Domestic Abuse on Pregnant Womens Health
Domestic abuse is a pervasive and preventable public health issue affecting many women around the globe with different race, ethnic, and socio-economic background. What is more devastating is the rate at which pregnant women are being abused. According to the literature, at least one in every five women is abused while pregnant. It is also indicated that these women experience life threatening maternal and fetal complications. The aim of this library research paper was to explore the effect of domestic abuse on pregnant women’s health through an extensive review of secondary analysis of the literature. The paper also touched briefly on the ethical issues encountered by the healthcare professionals when dealing with an abused person.
Domestic Abuse on Pregnant Womens Health
Introduction
The issue of violence against women, particularly against pregnant women is increasingly being recognized as an important and often devastating major health and social problem around the world with serious health consequences for the abused women and their children. Health care practitioners providing care to pregnant women need to consider how the experience of abuse in current or past intimate relationships could affect their clients’ health during pregnancy. Historical evidence indicates that there is a positive correlation between abused people and admittance to psychiatric institutions (March of Dimes, 2005). A high number of women if not all women who seek long term treatment from mental health institutions have histories of being abused previously. It is therefore, not surprising that in 1997, “The Violence Prevention Task Force” for the Region of Peel in Canada declared violence as the number one health hazard in the Region. Many of the studies and statistics which have been reviewed from different literature support this declaration. For instance, a Canada-wide survey shows that 61% of women physically or sexually assaulted by their intimate male partners are injured in the attack (Solicitor General of Canada, 1997).
Moreover, there is a belief that pregnancy is a joyous, and a period of complete and well-being in a woman’s life. A time of peace and safety, but unfortunately for most women this might not be the case. In an article by Hedin and Janson (2000), they mentioned that about 40% to 60% of women who are abused experience the abuse during pregnancy whilst 95% of those women abused during pregnancy were abused prior to getting pregnant.
Throughout the literature, pregnancy is known to be a high risk period during which domestic abuse may start or escalate in situations where the women were already being abused prior to getting pregnant. Negative effects such as attempted or self induced abortions, therapeutic abortions, spontaneous miscarriages, and divorce or separation during pregnancy are closely linked with abuse. Other injuries reported by women due to domestic abuse are abrasions, contusions, lacerations and fractures.
A Canadian study done in Newfoundland confirms the link between abuse and institutionalization of women in psychiatric setting. It proves that there is a high prevalence of woman abuse among psychiatric patients, reporting that 42% of the women currently being assaulted had been assaulted prior to their hospitalization (Carlisle, 2000). Another study indicates that the abuse of alcohol and prescription drugs is 3 to 5 times higher in women living in abusive relationships (Noel & Yam, 1998). The gap between these studies is that they do not prove conclusive which act is the cause of what. Does the alcohol and prescription drug abuse cause the mental problem that result in mental institutionalizations, or is it the abuse that causes the alcohol and drug abuse, and subsequently, the mental health issues?
One may argue that the issue of violence against women has been overblown and that the issue is private rather than public. The problem with this line of thinking is that the health-related cost of violence against women in Canada is estimated at $1.6 billion dollars per year (Carlisle, 2000), and in the United States, an unbelievable $10 to $67 billion dollars a year in lost productivity, health care cost, and reduced family income. However, the actual cost involved with violence against women and their children is not adequately reflected by this amount. The high cost involved with dealing with the issue as well as the psychological, emotional and possibly, the physical cost the victims pay makes it an urgent social problem that demands vigorous and immediate attention. Therefore, it is our responsibility as citizens, and more especially as health care providers to help these women gain a greater quality of life by stopping abuse. As is most often the case, when a woman looks for help, her first contact is with a health care professional.
Statement of Purpose
The focus of this research paper is to conduct an in-depth literature review on the prevalence of domestic abuse, and identify the effects that domestic intimate partner or spousal abuse has on pregnant women’s health. It will also outline some of the ethical issues concerning domestic violence that healthcare practitioners, specifically nurses may encounter when caring for abused pregnant women and how they can assess for abusive behaviours in pregnancy. In addition, the paper will provide the writer with additional scope and depth in this area and help in enhancing personal knowledge and skills as well as promoting professional creativity.
Definition of Domestic Abuse
According to the Public Health Agency of Canada, (PHAC), intimate partner violence or domestic abuse is not a single form of maltreatment. It comprises the entire collection of abusive behaviours such as sexual, emotional/psychological, financial, physical, and verbal – when they are directed exclusively or mostly at the abuser’s spouse, mate, girlfriend, or boyfriend. Also for the purpose of this paper, domestic intimate partner abuse/violence is defined as any of the above mentioned behaviours experienced by women at the hands of their partners.
Domestic abuse against women
It is known that battering has cultural, social, economic and psychological roots. The unequal power between men and women relationship contributes heavily to the problem. In many different part of the world, domestic violence is firmly entrenched in the culture. At times violence against women is accepted by cultural and religious norms therefore, for men to use force on women is not considered an offense (Payne, 2006; Carcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Valladares, Pena, Persson, & Hogberg, 2005). Women are traditionally in a position of being economically dependent on men. As a result, women have learned to be submissive, feel powerless, and respect the male dominance. The reported lifetime prevalence for abuse toward women is one in every three women in the world have been beaten, forced to have sex, or otherwise. There is still underreporting of this issue since battered women may be embarrassed about their situation because they feel that it reflects on their abilities as a woman, wife and mother. The battered person expresses feeling anxious, depressed, and insecure and feels that she cannot live without the perpetrator (CDC, 1989).
Sadly it was not until 1996 that the World Health Organization recognized domestic abuse or intimate partner violence as a public health and human rights issue. Violence against women has a long, dark past in both industrialized and non-industrialized part of the world. For example, once upon a time, the British common law allowed a male spouse to “chastise” his wife with “any reasonable instrument” (Frieze & Browne, 1989). In North America, state laws and cultural practices supported a man’s right to discipline his wife throughout the 1800s. It was not until 1895 that a woman can use the ground of domestic violence to divorce her husband. By 1994, the Violence against Women Act has been adopted and thus guided research of domestic abuse which generated social, legal and financial support for law enforcement and social services to protect battered women (Boyer, 2001). Violence by an intimate male partner against women manifests itself in the form of forced sexual intercourse, physical aggression, psychological maltreatment and controlling behaviours.
Types of abuse
Often times when we think domestic abuse the first thought is a woman has been beaten up by their partner. Not all domestic abuse actually results from a violent act. A woman does not need to be brutally beaten or bruised for us to suspect domestic abuse. An abusive behaviour can be in any form of the different abuse such as emotional or sometimes refer to as psychological, economic, physical and sexual. Review of both international and national literature suggests that between 10% and 52% of women experience or has experienced physical violence and 10% to 30% have suffered sexual abuse at the hands of the partner (Garcia-Moreno et al., 2006). Description of the types of abuse is provided.
Physical abuse is defined as a “deliberate application of force” to a person’s body (Statistics Canada, 2001, p. 11) which may result in a non-accidentally injury. Physically abusive behaviour can take many forms including hitting, slapping, pushing or anything that causes physical pain or discomfort. In the United States, an estimated 4 to 6 intimate relationships end up in physical violence each year and one in every three women would experience physical assault by an intimate partner in their adulthood. Also alarming is that 2 to 4 million of women in the U.S.A. per year are assaulted by an intimate partner (Newton, 2001). In the literature, it was reported by many women that the physical violence against them either began or escalated when they were pregnant or when their children were very young (Ulla Diez et al., 2009; Bostock, Plumpton, & Pratt, 2009). This increase in abuse may be a result of the abuser having feelings of jealousy over the woman’s concern for another individual, even if it is an unborn or small child. Violence including physical abuse also affects both physical and mental well-being depending on how severe the attack or injuries were (Payne, 2006).
Also economic and financial abuse is another form of domestic violence in which the abuser uses money to control his or her partner. A person is denied of financial mean when their partner refuse or when they are forbidden to work and if they are permitted to work, the abuser demands the abused individual to hand over their paychecks. This allows the abused partner to be dependent on the perpetrator for money. There are some economically abused women who are forced to beg their partner for everyday necessities such as food and/or health care. Furthermore many financial and economic abusers will put all of the family bills in their victim’s name in order to ruin their credit.
Psychological abuse, also known as emotional abuse is another avenue for a batterer to use to assert power and control of the woman. According to Health Canada, there is no accepted universal definition of emotional abuse. This abusive behaviour is usually used to damage the person’s sense of self-worth, perception, and independence. A person who is emotionally abused tends to experience verbal insults including name-calling, yelling, and threats and blaming. Social isolation and intimidation also consist of emotional abuse. What is more, emotional abuse may lead to physical violence. In the eyes of the public, emotional abuse may look less damaging to physical abuse due to the scars and bruises that physical abuse may leave. But despite it invisibility, emotional abuse cuts deep. To confirm, case-study interviews compiled by Statistics Canada with abused women suggest that for many women the cumulative impact of emotional abuse over a long period of time can equally be damaging as physical violence (Statistics Canada, 2001). No abuse, physical, sexual, or financial happens without any element of emotional consequences. One Canadian study on abuse done with both College and University dating relationships revealed 81 percent of the male respondents admitted to emotionally abusing their female partners (Health Canada, 2006).
In addition, sexual abuse is a pervasive form of violence against women. According to the World Health Organization (WHO), sexual abuse is any forced sexual contact, intimidation, and trafficking including unwanted sexual advances and harassment (2003). Research have show that sexual violence is associated with number of adverse mental health outcomes such as post traumatic stress disorder, depression and anxiety, eating disorder, drug and substance misuse, and suicidal behaviour (Payne, 2006; Galvani, 2007; Garcia-Moreno et al., 2006; Svavarsdottir & Orlygsdottir, 2008). In her study Galvani (2007) determined that 40% to 80% of women who receiving treatment for substance abuse at a treatment centre have experienced domestic abuse some point in their life. Also based on a WHO report, one in four women may experience sexual violence by an intimate partner whereas the National Coalition Against Domestic Violence states between one-third and one-half of all battered women are raped by their partners at least once during their relationship. As high as 15% of women have experienced sexual abuse in their life time and fewer than 10% in the last 5 years have experienced sexual abuse.
Whilst a multi-country standardized population-based survey by WHO report that between 15% and 71% of women were physically or sexually abused by their partner some point in their lives. However, numerical figures which represent all types of abuse against women underestimate the actual population experiencing it. Most women fails to report violent behaviour due to the shame, social stigma, and fear of repeated or escalation in abuse, as well as fear of material loss such as income. In other countries, women who report abusive behaviours tend to fear violence toward them from the authorities who are in place to protect them. A forced sexual activity even between intimate partners is still considered as violation of the person’s human rights.
Domestic abuse during pregnancy
Violence against women by male partners and ex-partners is a persistent major public health problem resulting in injuries and other short and long term health consequences, such as mental illness and complications of pregnancy. Domestic abuse often happens when the woman becomes pregnant with the child. It often leaves the pregnant women engaging in harmful behaviors and practices correlating with poor pregnancy outcome. Various researchers have critically reviewed and completed analysis of studies that identify pregnant women at risk of intimate partner abuse.
To my surprise, according to the Center for Disease Control, 4 to 8 percent of pregnant women (over 300,000) per year suffer abuse during pregnancy. Also, one Canadian study revealed that 6% to 8% of women had been abused while pregnant and 95% of them had experienced the abuse during the first trimester (Stat Canada, 2003). It is said that 40% to 45% of physical abused women are also forced to have sex (PHAC). It is estimated that 95% of the victims of domestic or intimate partner violence are women, and that two-thirds of all marriages will experience domestic violence at least once. Consequently, 4 million women a year are assaulted by their partners.
Domestic violence is the number one cause of emergency room visits by women. The number one cause of women’s injuries is abuse at home. This abuse happens more often than car accidents, mugging, and rape combined. Battering often occurs during pregnancy. One study found that 37% of pregnant women, across all class, race, and educational lines, was physically abused during pregnancy, and 60% of all battered women are beaten while they are pregnant.
Interviews with pregnant women suggest that abuse during pregnancy is an important link between the well established overlap of intimate partner violence. Abuse in pregnancy can affect maternal health and infant birth weight. Most complications of pregnancy such as low weight gain, anemia, sexually transmitted infections, and first and second trimester bleeding are significantly higher for abused women (Saltzman, Johnson, Colley Gilbert, & Goodwin, 2003; Martin et al., 2001; Kearney, Haggerty, Munro, & Hawkins, 2003). When a pregnant woman is subjected to violence, it is certainly a threat to her own health, but it also puts the fetus at risk. A woman’s ability to protect herself and her unborn baby is limited by the abuser. Abused women report alcohol and drug abuse, cigarette smoking, and insufficient nourishment.
An analysis of articles written in this area demonstrated that the number of expectant women who are abused in a relationship is unknown and that the consequences range from physical injuries, emotional distress to maternal and fetal death. However, many of the literature identified pregnancy as a common risk factor for domestic violence, and estimate the prevalence rate of violence during pregnancy to be 0.9% to 28%. These studies also yielded information on various demographic and lifestyle variables that correlates with spousal abuse during pregnancy. For example, according to data (Espinosa, & Osborne, 2002; Bostock et al., 2009; Garcia-Moreno et al., 2006; Valladares et al., 2005), younger women may be more at risk for abuse during pregnancy. The researchers found that young women may lack the life experience that could forewarn them of the seriousness of becoming involved with dangerous or violent individuals and may experience violence within a larger context related to their vulnerability. As well as having an unplanned pregnancy. A population-based research confirms by indicating that women who had unplanned pregnancy were 2.5 times more likely to experience abuse than those who had planned their pregnancy (Whitehead & Fanslow, 2005). Approximately about half of all these unplanned pregnancies in the US end up in termination. Parker, McFarlane, and Soeken (2000), found that 20.6% of teens reported abuse during pregnancy, in comparison to 14.2% of adult women based on a structured interviews of pregnant women ages 13 to 42. In addition, Persily and Abdulla, (2001), analyzed data from a pilot study conducted in rural part of West Virginia. In that study, pregnant women under 20 years old experienced domestic abuse at a shocking rate of 18.5%, compared to 9.4% for the pregnant women ages 20 to 29, and 4.4% for pregnant women 30 years and older.
Furthermore, the relationship between alcohol uses, tobacco use and other substance abuse and domestic violence during pregnancy have been investigated. Persily and Abdulla noted there was a significant relationship between tobacco use and abuse but no significant difference were found between alcohol and illicit drug use and abuse of pregnant women. In contrast, Galvani, (2007), Parker et al, (2000), and Amaro, et al, (1998) found that more victims of domestic violence during pregnancy reported use of cigarettes, alcohol or other drugs than non-victims. The findings also suggested that abused pregnant women were significantly more likely to continue substance abuse during pregnancy.
Another shocking finding was that, pregnant women who are in an abusive relationship tend to initiate prenatal care late in their pregnancy because of their partners’ controlling behaviour. McFarlane et al (1998) researched that abused women were almost twice as likely as non-abused women to begin prenatal care in the third trimester. Work by Persily and Abdulla (2001) showed that 38% of the women in their sample who were victims of domestic violence registered for prenatal class after 20 weeks of gestation, comparing to 23% of the women who were not abused.
Moreover, majority of pregnant women experiencing domestic abuse simultaneously experience depression and anxiety (Collins, & Thomas, 2004; Ulla Diez et al., 2009). According to Persily and Abdulla (2001), 83% of victims of domestic abuse during pregnancy report being depressed, and 89% report feeling anxious. Amaro and partners (1998) found that victims of domestic violence were more likely than non-abused pregnant women to be depressed during pregnancy, to feel less happy about being pregnant, and to have had a history of depression and attempted suicide. The question is: is it the abuse that results in the depression or the history of depression that manifest itself again at pregnancy?
To combat and eliminate violence against women, especially expectant women, a variety of social support resources need to be available to women abused during pregnancy. In one Canadian study sample (Wathen, & MacMillan, 2003), 8 of 109 women entering prenatal care who reported abuse shared a common source of social support. The eight women abused demonstrated a sole identification of non familial support people, whereas the remaining 101 non-abused women all identified family members as their source of support. In addition, Amaro et al (1998) reported an association between feeling a lack of support during pregnancy and higher rates of violence during pregnancy. Espinosa and colleague (2002) similarly states that women who were battered during pregnancy reported they had fewer people whom they could “get together” or discuss personal issues.
However, in some international papers, women often felt that domestic abuse was a private family matter and should not be discussed. But based on the findings of Bostock et al., (2009), discussing relative safety from domestic abuse was dependent on whether there was empathy, understanding, shared experience, and effective help and protection offered by the support systems that were accessible to the abused victim. The implication is that, women who have contacts, such as, family, a close friend, legal, police, social and health services to contact stands a big chance of escaping abuse in their relationships; and that failing to recognize the unacceptability of violence against women were aspects of service that perpetuated abusive situations. It further indicates that, maybe it is the knowledge of “not having anyone to cry unto” that encourages men married to or in relationship with such women to abuse them.
The information found highlighted that there is a need for further evaluation of domestic violence in pregnancy and related factors regarding the unequipped health, social and legal resources available to respond to women and domestic abuse. Moreover, there are gaps found on which limited or no research have been performed. First, studies of domestic violence during pregnancy using studies of population-based sampling of women and studies incorporating a variety of clinical settings are very limited. Secondly, more research is also needed on the best ways to assess for domestic violence and the ways in which its severity and chronicity can be assessed. As it is now, there is no study out there indicating how spread the phenomenon is and the long term effect that the abuse have on children born under these circumstances. No study has answered whether the abuse also stops after delivery or not. Further research about perpetrator-focused intervention is needed. The only tool we have now on dealing with perpetrators of domestic abuse is punishment. However, common sense dictates that this does not eliminate abuse. To combat it properly therefore, we need to have more researches into workable treatment for abusive men. These areas will be necessary to explore because it is an obligation for health care providers to consistently assess for domestic violence and to intervene appropriately when violent and abusive situations are acknowledged.
Ethical consideration for health providers
As part of their professional role, nurses, in their everyday lives make ethical decisions in their nursing practice. When dealing with domestic violence, nurses are bound to encounter ethical issues such as dilemma, distress, distributive justice, violation, and locus of authority.
One of the greatest mysteries to many healthcare professionals attempting to help victims of violence from their intimate partners is the revolving door syndrome, which deals with the same victims who are admitted to care over and over again. The nurse may perceive this as an ethical dilemma, since the nurse may wish to break the cycle of the abuse but then the victim may not want any help. Their inability to “fix” the problem or what they perceive as women’s failure to follow their advice and change their situation lead both the doctors and nurses feeling frustrated and powerless. The inherent frustration leads to comments such as “you again?” or “Now, will you leave him,” or “Don’t you get it? when victims arrive at the emergency department. The fact is, for all their good intentions, it is the professional caregivers who don’t get it (McMurray, 2005). What they don’t get is these women are not happy in the situation in which they find themselves; neither do they necessarily attract violent men. They often just get caught up in a situation where they perceive that there is no way out. These women are often emotionally isolated and economically dependent on their abusers. The uncertainty of making it on their own outside of the marriage, and especially where children are involved, the fear of impoverishing or endangering the children forces the victims to stay in abusive relationships. As such, their main motivation is reducing the impact and frequency of the abuse rather than leaving the abuser (Bates & Hancock, 2001; Lutenbacher, Cohen & Mitzel, 2003). As a result, they become invested in the situation, and normalize it regardless of how difficult it becomes, even to the point of dismissing the threat of lethal violence (Nicolaidis, Curry, Ulrich et al, 2003). Carver (2003) a psychologist who has been trying to help victims out of this type of situation for over 30 years, describes this dilemma as a mix of the Stockholm Syndrome and cognitive dissonance.
In addition to overcoming the dilemma, health care professionals working with an abused client may experience moral distress. The distress comes about when a person know the ethically appropriate action to take, but is unable to act upon it or when one acts in a manner contrary to their personal and professional values which undermines the person’s integrity and authenticity (Redman, & Fry, 2000). Moral distress can be a serious problem in nursing. It results in a significant physical and emotional stress, which contributes to nurses’ feelings of loss of integrity and dissatisfaction with their work environment. Studies demonstrate that moral distress is a major contributor to nurses leaving the work setting and profession. It affects relationships with patients and others as well and can affect the quality, quantity, and cost of nursing care (Redman, & Fry, 2000).
Further more, nurses may feel overwhelmed from the need to help in the case of domestic violence. However, they may be unable to follow their moral beliefs because of clients’ personal, cultural values, even societal or institutional restraints. For instance, for a pregnant woman in an abusive relationship, the “right” action to the health care worker is very obvious, yet the client’s right to exercise autonomy and choice makes it impossible for the nurse to pursue the proper course of action without the victim’s consent.
Another ethical issue that can occur in domestic abuse is distributive justice. According to Keatings and Smith, (2000), distributive justice is the proper distribution of both social benefits and burdens across society. Within the health care ethics, the relevant application of the principle focuses on distribution of goods and services. Unfortunately, there is a finite supply of goods and services, and it is impossible for all people to have everything they might want or need. According to Burkhardt and Nathaniel, (1998), one primary purpose of the governing systems is to formulate and implement policies about broad public health issues (example, domestic violence) that deals with fair and equitable allocation of inadequate resources. In 2002, the Ontario government announced its plans to spend more than $21 million to address domestic violence after the recommendation of the Hedley jury inquest in February 2002 (Cross, Ontario Women Justice Network, 2002, November). Evidently, in Ontario, the provincial government is trying to do something about this pervasive issue that have taken a toll in today’s society, but the estimated cost of violence against women by the Middlesex-London Health Unit in 2000 was $4.2 billion annually ( Malone, 2005). Then clearly, the governments’ action is woefully inadequate and it needs to increase the funding if every domestic violence victim is to be catered for.
Clinical decision-making and appropriate implementation of decisions in the clinical environment is an essential component of professional nursing practice. However, implementation of decisions requires a critical look into the distribution of authority in the environment. In domestic violence situations, the power in the house usually rests in the hands of the men. Breaking the cycle of violence therefore requires changing the dynamics of the power through education and interventions rather than any medical interventions. Also, although nurses have the clinical knowledge and desires to help their abused clients, however, the power of autonomy that the clients have makes it impossible for nurses to make decisions about victims without first consulting and getting their consent. This is very frustrating for nurses because no matter what they know and how much they want to help, they cannot do it if the victim says no.
A factor influencing the nurse-physician relationship stems from the inequity in power relations between the two. Doctors exert direct power in the health care system, determining who will be admitted as well as the type of treatments to be performed. Nurses, although an essential component to the functioning of any health care organization and by far the most powerful group in terms of numbers, exert little authority in regard to initiating treatments for their clients. Nurses, because of their wholistic approach to health care tend to acknowledge that patients exist within social networks and that the relationships embedded in these networks are central to decision-making. As a result, nurses have a tendency to become concerned with the specifics of a situation and therefore, are slow to make decisions. On the other hand, doctors who are reductionist in nature are inclined to analyze problems, leaving details that nurses may believe are important out in their decision-making. Consequently, they make decision with little or no collaboration, and based on little information about the client. For instance, because of their personal values and moral beliefs, nurses might believe abused women require more wholistic treatment whereas a physician might just treat the bruises.
Furthermore, violence against women is a violation of human rights that cannot be justified by any political, religious, or cultural claim. A global culture of discrimination against women allows violence to occur daily and with impunity (Amnesty International, 2001). Domestic violence violates a woman’s right to physical integrity, to liberty, and all too often, to her right to life itself. These are universal human rights that every one everywhere is entitled to, simply by virtue of being human. Therefore, when states fail to take the basic steps needed to protect the basic human rights of women from domestic violence and allow these crimes to be committed with impunity, states are failing in their obligation to protect half of its citizens, namely women from torture.
Conclusion
Evidence through this library research indicates that, in some cases, domestic abuse perpetuated against women may be initiated when a wom
