the spouse and partner violence, appropriately. One participant stated the importance of maternal financial independence:
"I must have a source of income for myself. If I have my own income and can manage my life economically, I don't have to endure violence at any cost." (Participant 11)
1.4. Demand for preserving individual values
Maternal belief in self-worth, love herself, demand for individual rights, learn self-esteem, and promotion skills and confidence preserved individual values and should be considered for abused pregnant women. The following statements confirm the importance of maternal individual values:
"When I value myself as a mother, my husband values me too. If I value myself, I will not allow my husband to be violent." (Participant 13)
Category 2. Demand For Improved Health Care Services
The health care system must be able to provide effective services for abused pregnant women. This capability would be achieved through their informational and ethical promotion, psychological and physical care promotion, improve the infrastructures, and empowering the health education system to provide services to abused pregnant women.
2.1. Health care system informational and skills empowerment
Health care system empowering could be achieved by improving the informational capacity of health care providers in the field of domestic violence, their familiarity with relative laws and legal issues, and obtain the necessary information about supportive and referral centers for abused pregnant women. The following quote reflects the importance of health care providers' informational empowerment:
"The midwife must be trained for domestic violence counseling. She should be able to communicate well with abused pregnant women and guide them correctly." (Key informant- participant 23)
2.2. Professional ethics requirements
Learning professional ethics by health care providers, offer equitable and non-judgmental services for abused women, and respect the privacy and confidentiality of maternal information improve health system ethical empowerment. One abused mother explained:
"I need to be supported without judgment and blame during perinatal care, while keeping my information confidential." (Participant 14)
2.3. Service demand for psychological care
Psychological counseling improvement could be achieved by providing effective psychological counseling for all pregnant women and specific psychological care for abused women. One participant stated maternal requirement of psychological care:
"I did not know that the health center has a psychologist who provides me free counseling and I can talk to her about the effective ways to deal with my husband's violence. I needed psychological counseling." (Participant 14)
2.4. Need to maternity care improvement
Improving the provision of care services was essential for abused pregnant women. Continuous midwifery care aimed at identifying and managing all kinds of violence during pregnancy and postpartum and carefully monitor the consequences of domestic violence on maternal and fetal health was essential for improving maternal physical care. One participant pointed out the necessity of the presence of experienced health care personnel:
"The midwife never asked me about the violence during perinatal care. Every time I went to the health center, she took care of me carelessly and quickly."(Participant 1)
2.5. Investing for health care infrastructures
Empowering the health care system to provide effective services for abused pregnant women required infrastructure reforms such as developing a comprehensive protocol, reforming of the personnel structure, allocation of required resources and providing health care professionals' physical and legal security. The following statements indicate the necessity of providing human resources for health care system to provide effective services for abused pregnant women:
"We do not have enough midwives in the health care system to provide adequate care for abused pregnant women." (Key informant- participant 15)
"The midwife cannot be directly involved in domestic violence because her safety may be compromised." (Key informant- participant 20)
2. 6. Empowering the health education system
The midwives should be empowered through academic education and empowering curriculum planning. Similarly, it was essential to improve the practical skills of midwifery teachers and students. One participant explained:
"I don't want the midwifery student to look after me. She cannot communicate properly." (Participant 3)
Category 3. Need To Strengthen Inter-sectoral, Legal And Social Supports
Strengthen inter sectoral, legal and social supports included the provision and strengthen inter sectoral support, reform the education system, reform and implementation of women's protection laws, and receive social support.
3. 1. Provision and strengthening inter-sectoral support
The Welfare Organization was one of the most important supportive organizations, which provided social emergency services, face-to-face and telephone counseling, and a safe house for abused women. Strengthening welfare services could provide effective supportive services for abused pregnant women. The following statement confirm this:
"Many times abused mothers are imprisoned at home and cannot go out for perinatal care and psychological counseling. There should be a 24- hour- telephone counseling center so that they can call for psychological advice." (Key informant- participant 18)
Threat to the pregnant women's physical security forced them to go to forensic centers to document the domestic violence. Facilitate and accelerate the provision of forensic services was essential for abused pregnant women. The following statements indicate it:
"I come to forensic medicine because of my wife's physical violence, but I do not know what they will do here. I have been waiting for several hours and I am very tired." (Participant 8)
Abused pregnant women should be supported by the social worker and closely monitor their living conditions. In order to provide optimal services, it was essential to establish a direct link between social work and other supportive system and refine the process of providing social work services to abused pregnant women. This quote reflects it:
"In cases of domestic violence, it is necessary for a social worker to be present in the health centers along with the psychologist, to connect with the social environment and the living environment of the abused mother."(Key informant- participant 21)
Police should support the abused pregnant women in the case of going to police stations as well as establishing the possibility of health centers to contact the police in the case of domestic violence which requires legal action. This statement reflects it:
"A mother who is physically abused by her husband should get a forensic referral letter from the police station...." (Key informant- participant 19)
Establish communication between different organizations providing support services for abused women such as the health care system, welfare organization, social emergency, social work, forensic medicine, judicial and legal system, and police was essential to have inter sectoral supports and reduce domestic violence in pregnancy. One participant stated:
"There is a need for more inter-sectoral cooperation. I should have the opportunity to refer the abused mother to welfare or forensic medicine." (Key informant- participant 20)
3. 2. Reform the educational system
It was necessary to reform the educational system with the purpose of preventing violence against women such as creating a culture of violence denial through textbooks, considering self-awareness and consider life skill workshops at different educational levels from kindergarten. One participant explained:
"We should learn about violence in our school and university." (Key informant- participant 15)
3. 3. Reform and implementation of women's protection laws
The legal system needs to be reformed in order to provide effective services to abused women. These reforms include eliminate the context of gender discrimination laws, refinement and implementation of women's protection bill and prohibition of violence against women, and modify the divorce and child custody law. The following statement indicate this:
"Men allow themselves to be violent to the pregnant women because the law always protects them." (Participant 10)
3. 4. Need to receive social support
Community support for abused pregnant women in denying violence, supporting women entrepreneurship, and eliminate the pyramid of gender power in the workplace were essential to reduce violence against pregnant women. Similarly, the media had an important role in reducing and managing violence at the community level. The following statements confirm this:
"Society should react to violence against pregnant women. Society should not remain silent in the face of violence against women." (Key informant- participant 23)