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On-line version ISSN 1518-8787Print version ISSN 0034-8910
Rev. Saúde Pública vol.42 n.5 São Paulo Oct. 2008 Epub July 31, 2008
Violencia domestica durante el embarazo: prevalencia y factores asociados
Celene Aparecida Ferrari AudiI; Ana M Segall-CorrêaI; Silvia M SantiagoI; Maria da Graça G AndradeI; Rafael Pérez-EscamillaII
de Medicina Preventiva e Social. Universidade Estadual de Campinas. Campinas,
IICenter for Eliminating Health Disparities Among Latinos. University of Connecticut. Storrs, CN, USA
To identify the factors associated with domestic violence against pregnant women.
METHODS: Interviews were conducted with 1,379 pregnant women undergoing antenatal care in basic health care units of the Brazilian Health System, within the municipality of Campinas (Southeastern Brazil). A structured questionnaire on domestic violence, validated in Brazil, was applied between July 2004 and July 2006. The first and second interviews in a cohort study were analyzed. Descriptive and multiple logistic regression analysis of the data were conducted.
RESULTS: Psychological violence was reported by 19.1% (n=263) of the total sample of pregnant women and physical/sexual violence was reported by 6.5% (n=89) of them. The factors associated to psychological violence were: adolescent intimate partner (p<0.019) and the pregnant woman had witnessed physical aggression before she was 15 years old (p<0.001). The factors associated to physical/sexual violence were: difficulties encountered by the pregnant woman in attending her antenatal appointments (p<0.014), intimate partner uses drugs (p<0.015) and does not work (p<0.048). The factors associated to psychological and physical/ sexual violence were: low level of education of the interviewee (p<0.013 and p<0.020, respectively), the pregnant woman being responsible for the family (p<0.001 and p=0.017, respectively) pregnant woman had suffered physical aggression during childhood (p<0.029 and p<0.038, respectively), presence of common mental disorder (p<0.001) and intimate partner consumes alcoholic beverage twice or more weekly. (p<0.001).
CONCLUSIONS: A high prevalence of different categories of domestic violence by an intimate partner during pregnancy was found as well as different factors associated with them. Appropriate mechanisms are necessary, particularly in primary health care, to identify and deal with domestic violence during pregnancy.
Descriptors: Violence Against Women. Pregnant Women. Battered Women. Spouse Abuse. Domestic Violence. Risk Factors. Cross-Sectional Studies.
Identificar los factores asociados a la violencia domestica contra gestantes.
MÉTODOS: Se entrevistaron 1.379 gestantes usuarias del Sistema Único de Salud que frecuentaban las unidades básicas de salud en el municipio de Campinas (Sureste de Brasil). Se analizaron las primera y segunda entrevistas de un estudio de cohorte, aplicándose cuestionario estructurado sobre violencia domestica valido en Brasil, de julio de 2004 a julio de 2006. Se realizaron análisis descriptiva y regresión logística múltiple de los datos.
RESULTADOS: Del total de las gestantes, 19,1% (n=263) reportaron violencia psicológica y 6,5% (n=89) violencia física/sexual. Los factores asociados a la violencia psicológica fueron: pareja íntima adolescente (p<0,019) y gestante que ha presenciado agresión física antes de los 15 años (p<0,001). Se asociaron a la violencia física/sexual: dificultad de la gestante para acudir a las consultas de pre-natal (p<0,014), pareja íntima que hace uso de drogas (p<0,015) y no poseer empleo (p<0,048). Los factores asociados a la violencia psicológica y física/sexual fueron: bajo nivel de escolaridad de la gestante (p<0,013 y p<0,020, respectivamente), ser la gestante responsable por la familia (p<0,001 y p=0,017, respectivamente), gestante que ha padecido agresión física en la infancia (p<0,029 y p<0,038, respectivamente), presencia de trastorno mental común (p<0,001) y consumo de bebida alcohólica, por parte de la pareja íntima, dos o más veces por semana (p<0,001).
CONCLUSIONES: Se pudo constatar alta prevalencia de las diferentes categorías de violencia domestica practicada por la pareja íntima durante el período gestacional, así como, con los diversos factores asociados a las mismas. Mecanismos apropiados para la identificación y abordaje de la violencia domestica en la gestación son necesarios, especialmente en la atención primaria.
Descriptores: Violencia contra la Mujer. Mujeres Embarazadas. Mujeres Maltratadas. Maltrato Conyugal. Violencia Doméstica. Factores de Risgo. Estudios Transversales.
Violence against women is widely acknowledged as a grave public health problem. A multicentric study on domestic violence coordinated by the World Health Organization (WHO) found that the prevalence of domestic violence perpetrated by an intimate partner against women throughout their lifetime varied from 15% in Japan to 71% in Ethiopia and the prevalence of physical/sexual violence in the past year ranged from 4% to 54%, respectively.4
Pregnant women are not free from domestic violence: in a review of the literature, prevalences varied from 0.9% to 20.1%. This variation in prevalences is attributed to the heterogeneity of the definitions of violence, to the different research methodologies utilized, as well as different sample sizes and sampling procedures.5
Some women's life experiences have been described as factors associated to domestic violence: low socioeconomic status, low level of social support, black race/ethnic group and being young.3,13 As to the reproductive history of women, the following events were found to be associated to domestic violence: under 19 years of age at first sexual intercourse, unplanned pregnancy, partner's refusal to use condoms and the use of legal and illegal drugs.3,13 Pregnant women who had observed or suffered violence when they were young were also more susceptible to suffering violence during pregnancy.3,5 However, there is no consensus concerning pregnancy as a risk factor for this type of violence.5
Violence during pregnancy may have grave consequences for women's health, including hemorrhages and the interruption of pregnancy.18 As to the child's health, there is an increased risk for perinatal mortality and for newborns with low birth weight or prematurity.2
Studies that can contribute to our understanding of this issue are of fundamental importance in order to help us confront it and, in this sense, to define new approaches, particularly in the health services.
The objective of this study was to identify the factors associated to domestic violence, psychological, physical and/or sexual, perpetrated by an intimate partner during the gestational period.
A cross-sectional analysis of the first and second interview of a cohort study initiated in March 2004 and concluded in July 2006 is the object of this paper. The interviews were conducted with pregnant women who were receiving antenatal care at primary health care units of the Sistema Único de Saúde (SUS) [Brazil's Unified Health System] within the municipality of Campinas, Southeastern Brazil.
The questionnaire validated in Brazil by Schraibera (2003) was adopted. It includes questions that refer to psychological violence characterized by insults, humiliation, intimidation and threat; physical violence, when women are slapped, pushed or shoved, hit with a fist, kicked, choked or threatened or actually hurt with a knife or gun; and sexual violence, when women report that they were forced to have some form of sexual intercourse they did not desire or had sexual intercourse because they felt afraid not to do so.
After conducting a review of the literature, the importance of investigating the history of violence suffered or observed during adolescence became clear. Thus, interviewees were asked: "Before you were 15 years old, did you observe any type of physical violence within your family? When you were under 15 years old, did you suffer any type of physical aggression from a family member? When you were under 15 do you recall if anyone touched you sexually or forced you to engage in any form of sexual activity you did not desire?
The questionnaire included variables related to: demographic and socioeconomic characteristics of the pregnant women and their intimate partners, maternal reproductive history and situation of the current pregnancy, puerperal situation and infant feeding, smoking, consumption of alcohol and illicit drugs by the intimate partner. The intimate partner was considered the husband/companion, boyfriend with whom the woman was having sexual relationships or the father of the child that she was carrying in her womb.
The classification elaborated by the Associação Nacional das Empresas de Pesquisa de Mercado (ANEP) [National Association of Market Research Enterprises] was utilized in the elaboration of the social stratification of the sample. The Alcohol Use Disorders Identification Test (AUDIT)15 was applied during the first interview in order to attain an understanding of the use of alcohol by pregnant women. In order to identify possible mental disorders, the SQR-20-Self-Report Questionnaire was utilized in both the first and second interviews.9
The interviewers were over 20 years old and had completed high school.
A sample of 1,400 pregnant women was calculated for the cohort study. Among these, 1,379 women were selected in a non-random manner when they came to the service for their antenatal consultation. The level of statistical significance adopted in this study was 5% and the sample error was 1%.
Pregnant women were included in this study between July 2004 and July 2006, when they came to the health care unit for antenatal consultations. On this occasion they were invited to participate, and informed of the objectives and procedures undertaken by the study. They were also asked to sign an Informed Consent form. When the pregnant woman was 18 years of age or under and legally dependent of her parents or guardians, this Consent form was signed by her and by her legal guardian.
The interviews were conducted with all pregnant women who agreed to participate in this study, regardless of their gestational age.
Only one interview was conducted with pregnant women whose gestational age was over 28 weeks as well as with those whose gestational age was up to 28 weeks and who reported in their first interview that they had suffered physical and/or sexual violence during their current pregnancy.
More than one interview was conducted during pregnancy and particularly during the last trimester with the objective of minimizing the false negative responses and verifying, among the women interviewed during the first trimester, violent events that occurred after the first interview.
During the entire period of fieldwork meetings were held every two weeks with the interviewers and the field coordinator, under the supervision and orientation of a psychologist.
Initially, descriptive procedures used in calculating prevalences and bivariate tests for estimating non- adjusted risks were conducted, considering the types of violence (psychological and physical/sexual) as dependent variables and the sociodemographic characteristics and lifestyles as independent variables. After these analyses were completed, procedures involving a multiple model approach were undertaken by means of logistic regression, including all the independent variables that demonstrated an association with the two dependent variables - psychological and physical and/or sexual violence - in the model, with a 10% level of significance.
The stepwise forward approach was utilized when running the multiple regression model. The variable remained in the model if p<0.05. The strength of the association between the independent and dependent variables was expressed as crude and adjusted estimated odds ratios (OR), and their respective 95% confidence intervals. Adjustments were made considering the independent variables described above and also including the variables race/ skin color and marital status, which differed among the pregnant women who were and were not followed-up in this study. Data was digitalized in a 6.04 version of EpiInfo. All the questionnaires included in the databank were entered and the consistency of the data was also checked. The 13.0 version of the SPSS program was utilized in data analysis.
The study was approved by the Research Ethics Committee of the Faculdade de Ciências Médicas da Universidade Estadual de Campinas [School of Medicine of the State University of Campinas] (Processo nº 116/2004).
Descriptive data as well as the bivariate analysis of the sociodemographic factors associated to psychological and physical/sexual violence perpetrated against the pregnant woman by her intimate partner are presented in Table 1.
In the first interview, 16.3% (n=225) of the pregnant women reported that they had been victims of psychological violence, 5.7% (n=79) had been victims of physical violence and 1.3% (n=18) had been victims of sexual violence. In the second interview with participants whose gestational age was under 28 weeks and who had not reported violence in the first interview (n=806), psychological violence was reported by 8.3% (n=114) of the pregnant women, physical violence was reported by 1.7% of them (n=24) and sexual violence by 0.8% (n=11). If occurrences of violence reported in both interviews are summed up, the prevalence of psychological violence is 19.1% (n=263) and of physical/sexual violence combined is 6.5% (n=89).
The average age of the pregnant women was 23.8 years (sd=5.50), with 23.6% being adolescents. Those who declared their skin color to be white or yellow represented 56.4% of the sample. The pregnant women had a low level of schooling, 47.1% had concluded junior high school and 1.0% had college education. The majority of the women (81.2%) reported they were either married or in a stable union. Half of them declared they were catholic and a third that they were evangelical. Approximately one fourth of the pregnant women were working at the time they were interviewed; almost half belonged to the D/E economic strata and the remaining women belonged to the C strata.
Among the women interviewed, 5.5% declared they were responsible economically for their families. The prevalence of the use of alcoholic beverages during pregnancy was 1.4%, 13.6% were cigarette smokers. The prevalence of pregnant women who reported some experience of violence during their childhood was 55.8%. Among the latter, 31.3% witnessed physical violence in their families, 17.8% were victims and 6.7% suffered some type of sexual abuse. There was no significant statistical association (p>0.05) between any type of violence and current age, declared race/skin color, current work status and cigarette smoking among the women interviewed. On the other hand, the following were considered risk factors for domestic violence ( psychological and physical/sexual) against pregnant women: low educational level, non stable union, the pregnant woman alone and/or she and her partner being responsible for sustaining the family economically, and having witnessed or been a victim of some kind of violence during her childhood. Belonging to the catholic religion was a protective factor for psychological violence, but did not remain so in the logistic regression model. The use of alcoholic beverages by pregnant women increased by four times the chances of them suffering physical/sexual violence and if they were in unstable unions, this increased their probability of having such experiences more than twice (Table 1).
Table 2, presents the variables representing the reproductive and mental health histories of these pregnant women and the bivariate analyses with each respective OR, confidence interval and p value may be observed. More than half of the pregnant women had their first sexual intercourse at the age of 16 years or less and 23.4% became pregnant for the first time at that age. The majority (79.2%) initiated antenatal care in the first trimester of pregnancy. Less than 7% reported difficulties in coming to their antenatal appointments. Approximately 20% had children with other intimate partners, that is, not the current one, whereas 45% were primiparas. The presence of common mental disorders was reported by more than half of the interviewees.
Having had the first sexual intercourse and the first pregnancy before the age of 16 years, difficulty in arriving at the antenatal appointments, being a primipara and presenting common mental disorders constituted situations that increased the chances of the occurrence of physical/sexual and/or psychological violence.
The average age of the intimate partner was 27.6 years, with 8.5% being adolescents. Like their partners, the men had a low educational level: 53.8% had completed junior high school and 2.1% college education. The majority of the women worked (87.5%) and 81.9% lived with their spouses. Among the latter, 26.3% had lived together less than a year and 21.2% had children with another man. The prevalence of cigarette smoking among pregnant women was high (33.4%) and so was the use of alcoholic beverages by intimate partners (30% drinked twice or more times per week). Six per cent of the intimate partners used illicit drugs. All variables except duration of cohabitation with the pregnant woman were associated to violence perpetrated against her.
The results of logistic regression analysis are presented on Table 4. Low educational level - up to eight years of schooling - increased the probability of psychological violence 1.5 times and almost doubled the chances of physical and sexual violence taking place. The presence of common mental disorders increased the probability of the occurrence of psychological violence more than one and a half times and almost tripled the chances of physical and sexual violence taking place. Having witnessed within the family or experienced violence before the age of 15 years also increased the probability of psychological violence occurring to almost twice as much as among those who had not witnessed or experienced such violence before that age. It also increased one and a half times the chances of physical and sexual violence occurring during the current pregnancy. When the pregnant woman was financially responsible for her family the chances that she would suffer psychological and physical/sexual violence was almost twice as great.
Having reported difficulties in getting to her antenatal appointments more than doubled the chances of the pregnant woman becoming a victim of physical and sexual violence. If the frequency with which alcoholic beverages were consumed by the intimate partner was twice or more times per week, this more than doubled the chances that psychological violence and physical and sexual violence would occur. Likewise, the consumption of illicit drugs more than doubled the chances of perpetration of physical and sexual violence against the pregnant woman.
The intimate partner's age presented a positive association with psychological violence. The fact that the intimate partner was unemployed increased in 77% the probability that physical and sexual violence would occur.
Violence against women in whatever phase of their lives represents a grave social and public health issue that must be confronted in Brazil. Violence during pregnancy demands special attention from the health services because it affects women in a moment of great physical and emotional vulnerability.
This is the first cohort study conducted in Brazil that followed-up pregnant women that were undergoing antenatal care in public primary health care units. These cross-sectional analyses were based on two interviews undertaken with pregnant women during their pregnancy. Approximately 2% of the women interviewed in this study reported they had suffered physical violence during the second interview. In the studies in which domestic violence questions were asked more than once during pregnancy or during the third trimester, higher prevalences of domestic violence were found, varying from 7.4% to 20.1%.5
The high prevalences of domestic violence perpetrated against pregnant women in this study corroborate the results of the multicentric study undertaken by the WHO. Among the countries included in that study, wide variations of prevalences of physical and sexual violence were registered. The smallest rate was observed in Japan (8%), followed by Siberia and Montenegro (13%), Thailand (11%) and the highest rates were registered in Brazil, in the cities of the Zona da Mata [Forrest Region] in Pernambuco (32%), and in a province in Peru (44%).4
Large variations in the prevalences were also reported by other authors in literature reviews on violence against women during pregnancy.5,8 Caution is necessary in interpreting these results, for these differences may be related to the diverse characteristics of the populations studied, to the definitions of violence and to the diversity of instruments and methodologies utilized in collecting data.
Among the factors associated to domestic violence during pregnancy are low educational level, frequent use of alcohol, unemployment and low income5,7,8,14 of the pregnant women and their intimate partners. However, no other studies were found that dealt with some of the variables investigated in the present study and that constituted factors associated with psychological or physical/sexual violence, such as: the pregnant woman being the person responsible for the family economically or the pregnant woman reporting she faced difficulties in coming regularly to her antenatal appointments.
One may suppose that the latter is a woman who suffers various kinds of constraints such as jealousy, threats and lack of economic resources that may result in restrictions with respect to her liberty, being her irregular attendance at antenatal appointments indicative of this state of things. The fact that the greater probability of violence was observed when the pregnant woman was the person responsible for her family's income may be related to her partner's unemployment status, as observed in this study. A revision of the literature8 indicates that unemployment of the intimate partner is a risk factor for violence. There is also a report according to which violence is greater when women begin to assume non-traditional roles or when they start to work.14
Another frequently observed indicator of risk for violence is the frequent use of alcoholic beverages by the intimate partner. Some authors believe that the use of alcohol facilitates acts of violence since it modifies behavior patterns, creating conditions for discussions, offenses, curses, insults and threats that may culminate in sexual and physical aggressions.11,12
In the present study, consumption of alcohol and illicit drugs by the intimate partner represents a greater probability of the occurrence of violence against pregnant women. Such a situation may lead to delays in searching for help and, consequently, in interventions that could minimize the effects of or interrupt these acts.1,11
According to Schraiber17(2003), studies of men and women in a situation of domestic violence indicate a multifactorial condition that acts as a precursor of this type of violence. Although alcohol and poverty favor violence, they cannot be considered its direct causes. Another factor that is consistently related to an increase in the risk for violence is the pregnant woman having witnessed domestic violence during her childhood.17 This condition, observed in the present study, may indicate that violence initiated in the pregnant woman's adolescence may currently be experienced as a "natural" part of life, contributing to her low self-esteem and to the lack of autonomy to create mechanisms that may help to modify this situation.3
It was observed in this study that common mental disorder presented a strong association with the characteristics of violence during the pregnancy currently investigated. However, since this is a cross-sectional analysis, it was not possible to verify if this was a causal association or not. This relationship was also observed in a study conducted with women who reported they were victims of violence during pregnancy, attended in public health services.3
Violence against women is a complex and multidimensional problem that has gradually been approached as an issue of public health.10 The health sector has an important role in combating this type of violence by means of research, case notifications, the organization of reference services for victims as well as other proposals involving intervention. However, none of these strategies for combating violence can ignore the issue of the cultural roots of these abuses besides, evidently, attending to the immediate needs of the victims. According to Heise6 (1994), this signifies challenging attitudes and social beliefs that sustain violence perpetrated by men against women, and creating ways of negotiating power between genders at all levels of society.16
High prevalences of different categories of domestic violence perpetrated by the intimate partner against pregnant women were found in this study. These are associated to diverse factors related to the socio-economic, demographic and health conditions of the woman and her intimate partner. Appropriate methods for identifying and approaching domestic violence during pregnancy are necessary, particularly in primary health care.
To Sílvia Nogueira Cordeiro, psychologist at the Laboratório de Pesquisa Clínico-Qualitativa da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, for the psychological support given to interviewers.
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Correspondence: Received: 5/22/2007 a
Schraiber LB, D'Oliveira AFPL, Couto MT, Pinho AA, Hanada H, Felicíssimo
A, Kiss LB, Durand JG. Ocorrência de casos de violência doméstica
e sexual nos serviços de saúde em São Paulo e desenvolvimento
de tecnologia de atendimento para o programa de saúde da mulher [Relatório
Científico]. São Paulo: Faculdade de Medicina da USP; 2003.
(Projeto FAPESP: Linha Políticas Públicas, nº 98/14070-9).
Celene Aparecida Ferrari Audi
Departamento de Medicina Preventiva e Social
Pós-Graduação em Saúde Coletiva
R. Tessália Vieira Camargo No 126
Cidade Universitária "Zeferino Vaz" Unicamp
13084-270 Campinas, SP, Brasil
Supported by the Secretaria de Ciência, Tecnologia e Insumos Estratégicos Departamento de Ciências e Tecnologia (SCTIE/DECIT) and the Fundo Setorial de Saúde (CT-Saúde)/CNPq(CT-Saúde/CNPq) Process n. 505273/2004-7.
a Schraiber LB, D'Oliveira AFPL, Couto MT, Pinho AA, Hanada H, Felicíssimo A, Kiss LB, Durand JG. Ocorrência de casos de violência doméstica e sexual nos serviços de saúde em São Paulo e desenvolvimento de tecnologia de atendimento para o programa de saúde da mulher [Relatório Científico]. São Paulo: Faculdade de Medicina da USP; 2003. (Projeto FAPESP: Linha Políticas Públicas, nº 98/14070-9).