Prevalence and incidence of domestic violence during pregnancy and associated risk factors: a longitudinal cohort study in the south of Sweden

Domestic violence (DV) during pregnancy is not simply a severe public health issue that jeopardizes maternal and foetal health, [1–8] but also a violation human rights [6] and according to the Swedish penal code a criminal act [9]. The World Health Organization (WHO) has reported that more than 90 % of the abused pregnant women are abused by the biological father of the child the woman was carrying [10]. There is a large variation in the prevalence of reported violence, which can be explained by differences in the material, definitions and methodologies used, as well as the context [11–14]. However, longitudinal studies that shows the incidence of DV during pregnancy are rare. Further there is a lack of evidence about potential risk factors that are associated with the incidence of DV during pregnancy.

A meta-analysis of 92 independent studies completed in 23 countries (Sweden included) published in 2013, revealed an average prevalence of DV during pregnancy of 19.8 % where 28.4 % of these were characterised as emotionally based, 13.8 % as physical violence and 8.0 % were sexual abuse [14]. The overall prevalence of DV during pregnancy in developed countries was reported as 13.3 % in comparison to 27.7 % in the less developed countries [14]. In Sweden the prevalence of abuse during pregnancy has previously been reported as 1.0 % DV during early pregnancy (mean 12.8 week, SD 5.11) [11], 1.3 % perpetrated by a close acquaintance or relative during or shortly after pregnancy [12], and 4.3–14.5 %, depending on the severity of the violence, was perpetrated by a current or ex-partner [13].

In a meta-analysis of 55 independent studies, the strongest predictor for DV among pregnant women disclosed as having a history of violence [14]. In addition, it has been reported in a study from six countries in northern Europe that a history of abuse is common among pregnant women [15] which was also revealed in our earlier study [11]. Other identified risk factors for DV among pregnant women are being single, having a lower standard of education as well as low socioeconomic status, an unintended pregnancy and when the perpetrator of the abuse misused alcohol [14]. Another systematic review and meta-analysis showed that high levels of anxiety, symptoms of perinatal depression and posttraumatic stress disorder (PTSD) were significantly associated with the experience of DV during a woman’s lifetime, including while pregnant [7].

The health and well-being of a mother-to-be is also reflected in the offspring’s health and the pregnancy outcome. A systematic review of 30 studies, disclosed that pregnant women exposed to DV are almost 1.5 times more likely to have a preterm baby as well as delivering a low-birth-weight baby [8]. Abuse of pregnant women indirectly affects (i.e. increased risk of various psychological and physical health problems) or directly (i.e. abrupt trauma to the stomach) the morbidity and mortality of both the mother and the offspring [1–5].

An absolute condition for a pregnant woman surviving the abuse is that it is identified early in order to get adequate help in the form of support and care. A Cochrane review supports the fact that disclosure of violence increases significantly, when the question of exposure to violence is addressed, especially at Antenatal Care (ANC) [16]. In late 2014, The National Board of Health and Welfare in Sweden recommended that all women received by a midwife at an ANC should be asked about any experience of violence they had [17]. However, it can vary locally from county to county as to how and to what extent this sensitive matter is addressed. It is the Healthcare providers’ responsibility to develop procedures for how and when the issue of violence is to be discussed with the mother-to-be. As well as to develop procedures for the staff to follow when they detect a woman who has been exposed to violence. Further, it is also the health care provider’s responsibility to ensure that the staff are working in accordance with these procedures. Today, there are not only public, but also private clinics for pregnant women in Sweden. In the year 2014, almost 80 % of all pregnant women in Sweden were asked by their midwife, at their ANC, if they had any experience of violence [18]. Obstacles to early recognition of the problems of violence can be the lack of local guidelines as well as lack of professional support and overall, the problem of the midwives themselves if they lack knowledge or confidence [19]. Added to this is also the fear of the possible reaction of the perpetrator (ibid). Also, it is fundamental to have prepared strategies to follow up and refer a survivor of violence to help in order to get positive effects for the pregnant woman and her child’s health and to decrease or eliminate the violence [16].

The literature appears to be inconsistent across cultures concerning whether pregnancy is a time of protection or risk to be exposed to DV [20]. In our previous report which is the first part of this whole project, the recruitment of pregnant women was undertaken at 17 ANC’s, both public and privately driven [11]. All violence-exposed women also reported a history of violence regardless of type or level of abuse. There was a seven-fold risk for having several symptoms of depression if exposed to violence (ibid). As there is a shortage of reports about the incidence of DV during pregnancy and related risk factors, there was a need to explore this subject area to get a better picture of the magnitude of this problem.

The aim was to explore the prevalence and incidence of domestic violence among pregnant women in the southwestern region of Scania in Sweden, as well as their experience of a history of violence. In addition, to explore the association between domestic violence during pregnancy and possible risk factors.

The present study showed the prevalence of DV as being 2 % in women during their current pregnancy (solely). This means that at least 180 pregnant women in the catchment area are exposed to DV during pregnancy annually (calculated on 9000 births in the catchment area or at one university hospital with two delivery apartments). This results in a twofold prevalence when compared with our earlier study [11] were the women answered QI in early pregnancy. This can indicate that DV during pregnancy is not only a continuum of pre-existing DV [10, 11], but likely to increase over time [29], which is also in accordance with the normalizing process (where the violence has become a natural part of the relationship) [30] and noted in an earlier study by Finnbogadóttir et al. [31]. However the true prevalence can be difficult to determine of many reasons, as for example fear concerning abuse escalation if the perpetrator would be made aware through disclosure [32], as well as any sense of shame over the situation the violence-exposed woman finds herself in [19, 31, 33–35]. In addition, in our prior study [11] it was indicated that the prevalence of DV during early pregnancy might be underestimated due to reported higher prevalence of lifetime physical abuse performed by an actual partner as well as due to selection or non-respondent bias. In the current study there is also an indication that the prevalence of DV might be underestimated due to that 5.1 % of the pregnant women reported experience of some abuse over the past year. This involves experience of abuse perpetrated some months prenatal as well as during pregnancy. This is also in agreement with earlier research from countries in northern Europe where the same questions from the same instrument NorAQ had been used; Norway 5 % [36] and 3.7 % respectively [15], Iceland 3.3 %, Belgium 3.0 %, Denmark 3.3 %, Estonia 6.5 % and Sweden 3.0 % (ibid). In the present study the prevalence of DV during pregnancy appears to be realistically perceived in a global perspective, because the prevalence in developed countries compared to less developed countries (more violence-tolerant societies) has shown to be lower [14, 37]. Still, the true prevalence is difficult to estimate but can approach the prevalence level indicated in reality studies performed in different contexts from different countries.

In addition, the present study showed the incidence of DV during pregnancy to be 7.3 new cases per 1000 pregnant women or at least 65 new violence-exposed pregnant women annually (calculated on 9000 births). It has been suggested that the pregnancy per se can trigger violence [38, 39] as well as that the violence during pregnancy may be only a continuum of previous violence [10, 11]. This was also supported by the current study, where all of the women who were exposed to DV during pregnancy also reported a history of violence. However, the literature is inconsistent regarding this point, but it has been pointed out that cultural factors may be important determinators [37]. Corresponding, studies have shown that repeated questioning about the experience of violence increases the possibility that the violence-exposed woman admits her vulnerability [12, 40]. The complexity of the topic and the pre-existing strain in the relationship, as well as new demands made during pregnancy, may also explain new cases of abuse during pregnancy. Further, in many cases the survivor wants the relationship to work [31, 41] and therby does not disclose the ongoing abuse. Correspondingly, violence-exposed pregnant women are prone to stay in a dysfunctional relationship in order to protect their unborn baby and are not willing to leave the relationship for reasons of abuse, and also if their self-esteem and self-respect has been lost and they experience that they feel drained of their energy [31]. Altogether this is extremly important information for every caregiver when meeting the violence exposed pregnant women and can guide them in how their actions/practises to help and support should be planned for each individual woman.

History of violence was separately, the strongest risk factor for being exposed for DV during pregnancy. This is congruent with previous research [11, 14]. Further, our data suggests that a history of violence is a common occurrence among pregnant women since more than four out of ten (44.3 %) women in the study had experienced a history of violence. This is also verified by earlier research [11, 15]. Indeed women with a history of violence in their relationship may be at increased risk for DV during pregnancy [11, 14] therefore it’s of utmost importance to approach the matter with the pregnant women at the ANC’s as well as to have the possibility to give the survivor first line support. This is in accordance with the WHO’s clinical guidelines from 2013 as well as the national recommendations in Sweden [17]. Furthermore, when a midwife or obstetrician discovers a violence-exposed pregnant woman in Sweden they are obliged to report their findings to the social services if there are other children in the family and/or in order to protect the unborn baby [42–44]. There can be a reluctance among women to disclose their current situation regarding DV due to their fear that their other children might be taken away from them. In our former study, this misapprehension was clearly pointed out by one of the interviewed midwives who had experience of an immigrant woman who thought the authorities would take her other children away from her if the violence was revealed [19]. However, in the same study the midwives also expressed their fear of retaliation against themselves or their families if they should report suspected DV to the authorities if the perpetrator was known to have shown very aggressive behaviour (ibid). Therefore, it’s extremely important to have a clear and safe plan of action for the violence-exposed pregnant women as well as for all of the health care personnel at the ANC’s.

The present study also revealed the following strong predictors for pregnant women to be exposed to DV during pregnancy on the grounds of their being; ‘single/living apart’ which is supported by earlier research [14] as well as the ‘presence of several depressive symptoms’ which is correspondingly supported by systematic review and meta-analysis [7]. Having a ‘lack of sleep’, which is also supported by earlier studies [11, 31]. Lack of sleep is one of the signs for PTSD as well as depression [45]. To be single/living apart as well as suffering from a lack of sleep during the last year to such an extent that the pregnant woman has problems coping with her daily life should be an alarm signal to the midwife and other health care providers indicating strong predictors for DV during pregnancy. Moreover, the presence of several depressive symptoms detected in early pregnancy [11], as well as in late pregnancy, [7] can also indicate that the woman is exposed to DV during pregnancy. Hypothetically, a pregnant violence-exposed woman who reports herself as being single/living apart and exposed to DV may have recently left the abusive relationship during pregnancy. Another possible scenario is that the perpetrator she has already left stalks her and will not leave her alone.

With the result that at least 2 % of the pregnant women in this study were enduring DV, there is a clear need to address the situation of this vulnerable group of women in order to take steps to improve maternal and child health. Midwives and obstetricians who meet women with a history of violence at ANC should be aware of the possibility of additional risk factors in the anamneses. Such as, being single/living apart, having a long term problem with sleeping and/or having several symptoms of depression during pregnancy. All these factors should be indicators to alert health care providers who can use this knowledge to develop or upgrade guidelines and plans of action for helping pregnant women who are exposed to violence.

AAS, abuse assessment screen; ANC, antenatal care; AUDIT, alcohol use disorders identification test; BMI, body mass index; CI, confidence intervals; DV, domestic violence; EDS, Edinburgh depression scale; EPDS, Edinburgh postnatal depression scale; NorAQ, NorVold abuse questionnaire; QI, questionnaire I; QII, questionnaire II; OR, odds ratios; SOC-13, sense of coherence scale-short form; WHO, World Health Organization