How Can Health Care Professionals Effectively Deal Sociologically With Issues Of Domestic Violence In Pregnancy - Essay Example

Introduction Domestic violence is one of the commonest crimes. It is present throughout the society, usually hidden, but there nonetheless. In any house, on any street, avenue or road, women regularly experience abuse and violence. Most frequently, it happens behind firmly closed doors. It is worth standing on such an average street — your street perhaps — and trying to imagine the reality of it behind those closed doors. You may not be aware that it is happening, but it is. My idea of choosing this topic and what I intend to incorporate in the paper is basically to provide a timely and comprehensive review of issues regarding the abuse of women during pregnancy. It is based on an extensive literature review as well as findings from the various projects and studies conducted in the United Kingdom that draws on police records. This paper shall be an ambitious effort to compile and describe evidence from a broad range of fields and will be a useful reference not only for researchers but also for health-care providers, advocates for victims of domestic violence, and professionals working in the field of criminal justice, particularly in the United Kingdom. One issue that, in my view, is critically important is the problem of research methodology. Most of the studies cited on prevalence and risk factors for violence cannot be easily compared because of marked differences in the way violence is conceptualized and measured. For example, many of the studies concerning abuse of pregnant women are cross-sectional surveys of women who are asked whether they have ever experienced violence during a pregnancy. Such studies are likely to underestimate the prevalence of violence as a result of recall bias, compared with findings from studies of currently pregnant women. Other issues that affect prevalence estimates include the number of times and at what point during pregnancy women are asked about violence. The most reliable data have been obtained from longitudinal studies that ask women about violence more than once in the childbearing year, including during the postpartum period. The way that violence is defined and measured varies greatly among studies: Some studies provide separate estimates for emotional, physical, and sexual violence, whereas others group all forms of violence under the single heading "domestic violence." Such issues, as well as the level of training and skill of interviewers and the use of measures to ensure privacy and confidentiality, have been shown to affect whether women are likely to disclose experiences of violence (Ellsberg et al. 2001; Jansen et al. 2004). Two issues appear to have a critical influence on violence against pregnant women. The first is abuse occurring prior to the pregnancy. Research in the United Kingdom and elsewhere indicates that the majority of women who are abused during pregnancy are also abused before and after the pregnancy (more than 80 percent, in most studies) (Castro et al. 2003; Campbell et al. 2004). In all countries studied, a minority of women surveyed report that they experienced violence for the first time during a pregnancy. A second important issue concerns differences in prevailing cultural norms with regard to pregnancy as a time during which women deserve special protection. Such differences are evident in a comparison of levels of violence during pregnancy in Ethiopia and Peru, countries where intimate partner violence is high. In rural Ethiopia, 49 percent of women surveyed have experienced physical violence from a partner during their lifetimes; in Cusco, Peru, this figure is 61 percent (Guezmes et al. 2002; Gossaye et al. 2003). The proportions of women reporting that they suffered from violence during pregnancy are substantially different: 8 percent of Ethiopian women reported abuse during pregnancy (15 percent of ever-abused women), compared with 28 percent of women surveyed in Peru (44 percent of ever-abused women.) In central Java, although 10 percent of women surveyed reported having been beaten by their husbands, less than 1 percent experienced such violence during pregnancy (Hakimi et al. 2002). These figures suggest that in some societies, pregnancy is a time of relative protection from physical violence, whereas in others abuse during pregnancy is widespread. This paper shall basically be able to provide a useful compendium of research findings and contribute to the increasing body of evidence indicating that violence against women during pregnancy is a significant public health problem with devastating consequences for the health of women and their children. The reader seeking a critical analysis of current findings or an international perspective on violence against women will need to look elsewhere, however. Domestic violence is one of the most explosive issues facing the criminal justice system today is how to react to and control it. Until recently, primary attention was placed upon the control of violence committed by strangers. Such acts were properly seen not only as inflicting serious harm, if not fatalities, on their victims but also as challenging the essence of a public order committed to nonviolent resolution of disputes. It seems that, throughout history, women have attempted to resist domestic violence by all sorts of means, wherever they have been able to. In the UK, there has been a social movement of women against domestic violence for many years. It was particularly evident in the nineteenth and early twentieth centuries, and became active again in the early 1970s. In the last twenty-five years, this movement has campaigned vigorously, its activists sustained by the vision of an end to male violence and of women growing more powerful together. Mainly as a result of its activities, we now hear about domestic violence frequently. It is talked about on radio and television, there is meant to be legal protection against it, and there are services available. This is in marked contrast to the situation before the 1970s, when there was silence about the issue, and women experiencing violence in the home had virtually no one to turn to for help. Even so, in the last decade, domestic violence has been in the public eye as it has never been before. Various governments now tell us that violence in the home is a crime and that it is not to be tolerated. Statutory and voluntary agencies say that it is unacceptable. International proclamations are made. Some of the women who have been active in the struggle against domestic violence for many years might be forgiven for asking just how much have really changed, but at least the beginnings are there. We have yet to see whether the public attention will last, and whether the political will exists to implement the necessary changes in comprehensive ways. The caring professions: social and health services The work of caring agencies like the social and medical services is vitally important for women fleeing violence. How they deliver their services, how easy it is to approach them, their attitudes to domestic violence — all these can affect whether women who have suffered violence make use of them or not. Often a woman delays seeking help, perhaps for years, because of shame about the violence that she has experienced, loyalty to or fear of her partner, and anxieties about the sort of reception she is likely to get. She may wonder, for example, if she will be believed and taken seriously, or if she will be treated in a judgmental, patronizing or pitying way. Most importantly, she may fear that the agency workers she speaks to will not be able to guarantee secrecy and that event will move out of her control. She may well have serious anxieties that her partner will find out and that she will face dangerous repercussions. Although there have been substantial improvements in recent years, many researchers, activists and workers in the domestic violence field have highlighted the obstacles that women may face in seeking help from agencies. In a study it was found that the women were generally reluctant to make contact with official caring agencies because of feelings of shame and guilt, and often because they themselves subscribed to widely held beliefs that marriage is meant to be happy, that it is the womans job to make sure that it is, and that the domestic sphere is private. These feelings and beliefs often had the effect of making women feel like failures if they reported the violence and hence admitted to the outside world that they were experiencing problems in their personal and intimate lives. However, if the violence became more severe, and with the passage of time, women in the study did seek help. Many abused women confide initially in women family members, most commonly mothers and sisters, or other relatives and friends. In another study it was only later and after some deliberation that women approached official agencies. As time went on, however, the number of contacts that women in this and other studies made with agencies increased. In the face of agency unhelpfulness, they often quested around trying to find effective help to alleviate the abuse that they faced, perhaps approaching one organization after another. The findings of various studies demonstrate the active and positive attempts that abused women make to change their situation, and counteract theories that stress womens helplessness and passivity, or which suggest that they enjoy the violence to which they are subjected. Nevertheless, women may be deterred from seeking further help by the negative and unhelpful responses that they sometimes still encounter in official agencies. Such responses can be blaming, disbelieving and judgmental. It seems deeply sad and unjust for abused women that, having quite possibly overcome feelings of shame and self-blame in order to take the enormous step of seeking help, they often encounter further blaming attitudes from the agencies that they approach. In a major longitudinal study conducted in the 1980s, more than half of the women interviewed had been in contact with their general practitioner, the police or the social services before going into a refuge. Fewer than half of the doctors and the police officers, and just over half of the social workers, had proved helpful. Such problems can be experienced particularly acutely by black women, immigrant women and women from ethnic minority communities. In another study, it was found that black women faced widespread disadvantage in their contacts with a variety of helping agencies. Lesbians may also face difficulties, as may very young and much older women who have suffered violence, or indeed any woman living an unconventional lifestyle. For an abused woman in a difficult situation, getting effective and non-judgmental help can therefore depend on having someone else to represent her and to help her to put her case forward. Women in refuges are usually able to get support and help from refuge staff who will act as their advocates with other agencies if they wish. There is little information available, however, on what happens to women experiencing violence who approach agencies for help without the support of Womens Aid or of other refuge groups. It seems that they fare much less well and are particularly isolated and vulnerable, especially if the agency approached responds in a negative way. As we saw earlier formal attempts are now being made to improve the way that official agencies deal with women who have experienced violence. Many guides, resource packs and information leaflets have been produced both for the public and for workers in agencies. The London Borough of Islington, for example, in conjunction with other local agencies, has produced a comprehensive good practice guide for local authority workers, a guide for community advisers and a detailed pack for teachers and youth workers called Stop Domestic Violence (Dunham, & Senn, 2000). Literature Review Living in a violent relationship has negative effects on womens mental health, including higher levels of depression, anxiety, and posttraumatic stress symptoms. Protective factors that might mitigate these negative consequences are less well known. Although much evidence exists linking social support to positive mental and physical health in populations other than those experiencing domestic violence, only a few research studies have examined whether social support is a protective factor for women in violent relationships. These studies generally find that women in violent relationships have an inadequate number of supporters and that they are often reluctant to ask these supporters for help. When support does exist, however, it is directly and positively related to womens mental health (Levendosky , Bogat, Theran, Trotter , Eye , Davidson II, 2004.). These studies also have several limitations. They have focused almost exclusively on women living in shelters; thus, these findings may or may not generalize to women in the community who live in violent relationships--the largest group of women experiencing domestic violence. In addition, the specific effects of different types of social support, such as practical support or negative support (e.g., criticism), are not independently examined. Functional support (the quality of support provided by the network) is typically measured by emotional support, which may or may not be the crucial form of support that women in violent relationships need or want. Little research has examined the structural aspects of support (i.e., the composition of the support network). The number of supporters is only one dimension of structural support; other qualities of the network may help or hinder womens access to support. Finally, reasons for the lack of supporters and the low quality of support have not been fully explored. The current study examines both structural and functional aspects of social support for community-dwelling women in violent relationships and tests several theoretical rationales that might explain poor support (Levendosky , Bogat, Theran, Trotter , Eye , Davidson II, 2004.).. Social support is important throughout the different stages in womens lives as a protective factor for mental health functioning. Specifically in pregnancy, social supports have an overall positive impact on mental health. The social support in pregnancy can be a critical factor in the long-term functioning of the woman and her child. Because the participants in the current study were all in their last trimester of pregnancy, a unique opportunity to examine social support, pregnancy, and domestic violence was afforded (Levendosky , Bogat, Theran, Trotter , Eye , Davidson II, 2004.).. METHOD Participants Participants in this study were 203 women, in their last trimester of pregnancy, recruited from the mid-Michigan area. The sample was 63% Caucasian, 25% African American, 5% Latina, and 7% other ethnic backgrounds. The womens mean age was 25.3 years. Forty-nine percent of the women reported that they were single, never married; 40% were married; and 11% were separated, divorced, or widowed. They were involved in a relationship with their respective partners for an average of 4.65 years (range: 3.5 months - 20 years). Fifty-seven percent of the women had at least one child (0 children = .98). The women had a median monthly income of $1500 (range: $0-$9500). Sixteen percent of the women had less than a high school education, 30% had graduated from high school, 41% had post-high-school training, and 13.5% had graduated from college. One hundred forty-five women had experienced domestic violence (criteria described below), and 58 of the women had not. The severity of the physical abuse experienced by the women in the DV group was mild to moderate (range 23.29, mean 5.00, SD 5.57) and the severity of the psychological abuse experienced by the women in the DV group was also mild to moderate (range 15.64, mean 3.82, SD 3.54). The women who had experienced domestic violence (DV group) differed from the women who had not (no DV group) on several demographic variables. The DV group was significantly younger (x = 24.67, SD = 5.21 vs. x = 26.94, SD = 5.45 years of age) and less educated, and had a lower monthly income (x = $1562, SD = $1346 vs. x = $2524, SD = $1676). They also had partner relationships of shorter duration and were less likely to be married to those partners. There was no difference between the groups on ethnicity or number of children (Levendosky , Bogat, Theran, Trotter , Eye , Davidson II, 2004.).. Procedure Participants were recruited from three counties in the mid-Michigan area at over 50 sites (e.g., ob/gyn clinics, prenatal pregnancy classes, WIC) as well as flyers posted throughout the community (e.g., laundromats and grocery stores). Two types of flyers were used. One asked for pregnant women to participate in a research study: the other for women who had ever been hurt (pushed, slapped, kicked, punched, or worse) by someone they loved during their pregnancy. Women who called the project offices for more information about the study were screened for eligibility. In order to participate, women had to be in their last trimester of pregnancy (for the interview), between the ages of 18 and 40 years, currently involved in or having had a romantic relationship of at least 6 weeks during their pregnancy, and proficient in English. Fifteen women were excluded from the study due to (a) language or age limitations or (b) a relationship of insufficient duration, (c) inability to conduct the interview before the birth. There were no significant differences (i.e., demographics, partner violence) between those who did and did not participate. In addition, three participants from the total sample (N = 206) were excluded because two lived at a domestic violence shelter during the time of the interview and one did not complete the social support questionnaire. Interviews were conducted either at the project offices or in the womans home. Consent forms were administered prior to interviewing. To ensure that the interviewers remained blind to the battering status of each participant as long as possible, domestic violence questionnaires were administered last (Levendosky , Bogat, Theran, Trotter , Eye , Davidson II, 2004.).. Approximately 13 female, undergraduate and graduate, students were trained for 10 weeks to administer the questionnaires. They attended a weekly training meeting throughout the course of their involvement. They role played and audio-taped the administration of the questionnaires numerous times and received feedback from project staff. Prior to conducting independent interviews, one final interview was required in which a trained interviewer oversaw the administration with an actual study participant. RESULTS Descriptive statistics and a correlation matrix for study variables are provided in Tables I and II. These tables include information about the entire sample and about the subgroup of battered women. In first analyses, whether women who had experienced domestic violence at any of the three time periods (DV; n = 145) had impaired support when compared to those women who had not (no DV; n = 58) was examined. (3) Because the two groups significantly differed on age, income, and education, these variables were entered with DV status in three multiple regressions predicting emotional support, practical aid support, and criticism. In all equations, DV was a significant predictor above and beyond the contribution of the demographic variables (see Table III). SES Differences as a Reason for Impaired Support Among the DV Group In this study, differences in education and income between the DV and no DV groups suggested that the DV group was of lower SES. However, as described above, income and education did not explain the differences for impaired support in the DV group (Levendosky , Bogat, Theran, Trotter , Eye , Davidson II, 2004). DISCUSSION Previous research indicates that battered women have poorer quality support than non-battered women (e.g., Barnett et al., 1996; Mitchell & Hodson, 1983; Thompson et al., 2000); however, this research has focused primarily on women living in shelters. Our results, from a sample of pregnant battered women living in the community, indicated that, they too, have less emotional and practical supports and more criticism from network members than do non-battered women. Most of the women in this study experienced mild to moderate levels of abuse. This study was unique in that it tested five theoretical reasons that might account for the DV groups poor quality of support: SES, number of supporters, severity of abuse, disclosure, and homophily. In this study, income was used as a marker of SES. The DV group had significantly lower monthly income than the no DV group. However, domestic violence was a more significant predictor of mental health outcomes than was income. The findings suggest that, in a community sample of women experiencing domestic violence, while SES has an impact, it is not a proxy for poor support. Perhaps the disparate findings as to whether SES has a positive or negative relationship to support reflect variations within particular samples. The two groups also did not differ in the total number of supporters in their respective networks. This finding, which runs counter to prevailing theory, may represent differences in community versus shelter populations. However, since most studies in this field do not report the detailed descriptive statistics on the severity of violence experienced by participants, this is an assumption that is difficult to test. Whether or not women disclose their abuse to network members also could not account for the DV groups poor quality of support. Researchers have suggested that women do not disclose the violence to network members, and, thus, supporters cannot offer the help and support that the abused woman needs. In contrast to previous research (Dunham & Senn, 2000; El-Bassel et al., 2001), nearly all the abused women in this study disclosed to at least one confidant (95%). Thus, disclosure itself, could not discriminate quality of support. Differences between the participants in this study and previous research may account for these discrepancies. Dunham and Senn (2000) studied college women who may (rightly or wrongly) perceive themselves to be unique in their experiences of partner violence, and, hence, unwilling to disclose. El-Bassel et al. (2001) interviewed battered women in methadone treatment. These women may have had additional barriers that made it difficult to confide in friends and family (Levendosky , Bogat, Theran, Trotter , Eye , Davidson II, 2004). The homophily of the networks was also examined as an explanation for poor support. Battered women, compared to non-battered women, had more supporters who were experiencing violence themselves. Within the DV group, homophily was negatively related to emotional support and criticism. The emotional support findings suggest that network members who have, themselves, experienced violence, have fewer psychological resources to offer. However, along with the emotional support comes increased criticism. One possible explanation is that the network members experiencing violence are likely to be depressed and depression has been associated with an internal attributional style, in which negative events are seen to be the result of personal responsibility (Sweeney, Anderson, & Bailey, 1986). This could lead to increased criticism on the part of network members as well as self-blame by the battered women. Thus, homophily seems to be the best explanation for the impaired social support of the battered women compared to the non-battered women. Surprisingly, and in contrast to previous research on women residing in domestic violence shelters, emotional support was not a significant predictor of mental health when severity of violence was controlled. Practical aid, however, predicted both anxiety and self-esteem. This finding is consistent with the only shelter study that compared emotional and practical supports. Most studies that examine support among battered women, combine several types of support in data analysis. The results of the study suggest that combining types of support obscures important differences between them and their effect on womens mental health. Another unexpected finding was that there were only two stress-buffering effects of social support: for women experiencing lower levels of violence, more practical aid and less criticism was related to higher levels of self-esteem. Cohen and Wills (1985) suggest that social support can mitigate stress either during the stress appraisal process or afterwards, before the negative response occurs. In a domestic violence situation, the violence may be frequent and/or chronic, and thus stress appraisal occurs continually. Perhaps practical aid mitigates the stress of domestic violence by helping the woman to solve some of the problems other than the violence, thus reducing hopelessness, which is associated with depression. However, in this population, it appears that direct effects of social support are far more important and prevalent than buffering effects. Finally, some demographic issues present limitations for generalizability beyond this sample. For example, this sample was drawn from a population of pregnant women. It is possible that pregnancy may have a unique impact on the relationship of social support and mental health which cannot be tested in this study. However, previous research demonstrates that social support has a similar function for pregnant womens mental health that it does for non-pregnant womens mental health. Thus, it is likely that these findings are generalizable to non-pregnant battered women. There are several important intervention implications from this study. First, critical support plays a key role in the mental health of women who have violent partners. Thus, support for women in violent relationships must avoid criticism of their lives and decisions. Clearly, the ability to talk about the abuse in an empathic, non-critical environment is an important key to positive mental health for these women. Because homophily was related to criticism in this study, it may be that advocates, rather than homophilous peer support groups, provide the most effective interventions. In addition, practical aid, rather than emotional support, was related to positive mental health. Thus, concrete assistance with daily life hassles and challenges should be a high priority for agencies serving battered women. Finally, the positive relationship between nonhomophilous supporters and mental health suggests that agencies might assist battered women in locating new sources of support in order to develop a social network composed of more women who have not been battered (Levendosky , Bogat, Theran, Trotter , Eye , Davidson II, 2004). Reference: Alytia A. Levendosky , G. Anne Bogat , Sally A. Theran , Jennifer S. Trotter , Alexander von Eye , William S. Davidson II, 2004. The Social Networks of Women Experiencing Domestic Violence. Campbell, Jacqueline, Claudia Garcia-Moreno, and Phyllis Sharps. 2004. "Abuse during pregnancy in industrialized and developing countries." Violence Against Women 10(7): 770-789. Castro, Roberto, C. Peek-Asa, and A. Ruiz. 2003. "Violence against women in Mexico: A study of abuse before and during pregnancy." American Journal of Public Health 93(7): 1,110-1,116. Ellsberg, Mary, Lori Heise, Rodolfo Pena, Sonia Agurla, and Anna Winkvist. 2001. "Researching domestic violence against women: Methodological and ethical considerations." Studies in Family Planning 32(1): 1-16. Gossaye, Yegomawork, Negussi Deyessa et al. 2003. "Womens Health and Life Events Study in rural Ethiopia." Ethiopian Journal of Health Development 17(second special issue): 1-49. Guezmes, Ana, Nancy Palomino, and Miguel Ramos. 2002. Violencia Sexual y Fisica contra las Mujeres en el Peru. Lima: Flora Tristan, World Health Organization, and Universidad Peruana Cayetano Heredia. P. 119. Hakimi, Mohammed, Ellie Nur Hayati, Mary Ellsberg, and Anna Winkvist. 2002. Silence for the Sake of Harmony: Domestic Violence and Health in Central Java, Indonesia. Yogyakarta, Indonesia: Gadjah Mada University. Jansen, Henrica A.F.M., Charlotte Watts et al. 2004. 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