Frequency of Different Types of Domestic Violence in Ante Natal Patients

DISSERTATION

“FREQUENCY OF DIFFERENT TYPES OF DOMESTIC VIOLENCE IN ANTE NATAL PATIENTS”

By

Dr. sara gul

DGO

Supervised By

Prof: dr.Nasreen Ruby Faiz

DEPARTMENT OF Gynaecology

POSTGRADUATE MEDICAL INSTITUTE,

LADY READING HOSPITAL PESHAWAR

Dated: March 1, 2011

DEDICATED TO

MY PARENTS

AND FAMILY

ACKNOWLEDGMENT

First of all I am thankful to Almighty ALLAH who gave me courage and strength to complete this dissertation.

I am thankful to my supervisor, Prof: Nasreen Ruby Faiz, Head of Department Gynae/Obs Unit, Postgraduate Medical Institute, LadyReadingHospital, Peshawar, for her constant source of inspiration and motivation and her easy way of teaching enabled me to prepare my dissertation.

I am also thankful to Dr. Simi Fayyaz, Associate Professor and Dr. Khwaja Fawad Parvez, Junior Registrar during cases selection and data collection for the study.

I am also thankful to all senior and junior staff of Gynaecology Unit, PGMI/LRH, Peshawar for their cooperation and kind support during cases selection and data collection for the study.

I am thankful to Mr. Masal Khan Computer Operator Postgraduate Medical Institute, Lady Reading Hospital Peshawar for helping me out in composing and organizing the data.

Dr. Sara Gul

SUPERVISOR’S CERTIFICATE

I hereby, certify that Dr. Sara Gul has been working under my direct supervision with effect from:March 8, 2010 to date in the Department of Gynecology and Obstetrics, Postgraduate Medical Institute, LadyReadingHospital, Peshawar.

The enclosed dissertation titled:

“FREQUENCY OF DIFFERENT TYPES OF DOMESTIC VIOLENCE IN ANTE NATAL PATIENTS” was prepared according to the “Dissertation – Guidelines” under my supervision. I have read the Dissertation and have found it satisfactory for DGO examination in the subject of Gynae/Obs.

Signature of Supervisor:______

Name of supervisor: Prof: Dr. Nasreen Ruby Faiz

Designation: Head of Department & Incharge Gynae A unit

Date: March 1, 2011

Official Stamp:______

TABLE OF CONTENTS

Topic / Page#
PART – I:
Dedication……………………………………………………………….
Acknowledgment………………………………………………………..
Supervisor’s certificate………………………………………………..
Table of contents……………………………………………………….
List of tables…………………………………………………………….
List of Graphs ………………………………………………………….
List of abbreviations……………………………………………………
PART II:
Abstract…………………………………………………………………..
Introduction……………………………………………………………...
REVIEW OF LITERATURE
Epidemiology of Domestic violence………………………………….
Classification of Domestic Violence………………………………….
Clinical Presentation of Domestic Violence…………………………
Consequences of Abuse………………………………………………...
Diagnosing Domestic Violence ………………………………………
Treatment ………………………………………………………………..
Partner Violence During Pregnancy…………………………………..
ORIGINAL WORK
Objective of the study………………………………………………….
Material and methods…………………………………………………..
Data Collection …………………………………………………………
Results……………………………………………………………………
Discussion……………………………………………………………….
Limitation of the Study ………………………………………………..
Conclusion……………………………………………………………….
References………………………………………………………………. / II
III
IV
V
VI
VII
VIII
1
3
6
9
16
19
21
27
32
59
61
62
64
86
89
90
91

LIST OF TABLES

No# / Title / Page#
Table – 1
Table – 2
Table – 3
Table – 4
Table – 5
Table – 6
Table – 7
Table – 8
Table – 9
Table–10 / Patients Who Should Be Asked About Domestic Violence………...
Age Of The Respondents (N=129)………………………………….
Respondent's And Husband Education ……………………………..
Respondent And Husband Employment ……………………………
Length Of Marriage ………………………………………………...
Parity Of The Respondents (N=129) ………………………………
Gestational Age …………………………………………………….
Intimate Partner Violence (N=129) …………………………………
Different Forms Of Domestic Violence In Pregnancy (N= 129) …...
Different Types Of Physical Violence (N=46/129) ………………... / 67
68
69
70
71
72
73
74
75
76

LIST OF GRAPHS

No# / Title / Page#
Graph – 1
Graph – 2
Graph– 3
Graph– 4
Graph – 5
Graph – 6
Graph – 7
Graph – 8
Graph – 9 / Age Of The Respondents (N=129 ………………………………….
Respondent's And Husband Education ……………………………..
Respondent And Husband Employment ……………………………
Length Of Marriage ………………………………………………...
Parity Of The Respondents …………………………………………
Gestational Age …………………………………………………….
Intimate Partner Violence (N=129) …………………………………
Different Forms Of Domestic Violence In Pregnancy ……………..
Different Types Of Physical violence ……………………………… / 77
78
79
80
81
82
83
84
85

LIST OF ABBREVIATIONS

Abbreviation / Meaning
AAS
ACNM
ACOG
AMA
CDC
CI
CTS
DA
GA
GI
HIV
IPV
IQ
IT
LBW
LRH
MVC
OR
PGMI
PRAMS
RSV
SAFE
SES
SGA
SPPS
STD
US
USPSTF
VR
WAST
WHO / Abuse assessment screening
AmericanCollege of Nurse-Midwives
AmericanCollege of Obstetricians and Gynecologists
American medical association
Center for disease control and prevention
Confidence interval
Confect Tactics Scale
Danger assessment
Gastroenterology
Gestational age
Human immunodeficiency virus
Intimate partner violence
Intelligence quote
Intimate terrorism
Low birth weight
Lady reading hospital
MVC
Odd ratio
Postgraduate medical institute
Pregnant Risk Assessment Monitoring System
Respiratory Synctial Virus
Stress/Safety, Abuse/Afraid, Friends/Family, Emergency Plan Socioeconomic status
Small for gestational age
Statistical Program for Social Sciences
Sexually transmitted disease
United States
United States Preventive Services Task Force
Violent resistant
Woman Abuse Screening Tool
World Health Organization

1

ABSTRACT

INTRODUCTION:Domestic violence is any behavior within intimate, relationship which causes physical psychological or sexual harm to these relationsDomestic violence against women is a significant public health issue in both developed and developing countries of world. For women who experience abuse, the prevalence of lifetime physical, emotional and sexual IPV is 34.2%, 28.4% and 8.7%, respectively. Domestic violence against women during pregnancy is animportant public health problem worldwide, and isassociated with adverse health consequences for both themother and fetus. The prevalence rates of physical abuse found in the pregnancy in developing nationsis quite high and estimatedto be between 4% and 29%.

OBJECTIVES: To determine the frequency of different type of domestic violence in

ante natal patients.

STUDY DESIGN: Hospital based Cross-Sectional study

PLACE AND DURATION:Department of Gynecology and Obstetrics, Postgraduate Medical Institute, Lady Reading Hospital Peshawar, from October 23, 2009 to October 22, 2010.

MATERIALS AND METHODS:Patients received in antenatal clinic were enrolled in the study. Informed consent was taken from participants meeting the inclusion criteria. The tool used to measure abuse was derived from the widely usedAbuse Assessment Screen (AAS).11 The tool included questions on physical, emotion and sexual violence during three periods; marital lifetime, last year and current pregnancy. Factors associated with domestic violence during pregnancy, such as the respondent’s education,employmentof husband and women, husband addiction and reproductive health related factors, such as parity (primipara or multipara) duration of marriage and gestational age at the time of screening were also recorded.

RESULTS: A total of 129 of pregnant women participated in this study. The respondents were relatively young, with an average age of 31 years. Education level of both the respondents and husbands was low, 24.0% and 45.7% respectively. In 113 (87.6%) of the respondents the length of marriage was more than one year. 96 (74.4%) of the pregnant women were multipara and more than half 51.2% (66) of these were in third trimester. Among 129 respondents 69 (53.5%) were abused (any type) marital lifetime and 51 (39.5%) experienced physical violence last year. In our study 35.7% (46) of the respondents were abused physically during pregnancy. Of these slapping (43.4 %) and pushing, shaking (21.7%) was most common followed by beating (17.3%), hair pulling, (8.6%) and kicking (6.5%). Verbal violence (51.9 %) was most common, followed by experienced emotional violence (46.50%) and economic violence (33.3%), while 20.40% of pregnant women were subjected to nonconsensual sex (sexual violence). Husband was involved directly in most of the events of violence 49 (38.0%), while in-laws were involved only in 26 (20.2%) of cases. Violence during pregnancy was strongly associated with marital life-time violence and physical violence during last year (P < 0.05).

CONCLUSION: Domesticviolence during pregnancy is a common problem and

Highlights the need forinterventions by health professionals.

KEY WORDS: Domestic violence, Pregnancy, Physical abuse, emotional abuse, Sexual abuse.

INTRODUCTION

Domestic violence is any behaviour within intimate, relationship which causes physical psychological or sexual harm to these relations1. Domestic violence against women is a significant public health issue in both developed and developing countries of world. According to the world Health Organization (WHO) surveys from around the world indicate that approximately 10% to 69% of women report being physically assaulted by intimate partner at some point in their lives2.

In another study the prevalence of any domestic violence (physical, sexual or emotional) is 45.1%. For women who experienced abuse, the prevalence of lifetime physical, emotional and sexual IPV is 34.2%, 28.4% and 8.7%, respectively3.

In another study a total of 26.9% of women reported to be physically abuse. Emotional and sexual abuse was reported by 29% and 6.2% respectively. The husband was the main perpetrator (47.4%); other family members were responsible in 31%4.

Pregnancy does not protect women from violence. This is reflected by the alarming prevalence rates of physical abuse found in the pregnancy, antepartum and postpartum periods, demonstrating that all women of reproductive age are at risk for intimate partner violence5.

Studies conducted in developing nations report that between 4% and 29% of all the women are abused during pregnancy6-7.

In a study (13.6%) respondents reported being physically abused during the current pregnancy. However out of those respondents, (47.7%) reported the most severe incident to be the threats of abuse, including use of weapon i.e. a nonphysical reported punching, kicking, bruises, cuts and / or continuing pain, (7.5%) reported being beaten up and receiving severe contusions, burns or broken bones; (3%) reported internal and/or permanent injury, while (6%) reported the most severe incident to be the use of a weapon, or wound from weapon8.

Various factors leading to domestic violence were identified among the husbands of women subjected to violence during pregnancy. The factors associated with domestic violence included addiction in 32(39%), allegedly aggressive nature of husband in 21 (25.6%), unemployment of husband in 6(7.31%) cases9.

Women whose mother or mother in law had experienced physical spousal abuse had increased odds of experiencing abuse during pregnancy (odds ratios, 2.1 – 3.4)10.

The rationale of my study is to find out the frequency of domestic violence during pregnancy and to find common factors associated with domestic violence among pregnant women. Pregnancy provides a unique opportunity to routinely ask screening questions on domestic violence against women, as it’s a period when women tend to rake greater interest in and responsibility for their own health and have more contact with health professionals. Screening of violence in primary health care settings may help to detect and reduce violence against women and interventive programmes are also needed to provide support and medical services to women in abusive relationship.

LITERATURE

REVIEW

DOMESTIC VIOLENCE

Domestic violence is defined as intentional controlling or violent behavior by a person who is or was in an intimate relationship with the victim. The controlling behavior may include physical abuse, sexual assault, emotional abuse, economic control, and/or social isolation of the victim. Abusive relationships are characterized by episodic, unpredictable outbursts by the abuser that often begin as verbal and emotional abuse but, over time, tend to become physical. As the abusive relationship continues, the victim begins to live in a state of constant fear, terrified about when the next Episode of abuse will occur.Domestic violence is a serious and common problem. It frequently remains hidden and undiagnosed since patients often conceal that they are in abusive relationships and the clues pointing to abuse may be subtle or absent. Thus, it is important that clinicians seek the diagnosis in certain groups of patients (table 1).Many clinicians recommend screening all women patients for domestic violence, although evidence for the efficacy of screening is lacking, and in practice many primary care physicians are not currently asking screening questions.13

EPIDEMIOLOGYOF DOMESTIC VIOLENCE

The reported frequency of domestic violence varies with the setting studied, the methodology, and the definition of domestic violence that is used.

A United States Department of Justice survey of 50,000 households in 1992 and 1993 estimated that over 1 million women and 150,000 men are victims each year of physical abuse or sexual assault by their partner.A United States survey of family violence based upon interviews of 8,145 families in 1975 and 1985 found that 16 percent of couples reported episodes of physical violence in the previous year.14

A study of emergency departments in Colorado found that 9 percent of the women patients were currently in an abusive relationship and 54 percent had a past history of being in an abusive relationship.15 In this study, the definition of domestic violence included both physical and nonphysical abuse. A more recent report of community hospital emergency departments found that 2 percent of women reported acute trauma from abuse by an intimate partner, 14 percent reported physical or sexual abuse in the last year, and 37 percent reported lifetime emotional or physical abuse.16

In a study of primary care practices that defined domestic violence as physical or sexual abuse, 5 percent of the women patients were currently in an abusive relationship and 20 percent revealed a history of past abuse .17

Studies of women in two gastroenterology (GI) clinics reported that 40 to 50 percent of women had a history of childhood or adult sexual or physical abuse. The prevalence of abuse was 31 percent among patients with functional GI complaints such as dyspepsia, chronic abdominal pain, and irritable bowel syndrome, and 18 percent among patients with organic problems such as peptic ulcer disease, inflammatory bowel disease, and liver disease.18

A study of women in a neurology clinic found that 66 percent with chronic headaches had a history of physical and/or sexual abuse.19

Family studies show that women are far more likely than men to be the victims of chronic physical abuse. Women are the victims in 95 percent of cases of domestic violence that lead to criminal investigation.20

Domestic violence is also a significant problem among the elderly. Community surveys have estimated that 3 to 4 percent of individuals over the age of 65 are victims of physical abuse, verbal abuse, or neglect, and 2 percent report sexual abuse. Elderabuse is associated with an increase in reports of chronic pain, depression, number of health conditions, and an increased mortality. The abuser is most commonly a relative (usually the spouse) .21,22 Societal costs attributable to domestic violence are not known. An estimate of the costs must include the costs of managing the medical and psychological consequences of domestic violence in the victims and their children, and the costs of bringing legal action against, jailing, and treating the abusers.

DOMESTIC VIOLENCEIN PREGNANCY

Domestic violence often begins or, if already present, increases during pregnancy and the postpartum period.23The relationship between domestic violence and pregnancy is illustrated by the following findings:

A review of the obstetrical literature found that physical abuse occurred during 7 to 20 percent of pregnancies.23This is higher than the prevalence of gestational diabetes and preeclampsia, conditions for which pregnant women are routinely screened.Women with an unintended pregnancy had a three-fold higher risk of physical abuse compared to those whose pregnancy was planned.24

A meta-analysis showed that victims of physical, sexual or emotional abuse during pregnancy were more likely than nonabused women to give birth to a baby with low birth weight (odds ratio 1.4, 95% CI 1.1-1.8).25 Another investigation found that women who report physical violence in the 12 months prior to delivery are more likely to deliver by cesarean and be hospitalized for maternal complications including kidney infection, premature labor, and trauma due to falls or blows to the abdomen. Despite this, women who report physical violence do not appear to be at increased risk for spontaneous abortion.26

Abused pregnant women have a three-fold higher risk of being victims of attempted/completed homicide than nonabused controls with similar demographic characteristics.27

A study that used an expanded definition of pregnancy-associated death, including death from any cause while pregnant or within one year of terminating pregnancy, found that homicide was the leading cause of pregnancy-associated death among women in Maryland between 1993 and 1998.28

CLASSIFICATION OF DOMESTIC VIOLENCE:

All forms of domestic abuse have one purpose: to gain and maintain total control over the victim. Abusers use many tactics to exert power over their spouse or partner: dominance, humiliation, isolation, threats, intimidation, denial and blame.

The form and characteristics of domestic violence and abuse may vary in other ways. Michael P. Johnson argues for three major types of intimate partner violence. The typology is supported by subsequent research and evaluation by Johnson and his colleagues,172 as well as independent researchers.173

Distinctions need to be made regarding types of violence, motives of perpetrators, and the social and cultural context. Violence by a person against their intimate partner is often done as a way for controlling "their partner", even if this kind of violence is not the most frequent. Other types of intimate partner violence also occur, including violence between gay and lesbian couples, and by women against their male partners. Distinctions are not based on single incidents, but rather on patterns across numerous incidents and motives of the perpetrator. Types of violence identified by Johnson:174

• Common couple violence (CCV) is not connected to general control behavior, but arises in a single argument where one or both partners physically lash out at the other. Intimate terrorism is one element in a general pattern of control by one partner over the other. Intimate terrorism is more common than common couple violence, more likely to escalate over time, not as likely to be mutual, and more likely to involve serious injury.
• Intimate terrorism (IT) may also involve emotional and psychological abuse.
• Violent resistance (VR), sometimes thought of as "self-defense", is violence perpetrated by victims against their abusive partners.
• Mutual violent control (MVC) is rare type of intimate partner violence occurs when both partners act in a violent manner, battling for control.

Another type is situational couple violence, which arises out of conflicts that escalate to arguments and then to violence. It is not connected to a general pattern of control. Although it occurs less frequently in relationships and is less serious than intimate terrorism, in some cases it can be frequent and/or quite serious, even life-threatening. This is probably the most common type of intimate partner violence and dominates general surveys, student samples, and even marriage counseling samples.

Types of male batterers include "family-only", which primarily fall into the CCV type, who are generally less violent and less likely to perpetrate psychological and sexual abuse. IT batterers include two types: "Generally-violent-antisocial" and "dysphoric-borderline". The first type includes men with general psychopathic and violent tendencies. The second type are men who are emotionally dependent on the relationship.174