DISEÑO DE LA INVESTIGACIÓN

IPV can affect women at any stage of their life but pregnant women are particularly vulnerable to IPV because of changes in their physical, psychological, social and financial needs (Alhusen et al., 2013). Recent studies have shown that pregnancy presents an increased risk of IPV (Shamu et al., 2013). The prevalence of IPV during pregnancy has varied significantly across studies and within and between global regions. According to the findings from ten countries from the WHO’s multi-country study, the prevalence of IPV during pregnancy varied from 1% (in a Japanese city) to 28% (in a Peruvian province) (García-Moreno et al., 2005).

A difference in prevalence rates between various studies could be due to many factors such as techniques of data collection, assessment tools for IPV victimisation, population-based studies or clinical-based studies, sample characteristics, period of observation and the type of abuse assessed (Bailey, 2010; Stöckl, Watts & Kilonzo Mbwambo, 2010; Taillieu & Brownridge, 2010; Shamu et al., 2013; Onoh et

al., 2014). Variations could also be attributable to differences between studies in

cultural aspects, the definition of IPV and the study settings (such as a clinic, a hospital or in the wider community) (Finnbogadóttir, Dykes & Wann-Hansson, 2014). Some studies have found that high prevalence of IPV during pregnancy tends to be more common in hospital and clinical samples (Shamu et al., 2013), whereas

population-based studies have reported lower prevalence of violence against pregnant women (Janssen et al., 2003; Guo et al., 2004; Yost et al., 2005; Taillieu & Brownridge, 2010). One possible reason for this is the association between pregnancy complications such as hyperemesis, vaginal bleeding and urinary tract infections and a history of sexual violence which leads abused women to antenatal hospitalisation. It may also be the case that these women are readily available as research respondents and are asked these questions and therefore the prevalence in this group appears high (Audi et al., 2012; Henriksen et al., 2013; M. Hassan et

al., 2014). The implication is that those in the community who do not require

treatment are not being recorded. It is therefore difficult to compare the prevalence of IPV during pregnancy (Bailey, 2010; Finnbogadóttir et al., 2014). Importantly, there is evidence that the prevalence of IPV during pregnancy is more common than the recognised pregnancy complications such as pre-eclampsia, gestational diabetes or pre-term labour (Bailey, 2010). Clearly, there is a need for HCPs to play a critical role in the early identification, prevention and reduction of IPV in their pregnant patients.

1.6.1 Risk factors of IPV during pregnancy

Several factors, such as socio-economic status (SES), education level, age, race/ethnicity, marital status, history of past IPV, exposure to violence as a child and having an unwanted or unplanned pregnancy, have been found to be associated with women’s likelihood of experiencing IPV during pregnancy. Although the risk factors for IPV during pregnancy are often similar to those for IPV reported in general, the risk factors for pregnant women remain uncertain and unclear (Bailey, 2010; WHO, 2011; Fletcher, 2014). For example, there are inconsistent findings in the literature regarding the relationship between younger women and IPV during

pregnancy (Taillieu & Brownridge, 2010). Some studies have found that younger women were at increased risk of violence during pregnancy (Janssen et al., 2003; Saltzman et al., 2003; Dunn, 2004; Sagrestano et al., 2004; Makara-Studzińska et

al., 2013), whereas Makatoto et al. (2013) found that the woman’s age did not make

a difference to exposure to IPV during pregnancy.

1.6.2 Effects of IPV during pregnancy

Women experiencing IPV during pregnancy usually suffer both fatal and non- fatal adverse health outcomes for both the mother and her baby (WHO, 2011). In the USA, Palladino et al. (2012) found a pregnancy-associated homicide rate of two deaths per 100,000 live births and a pregnancy-associated suicide rate of 2.9 deaths per 100,000 live births. Suicide during pregnancy and in the postpartum period has a profound effect on the baby (Oates, 2003; Gold et al., 2012; Palladino et al., 2012; Alhusen, Frohman & Purcell, 2015). Examples of the possible effects on the growing foetus or baby are given below. In a cross-sectional study involving pregnant women (24 to 28 weeks of gestation), Alhusen et al. (2015) found that the prevalence of suicidal ideation was 22.89% and 60.52% of these women who had suicide ideation experienced IPV.

Non-fatal adverse health outcomes following IPV suffered by women during pregnancy are negative health behaviours, reproductive problems, and physical and mental health issues (WHO, 2011). I shall explore these in turn below. Bailey and Daugherty (2007) reported that physical IPV in pregnant women was associated with rates of cigarette smoking and other substance use such as alcohol and marijuana. A study assessing the prevalence of substance use during pregnancy showed that 63% of abused women used marijuana during pregnancy. The study also concluded that women who used marijuana during pregnancy could have a Small for

Gestational Age (SGA) baby, which is defined as a birth weight less than the tenth percentile, according to population birth weights (Alhusen et al., 2013).

A study of pregnant women conducted in Brazil found that 4.1% of the participants reported having unprotected sex and having multiple sexual partners, and that these sexual risk behaviours were associated with psychological violence during pregnancy (Audi et al., 2012). According to a review of the academic literature in the Latin American and Caribbean region, women who reported physical and psychological abuse were more likely to report inadequate prenatal care and increased alcohol use than non-abused women (Han & Stewart, 2014).

With regard to the gynaecological problems, compared with non-abused pregnant women, abused pregnant women demonstrated more obstetric problems, which included vaginal bleeding, spontaneous abortion, premature rupture of membranes, intrauterine growth restriction, perinatal death, caesarean section and pre-term labour (Janssen et al., 2003; Silverman et al., 2006; Moraes, Reichenheim & Nunes, 2009; Audi et al., 2012; Alhusen et al., 2013, 2014; Han & Stewart, 2014; Hassan

et al., 2014). Furthermore, several research studies have supported the strong

association between IPV during pregnancy and neonatal outcomes (Valladares et al., 2009; Alhusen et al., 2013). Alhusen et al. (2013) stated that the odds of SGA and delivery with low birth weight (LBW) were 4.81 and 4.20 respectively for women who had experienced IPV during pregnancy. These adverse neonatal outcomes, especially SGA, are associated with an increased risk of pre-term labour, poor development during childhood and consequent behavioural problems. Many studies have shown that IPV during pregnancy can directly affect the growing foetus through physical or sexual trauma. A study conducted in Tanzania found that women who experienced IPV during pregnancy were three times more likely to experience

pre-term birth and LBW (Sigalla et al., 2017). Consistent with the findings of some previous studies, IPV during pregnancy has been associated with a LBW of the new born and pre-term deliveries (Chen et al., 2017; Ferdos & Rahman, 2017; Laelago, Belachew & Tamrat, 2017). IPV during pregnancy also has an indirect effect by increasing maternal stress, causing inadequate nutrition and requiring greater prenatal care (Alhusen et al., 2014; Donovan et al., 2016).

In addition, the long-term consequences of prenatal exposure to IPV regarding the child’s mental development have been well documented. Evidence has been presented to show that prenatal exposure to IPV may predispose children’s externalizing and internalizing symptomatology. The externalizing symptomatology can be antisocial behaviour and conduct, and impulse control disorders, and internalizing symptomatology includes depression, anxiety and somatic symptoms (Levendosky et al., 2006; Silva et al., 2018). Many studies have demonstrated that physical health problems such as migraine, arterial hypertension, asthma, urinary tract infection (UTI), risk of urinary and faecal incontinence, insufficient gestational weight gain, severe nausea, severe vomiting and dehydration are consequences of IPV during pregnancy (Yost et al., 2005; Moraes, Amorim & Reichenheim, 2006; Silverman et al., 2006; Brown, McDonald & Krastev, 2008; Audi et al., 2012). Silverman et al. (2006) conducted a population-based study to investigate the association of experiencing IPV around the time of pregnancy with maternal and neonatal morbidity. The results showed a positive association between IPV during pregnancy and severe nausea, vomiting, dehydration and kidney infection or UTI.

IPV during pregnancy also has significant negative mental health consequences for women and can potentially affect an unborn child (Almeida et al., 2013).

Depression, post-partum depression, anxiety and PTSD are usually mental health consequences of IPV around the time of pregnancy (Almeida et al., 2013; Beydoun

et al., 2012; 2010; Brown et al., 2008; Barcelona de Mendoza et al., 2015; Fonseca-

Machado et al., 2015; Mahenge et al., 2013). Beydoun et al. (2010) found that pregnant women who reported being victims of IPV were associated with increased odds of post-partum depression compared with women who never reported being a victim.

1.7 The role of healthcare professionals in addressing intimate partner