Pregnant Women's experiences with intimate partner violence one year after the COVID‐19 pandemic in Jordan

To assess the prevalence and compare the levels of intimate partner violence (IPV) before and during the pandemic and to identify the factors that associated with physical IPV among Jordanian pregnant women.


| INTRODUC TI ON
Intimate partner violence (IPV) is defined globally as any behaviour by a current or past intimate partner that causes physical, sexual, or psychological harm (World Health Organization, 2021), while for the current study, it refers to any behaviour by husband that causes physical, psychological or sexual harm within a marriage relationship.
Intimate partner violence has four forms: Controlling behaviours, including isolating a person from family and friends; monitoring their movements; and restricting access to financial resources, employment, education or medical care. Emotional (psychological) abuse, such as insults, belittling, constant humiliation, intimidation (e.g. destroying things), threats of harm, threats to take away children.
Acts of physical violence, such as slapping, hitting, kicking and beating. Sexual violence, including forced sexual intercourse and other forms of sexual coercion (WHO, 2012). This type of violence is considered a global public health problem and a major violation of human rights (World Health Organization, 2021). Globally, one in every three women has been subjected to physical and/or sexual (WHO, 2020b). The rates of IPV differ by geographical region, with Africa having the highest rate (36.10%) and Europe having the lowest (5.10%) (Román-Gálvez et al., 2021). In the Arab world, women are experiencing substantial levels of IPV (6%-59% physical, 5%-91% emotional/psychological, and 3%-40% sexual) (Elghossain et al., 2019). Furthermore, in Jordan specifically, pregnant women are experiencing considerable levels of all types of IPV . In Jordan, despite the emergency situation caused by the COVID-19 pandemic, pregnant women are suffering from the violent behaviours of their husbands (80% control, 50.20% psychological, 13% physical, and 11.20% sexual) (Abujilban, Mrayan, Hamaideh, et al., 2021). reported that only 29% of women have never experienced any controlling behaviours by their husbands. Furthermore, the same survey reported that in at least one of the defined situations, 46% of evermarried women and 69% of all men aged 15 to 49 years old feel that wife beating is justifiable.
Pregnant women constitute a special case, as experiencing IPV affects both the mother and her unborn baby. For instance, mothers who experience IPV are more likely to have prenatal depression (Yu et al., 2018), fewer prenatal visits (Gardner et al., 2012), perinatal death (Pastor-Moreno et al., 2020), and negative experiences with parenting (Pels et al., 2015). Moreover, foetuses are at risk of low birth weight (Abujilban et al., 2017), preterm birth (Berhanie et al., 2019), birth defects, asphyxia, and stillbirth (Yu et al., 2018).
Since 2019, the world has been suffering from the COVID-19 pandemic. Jordan is no exception, as at the time of writing this report 1,260,983 cases have been diagnosed with COVID-19 and 13,248 people have died from COVID-19 (Worldometers, 2022).
COVID-19 affects everyone, including pregnant women. When a pregnant woman contracts COVID-19, she is at higher risk of preeclampsia or eclampsia, emergency caesarean birth, and longer hospitalization after birth. Moreover, the baby is at higher risk of fetal death and premature birth (Gurol-Urganci et al., 2021).
During every form of emergency, including epidemics, violence against women tends to rise (John et al., 2020;WHO, 2020b) because of the risks of loss of income, disruption of social and protective networks, and isolation (WHO, 2020a). In Jordan, the adults who might be most worried about the pandemic are women, and according to them, obtaining gender-based-violence services prior to the pandemic was easier than during the lockdown (UNFPA, 2020).
Although there is violence against women in Jordan, and specialists expect this violence to increase during the pandemic (John et al., 2020), there are no published studies showing the impact of the pandemic on violence. In a previous study (Abujilban, Mrayan, Hamaideh, et al., 2021) on a non-representative sample (online survey) of pregnant Jordanian women, it was found that all types of IPV decreased significantly during the complete lockdown (April to May 2020) in Jordan. However, a year after the pandemic (from 15 April to 1 September 2021), the situation in the country might have . This means that more attention needs to be paid to IPV in Jordan in order to understand its antecedents and to put appropriate plans in place to eradicate it. It is for these reasons that this study aimed to assess the prevalence and compare the levels of IPV before and during the pandemic and to identify the factors that associated with physical IPV during the pandemic. To this end, the study sought to answer the following three questions: (1) What are the current levels of IPV? (2) Is there a change in the levels of IPV from before the pandemic? (3) What are the associative factors physical IPV during the pandemic?
The worldwide cost of violence against women was estimated before the pandemic to be around USD 1.5 trillion (UN women, 2020).
Knowing levels of IPV during the pandemic and comparing them with the levels before the pandemic could shed light on the exact suffering of pregnant women. Such information could help decision makers in planning the most beneficial tailored protective programs at the appropriate time (e.g., psychological counselling, protection, and social services) (Almeida et al., 2017) in order to overcome IPV.
It may also give an indication of the importance of the role of early screening for IPV and highlight ways to help women in emergency situations such as the COVID-19 pandemic. Moreover, the findings may have broader implications because when people in the community are aware of the scope of the problem, it might be easier to discourage some men from engaging in IPV.

| Design
A cross sectional, correlational design was employed for this study.
This design is considered to be the best for researching a variable such as IPV (Polit & Beck, 2011).

| Setting
Data were collected from the National Woman's Health Care Center (NWHCC). The center is located in Tafila governorate in the south of Jordan and has a number of clinics. The center aims to provide high-quality comprehensive care for women of all ages in Tafila province and the other southern governates (Karak and Ma'an) of the country. The center is unique in providing specialized and comprehensive health care. The center has 43 employees, providing reproductive and sexual health services throughout the female lifespan, ranging from the care of newborns, children, and adolescents to the care of women during pregnancy and the menopause, as well as the treatment for various gynaecological diseases. The NWHCC's clinics provide services for 27,000 citizens annually in Tafila, Karak and Ma'an governates (AbuAbed, personal communication, January 4, 2022).

| Sample and sampling
All pregnant women in Jordan were considered as the target population, where pregnant women who received care at NWHCC clinics were the accessible population. Women who were married, living with their husband, and pregnant at the time of data collection were eligible for the study. Women who could not read or write in Arabic and those who had a health problem which necessitated hospitalization were excluded from the study. A convenience sampling technique was used to select the study participants, as it was judged to be the most appropriate method to access pregnant women during the pandemic. Thorndike's rule was used to calculate the sample size (10*k + 50), where k equals the number of variables (Thorndike, 1982). To compensate for missing data, the predicted sample size was increased by 10%. As a result, it was calculated that more than 200 individuals were required for the study.

| Instrument
The same questionnaire as that used in a previous study  was used in this study. The questionnaire is composed of three self-report tools: Part I: Demographic, Obstetrical, and Gynaecological History . The Demographic, Obstetrical, and Gynaecological History (DOGH) tool is used to measure the socio-demographic characteristics of pregnant women. It also measures their obstetrical and gynaecological history.  gave their permission to use the instrument for the purposes of the study. In the Jordanian context, the content validity index is 0.83 . The DOGH tool contains 34 questions that use different levels of measurement (nominal, ordinal, or ratio). The DOGH contains the following continuous variables: woman and her husband's age in years, gestational age, marriage duration, woman's personal income, household income, gravity, parity, number of children, compliance to antenatal visits, number of miscarriages, weight, height, and the following categorical variables: woman and her husband's educational level, woman and her husband's employment status, residence place, type of family, relative to husband, type of marriage (monogamy vs polygamy), history of miscarriages, health problems during pregnancy, place of antenatal visits, COVID-19 information (more details of categorical variables are presented in Table 1).   and sexual IPV (2 items). Each item has four possible options: never (score 1), once (score 2), little (score 3), and too much (score 4).
And items were summed up to have total scores for each of the four subscales. If the participant responds "once," "a little," or "too much" for any of the listed violent behaviours, she is considered to be a survivor of IPV and is given the code "1"; otherwise "0" (Clark, Bloom, et al., 2009;Garcia-Moreno et al., 2006). Examples of IPV items include; tries to keep you from seeing your friends (control behaviour), insulted you or made you feel bad about yourself (psychological IPV), slapped you or threw something at you that could hurt you (physical IPV), and physically force you to have sexual intercourse when you did not want to (sexual IPV).Women were asked to respond twice to the DVQT; the first response about her experience in the last year (during the pandemic) and the second about her experience with IPV before the last year (before the pandemic).
The DVQST is a reliable measure for IPV in the Jordanian context, as indicated by a Cronbach's alpha of 0.81 . Yoshikawa et al., 2014). The Justification of Wife Beating Scale was adapted to Jordanian culture by . The scale is a reliable measure (Cronbach's alpha = 0.75) and is composed of six situations. Each situation requires a "yes" or "no" response. If the participant responds "yes" for any of the listed situations, she is considered to show acceptance of wife beating and is coded as "1"; otherwise "0". The Mutual Understanding Scale and the Verbal Fighting Scale are each assessed by using one rating item on a five-point scale ranging from 1 = never to 5 = always (Clark, Bloom, et al., 2009)

| Data collection procedures
The data were collected after receiving approval from the University's Institutional Review Board (IRB) and permission from the NWHCC to access the participants. The data were collected by seven research assistants (RAs). The RAs were trained in how to select, motivate, and recruit eligible women in order to decrease experimenter bias. The purposes of the study were fully disclosed, and the rights of the participants were explained to the eligible women. Face-to-face recruitment was used to decrease the refusal rate. Women were approached to participate at their most convenient time, that is, while they were waiting in the clinic, in order to increase the response rate. They completed the questionnaire in a quiet room in the NWHCC center. Twenty minutes were needed to fill in the questionnaire. As IPV is a sensitive issue for Jordanian women, they were given privacy while filling in the questionnaire to enable them to be as truthful as possible and to decrease social desirability bias. To protect the privacy of the women involved, each questionnaire was given a number. Data were collected during the pandemic from 15 April to 1 September 2021.

| Data analysis
The data were analysed by using the Statistical Package for the Social

| Ethical consideration
The study protocol was approved by the Hashemite University IRB (#5/5/2020/2021). All the participants signed an anonymous consent form after being assured that their data would be treated confidentially and that only the researchers would have access to such data for research purposes. The women were motivated to participate in the study by knowing that their information would help other women in a similar situation. The women were also told that their participation was completely voluntary, that they could refuse to answer any question, that they could withdraw from the study whenever they wanted, and that doing so would have no impact on their care. The women were assured that their participation would expose them to minimum risks that were the same as those that they could encounter in their daily life. If the participants were identified as being exposed to IPV, they were followed up and referred to a psychiatric doctor if they greed (consent) for that.    Table 1 for more details.

| IPV during and before the COVID-19 pandemic
The women who participated in this study experienced considerable

| Description of marital relationship
Most of the employed participants were working in public sector jobs (n = 40, 88.90%). Only 20% (n = 8) of the women had the full decision-making power on how to spend their own money (see Table 1).    Overall, 28.30% (25.10% adjusted) of the variability in the physical IPV level was predicted by knowing the scores for the abovementioned nine independent variables. The correlations between physical IPV and the other five independent variables were weak, and they did not make a significant unique contribution to the prediction of physical IPV. Furthermore, other demographical variables (husband's age (r = 0.02), husband's employment status The closing parenthesis has been added to match the opening parenthesis.

| Associative factors with physical violence during the COVID-19 pandemic
Please check for correctness." (r = 0.01)), justification of wife beating (r = −0.09), verbal fighting (r = 0.05) had very weak non-significant correlations with physical IPV, so they were omitted from the regression.

| DISCUSS ION
We found that the pregnant women in our study encountered several types of IPV before and during the pandemic, and that control and psychological IPV levels significantly increased during the pandemic, while physical and sexual IPV levels remained approximately the same. We also found that woman's educational level, marriage duration, woman's employment status, and level of mutual understanding were independent inversely associative factors for physical

IPV.
The characteristics of our sample differ from those of the gen-  ., 2017). Therefore, the findings derived from the analysis of our sample are limited in terms of generalizability to the wider population. However, they provide important preliminary information about the levels of IPV in Jordan during the pandemic.
We found that pregnant women experienced considerable levels of IPV during and before the pandemic. Moreover, each type of IVP was strongly correlated with itself from before to during the pandemic. This finding is not surprising, as it supports the results of a study conducted a year earlier (in April 2020) during the total lockdown in Jordan, where substantial levels of all types of IPV were found before (65.10%, 30.70%, and 15.30% for psychological, physical, and sexual violence, respectively) and during (50.20%, 13%, and 11.20%, respectively) the full lockdown (Abujilban, Mrayan, Hamaideh, et al., 2021). These findings indicate that IPV is an enduring experience and that it starts early and continues throughout the lifespan (CDC, 2021). Moreover, IPV has not been resolved and women suffer from IPV even during emergencies such as the COVID-19 pandemic and even during pregnancy (Abujilban, Mrayan, Hamaideh, et al., 2021;Jetelina et al., 2021). Furthermore, the high levels of IPV that we found in our study are similar to those reported for other Arab countries, where Elghossain et al. (2019) reported that the levels were 5%-91% for emotional/ psychological, 6%-59% for physical, and 3%-40% for sexual IPV. However, lower levels of IPV have been reported for developed regions such as Europe and North America (4.20% and 28.60% for psychological, 2.10% and 9% physical, and 0.50% and 8.90% for sexual, respectively) (Román- Gálvez et al., 2021). The high levels of IPV in Jordan could be explained by the proportion of participants who agreed with some of the justifications of wife beating, where more than one third of the participants justified wife beating in specific situations. According to Yoshikawa et al. (2014), the justification of wife beating is an important risk factor for physical IPV.
In our study, we found that there was a statistically significant higher level of control IPV during the pandemic as compared to before the pandemic. One possible explanation for this result is that husbands were afraid that their wives might catch the disease, especially because their wives were pregnant. Our finding is congruent with Lyons and Brewer (2021), who stated that during the COVID-19 pandemic, abusers spend more time with their victims, giving the abusers more opportunities to watch and control the victims' actions. Such heightened control might result in the victim feeling like a prisoner (Lyons & Brewer, 2021) and becoming isolated (Smyth et al., 2021).
We also found that there was a higher level of psychological IPV during the pandemic than before the pandemic. This result TA B L E 4 Standard multiple regression of the effect of woman's age, woman's education, residence, marriage duration, household income, woman's employment status, number of live children, mutual understanding, and family type on physical IPV. contradicts that of the previous study conducted during the complete quarantine (April 2020), which found that psychological IPV decreased during the quarantine (Abujilban, Mrayan, Hamaideh, et al., 2021). It is possible to attribute this difference in the findings to the fact that the COVID-19 disease was new in April 2020, so spouses would have become emotionally closer to each other because of their fear of COVID-19 and would have found safety and comfort in being with their spouses, which might have decreased the incidence of IPV (Begawala & Umarji, 2020). Our finding of an increase in this type of IPV is in line with Rashid Soron et al. (2021), who found that psychological violence increased with the COVID-19 quarantine in the context of Bangladesh.
Yet, despite our expectation that all types of IPV would increase during the pandemic, this was not the case for physical and sexual forms of IPV: Even though we found high levels of both physical and sexual IPV before the pandemic, these forms of IPV remained at similar levels during the pandemic. The reason for this lack of change might be that the participants were pregnant, as during pregnancy the parents' primary concern is to protect the fetus.
Previous studies (Bagcioglu et al., 2014;Van Parys et al., 2014) have showed that pregnancy is a protective factor against IPV. For instance, Van Parys et al. (2014) stated that couples are less physically aggressive in general during pregnancy, but not necessarily less psychologically abusive. However, our finding for physical IPV contradicts Gosangi et al. (2021), who found that there was a higher prevalence and intensity of physical IPV during the pandemic than in the previous 3 years.
Our study found that woman's educational level and woman's employment status were inversely associated with physical IPV.
This means that the higher the woman's educational level, the less physical IPV she will experience. This result is congruent with the . We also found that employed women experienced less physical violence. A possible explanation is that when a woman is educated and employed, she is financially independent and empowered to make the right decisions for herself and for her children. This is congruent with a regional study from Egypt, which found that women's education and employment minimize the likelihood of women experiencing physical IPV (Abouelenin, 2022). Furthermore, according to autonomy theory (Goode, 1971), education lessens women's reliance on their spouse and empowers them to exit violent situations. An educated woman chooses a husband who is equivalent to her and has the same values in rejecting physical violence (Abouelenin, 2022). When the woman is empowered with money and education, the husband will be more careful before using physical violence to prove his control, as he Marriage duration was also inversely associated with physical IPV in our study. This means that the longer the marriage the lesser the physical IPV. This finding could be attributed to the fact that the longer the marriage period, the greater the understanding that the spouses have for each other, which leads to less tension and results in less confrontation and physical violence. Furthermore, it's possible that violent marriages end more quickly than non-violent ones, as divorce rate is higher when there has been IPV (Einiö et al., 2022).
However, our result contradicts Adebowale (2018), who found that couples who had been married for 0-4 years have experienced less IPV than those who had been married for 5-9 years.
We also found that mutual understanding was inversely associated with physical IPV. The better the understanding between spouses the lesser the physical IPV. We can better understand of our finding by referring to the cycles of violence theory (Rakovec-Felser, 2014;Walker, 1979), which clarifies that violence goes through three to four cycles: tension building, acting out period (acute battering), reconciliation (honeymoon) and calm. When couples have mutual understanding, the level of tension decreases, and then the cycle will break and IPV will end. Dokkedahl and Elklit (2019) suggested that incorporating partner dynamics into our understanding of IPV is critical.

| Implications
During the pandemic, it is crucial to understand the associated fac- Finally, future research should focus on measuring the effects of couple counselling on the levels of IPV among Jordanian pregnant women by using a rigorous research design (i.e., a randomized controlled trial). Furthermore, a large-scale study on a representative sample of the Jordanian population is needed to control the sampling bias.

| Limitations
Our study has some limitations. First, our sample was not representative of all pregnant women in Jordan because of the sampling bias that can result from the use of non-probability sampling. Our participants were younger, more educated, and more employed than the general population of women. This sampling error can potentially lead to incorrect findings and conclusion about IPV, so the findings can only be generalized to the participants in this study. Second, the data that were collected from the women was based on their memories of their experiences with IPV, which could have resulted in recall bias (that the survey did not accurately capture IPV) and the possibility of the misclassification of cases.

| CON CLUS ION
During the COVID-19 pandemic and pregnancy, Jordanian women continued to experience high levels of all types of IPV. Notably, the levels of control IPV and psychological IPV increased during the pandemic, while the levels of physical and sexual IPV stayed the same.
Women who were educated, employed, had a longer marriage, and had a mutual understanding with their husbands experienced a lower level of physical IPV. Antenatal screening for IPV is crucial to save women and their offspring from suffering this type of violence.
Also, encouraging girls to complete their schooling, find a stable job, and choose a husband who is equivalent to them in education and thinking would help to protect them from physical IPV and achieve Sustainable Development Goal 5. Furthermore, taking a community approach that builds resources in the community could empower families (both male and female) to stop cycles of violence. Providing alternative coping that helps the community rebuild resources, stability, and maintain attachments could ease anxiety, and anger. All authors read and approved the final manuscript.

ACK N O WLE D G E M ENTS
Open Access funding was provided by the Qatar National Library.
Many thanks for the women who gave their time to participate in the study.

FU N D I N G I N FO R M ATI O N
None.

CO N FLI C T O F I NTER E S T S TATEM ENT
The authors have no conflicts of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
All data generated during this study is included in this published article.

E TH I C S S TATEM ENT
The Hashemite University IRB approved the study protocol (#5/5/2020/2021). All the participants signed an anonymous consent form after being assured that their data would be treated confidentially and that only the researchers would have access to it for research purposes.