Emotional, physical and sexual violence against women before or during pregnancy
Correspondence: Dr O. Irion, Unité de Développement en Obstétrique, Hôpitaux Universitaires de Genève, CH-1211 Genève 14, Switzerland.
The objective of this study was to determine the prevalence of emotional, sexual or physical violence reported by women delivered at the University Hospital Geneva, a tertiary care university teaching hospital, where about 3000 women are delivered each year. This study showed that prevalence of violence against women is high, and is severely underestimated by health case providers.
Violence against women is a problem seriously underestimated by health care providers, who rarely ask specific questions during antenatal clinics1. Several reasons may explain their lack of interest in this problem, including the belief that this does not happen to women in their practice, doubts about the effectiveness of interventions to help these women or feeling uncomfortable in discussing this issue. During pregnancy domestic violence is a serious risk to both mother and fetus. Abuse was also shown to be a significant predictor of poor obstetric history1,5. Surveys in the United States, conducted in obstetric or gynaecological settings, revealed that the prevalence of domestic violence reported by women may be as high as 46%2–5.
A self-administered questionnaire adapted from The Abuse Assessment Screen4 was given to all women able to read French who were delivered in our hospital between 15 June to 27 July 1997. Five questions were asked, concerning history of emotional, physical or sexual violence during or before pregnancy, nature and severity of violence and the woman's relationship to the abuser. A body map is included to identify areas of the body affected, when physical violence is reported. We included additional questions on age, parity, marital status, education, nationality and religion.
The aim of the study and the questionnaire were given by one of the authors (J.B.) to the women after their admission in the postpartum department. Information was also given on the availability of clinics and support groups for women who experienced violent behaviour. Women were asked for written informed consent. After the woman completed the anonymous questionnaire by herself, she returned it to a ballot box. The medical charts of all women who were delivered in the department during the study period were reviewed for a history of violence.
Results are presented as proportions and their 95% confidence intervals (CI). Proportions were compared by the χ2 test and age by the Student's t test. We calculated that a sample size of 200 women was needed to obtain a precision of 5% for an expected prevalence of violence of 5% to 15%. The study was approved by the institutional ethics committee.
A total of 271 women were approached, of whom 27 (10%) were not able to read French. Thus, 244 women were invited to participate. Five women (2%) refused to participate. Among 239 women who received the questionnaire, 33 (14%) failed to return it despite initial consent. Thus, 206 questionnaires were returned and analysed.
The prevalence of reported emotional, physical and/or sexual violence during lifetime was 18% (95% CI 13–23%). Prevalence during the present pregnancy was 7% (95% CI 3%-10%). Emotional violence first occurred during the present pregnancy in 2/27 instances (7%) and physical violence in 4/23 instances (17%). All but one of these women had experienced another form of violence before pregnancy. One woman (3%) reported the first episode of violence during the index pregnancy. Detailed results are presented in Table 1. The violence was caused by the husband, the partner or a relative in 84% of instances. Among the 23 women (11%) who reported physical violence, 20 indicated one or more areas of the body involved: 14 indicated the head, one the neck, five the trunk, three the abdomen, and nine the limbs. The severity of the injury was reported by 19 women, of whom 10 sustained wounds or fractures.
Table 1. Prevalence of violence reported by 206 postpartum women at the University Hospital Geneva. Values are given as n (%).
|Emotional||25 (12)||10 (5)||27 (13)|
|Physical||19 (10)||6 (3)||23 (11)|
|Sexual||11 (6)||4 (2)||11 (6)|
|Any of the above||36 (18)||14 (7)||37 (18)|
The mean age of these women was 31 years but this was not different than those who did not (30 years). Violence was not associated with primiparity (reporting violence 46%; not reporting violence 38%); marriage (81% and 84%, respectively), or Swiss nationality (49% and 41%, respectively). A similar proportion of women who reported violence (5%) and who did not (10%) went to primary school only, or attended university (19% and 21%, respectively). We found no differences in religion among these reporting and not reporting violence, respectively: Catholic 56% and 58%; Protestant 22% and 15%; Muslim 8% and 8%; other 3% and 11%; none 11% and 8%; practising 16% and 19%). None of the above sociodemographic characteristics were statistically significantly associated with a history of violence (P > 0.35).
During the study period, only two medical charts mentioned a history of domestic violence.
This study confirms that the prevalence of violence against women is high in Geneva and is similar to that observed during pregnancy in other settings, where a prevalence ranging from 0.9% to 20.1% was reported6. Prevalence of violence during pregnancy reported by women in our study was 7%, compared with 18% before pregnancy. This lower proportion must be interpreted with caution, as the period at risk (the pregnancy) is much shorter than the period before pregnancy, especially as studies have shown that pregnant women were at higher risk of being victims of violence1.
We did not find a difference in the prevalence of violence reported by women with different sociodemographic characteristics. However, this was not the primary objective of our study. The sample size we chose would reach a power of 80% only to detect differences of prevalence from 20% to 7% or from 20% to 40%. Although it is recognised that there is no single profile of a victim of domestic violence, some authors reported that abused women were significantly more likely to smoke, to use alcohol and drugs, or to be less educated5.
Previous surveys were conducted in women seeking prenatal care, abortion and in women presenting to an urgent care obstetrics and gynaecology unit2–5. To our knowledge, this is the first study conducted in the postpartum department with anonymous self-administered questionnaires. We chose to conduct our study in the postpartum department as this allowed confidentiality and privacy: the average duration of the postpartum stay was four days, so women had the opportunity to complete the questionnaire by themselves, without witnesses. The women also had the opportunity to ask for support if they needed it.
There are a few limitations to our study. We acknowledge that the definition of violence is difficult to standardise. However, we believe that women are the most competent persons to define whether they had suffered from violence. Moreover, a high proportion of women reporting physical violence in our questionnaire sustained wounds or fractures. Thus, it is unlikely that we overestimated the true prevalence of violence. A small proportion of the women approached refused to participate (2%). However, 14% of the women who accepted to participate did not return the questionnaire. We cannot estimate whether these women have a different risk of being victims of violence. Although only women able to read French were included, they represented 90% of the population approached during the study period. Finally, because the questionnaires were anonymous, it was not possible to collect additional data (e.g. obstetric outcomes).
Despite these limitations, our data show that violence against women is severely underestimated by health care professionals in Geneva, as only two medical records mentioned this problem during the study period. Systematically asking women specific and simple questions about domestic violence may permit to offer victims the help of multi-disciplinary clinics or support groups. It will be important to evaluate the effectiveness of such a policy.
This study was supported by a grant from the Fonds Scientifique Maurice Chalumeau (Geneva, Switzerland).