The Influence of Intimate Partner Violence on Pregnancy Symptoms

Abstract

The current literature contains few studies conducted on the effects of intimate partner violence (IPV) on pregnancy symptoms. Does being subjected to IPV during pregnancy increase the incidence of pregnancy-related symptoms? The aim of the present study was to explore the impact of IPV on pregnancy-related symptoms. The study was conducted as comparative, descriptive, and cross-sectional research with a total of 370 participants. Data were collected using the Domestic Violence Against Women Screening Form, the Pregnancy Symptoms Inventory (PSI), and a descriptive questionnaire. The types of IPV the women in the study had experienced during pregnancy were, in order of frequency, verbal abuse (31.1 %; n = 115), economic abuse (25.9 %; n = 96), physical violence (8.4 %; n = 31), and sexual abuse (5.9%; n = 22). The PSI scores for the pregnant women subjected to physical violence related to gastrointestinal system symptoms (p < .05), cardiovascular system symptoms (p < .05), mental health symptoms (p = 0), neurological system symptoms (p < .05), urinary system symptoms (p < .01), and tiredness or fatigue (p = 0); their total PSI scores (p = 0) were significantly higher statistically than those of women who did not experience physical violence during pregnancy. The scores of the pregnant women subjected to sexual abuse related to mental health symptoms (p < .05), and their total PSI scores (p < .05) were significantly higher than those of women who did not experience sexual abuse. The scores of the pregnant women subjected to economic abuse related to tiredness or fatigue (p < .01) and their mental health symptom scores (p < .05) were significantly higher than those of women who did not experience economic abuse. Our results showed that women subjected to IPV during pregnancy experienced a higher incidence of pregnancy symptoms.

Keywords

intimate partner violence violence against women pregnancy pregnant women pregnancy symptoms common discomfort of pregnancy antenatal care

Introduction

Intimate partner violence (IPV) is an important public health issue and one of the more significant indicators of gender inequality. The World Health Organization (WHO) defines IPV (also known as domestic violence or family violence) as “behavior by an intimate partner that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors” (WHO, Western Pacific Regional Office [WPRO], 2014).

Although the Turkish government and governments around the world continue to take measures to reduce the prevalence of violence against women (Özvarış, Demirören, Şener, & Tümay, 2008), it is unfortunate that IPV still exists at serious level, particularly in less developed countries (WHO, WPRO, 2014).

According to a 2015 joint report from the Republic of Turkey (RT), Ministry of Family and Social Policies (MFSP), the Directorate General on the Status of Women (DGSW), and Hacettepe University Institute of Population Studies (HUIPS), despite the increased legal sanctions placed on violence against women in recent years in Turkey and the fact that many women now realize that it is a crime, for many different reasons women still do not report that they have experienced violence (fear of her spouse, fear of not being able to see her children, anxiety that her husband will be put in prison, etc.).

Women may experience IPV at any time during their lives, and the period of pregnancy is no exception. Exposure to IPV during pregnancy ranges from 1% to 28% in general around the world (WHO, Department of Reproductive Health and Research [RHR], 2011) and between 8% and 10% in Turkey (Bağcıoğlu, Vural, Karababa, Aksın, & Selek, 2014; RT, MFSP, DGSW & HUIPS, 2015; Yanıkkerem, Karadaş, Adıgüzel, & Sevil, 2006).

It has been reported in Turkey that women living in rural areas, women with lower levels of education and income, women whose husbands are unemployed, women who are smokers, women who have been married for a long time, women who are experiencing unplanned pregnancy or pregnancies with less than 2 years in-between, and multipara are more frequently subjected to IPV during pregnancy (Arslantas et al., 2012; Karaoğlu et al., 2006; Yanıkkerem et al., 2006).

It is reported in recent studies that being subjected to IPV during pregnancy leads to adverse effects in terms of women’s reproductive health, to miscarriage, low infant birth weight, premature delivery, obstetric complications, vaginal bleeding, and reproductive system infections (Donovan, Spracklen, Schweizer, Ryckman, & Saftlas, 2016; Hassan, Kashanian, Hassan, Roohi, & Yousefi, 2014; Hoang et al., 2016; Khaironisak, Zaridah, Hasanain, & Zaleha, 2017; Murphy, Schei, Myhr, & Du Mont, 2001; WHO, RHR, 2011; WHO, WPRO, 2014).

Experiencing IPV during pregnancy also impacts a woman’s physical health (physical injuries, trauma, fractures, etc.) and mental health (depression, anxiety, etc.; Campbell, Garcia-Moreno, & Sharps, 2004; WHO, RHR, 2011; WHO, WPRO, 2014). Moreover, it has been asserted that pregnant women exposed to IPV display a higher incidence of alcohol use (WHO, RHR, 2011), smoking (Campbell et al., 2004; Murphy et al., 2001; WHO, RHR, 2011), delays in obtaining prenatal care (WHO, RHR, 2011), and other similar negative health behaviors.

Pregnancy is an important time in a woman’s life, a period in which she experiences anatomical, physiological, and biochemical changes (Alden, 2016). Because of the changes taking place during the period of pregnancy, women experience symptoms associated with this condition, such as fatigue, weakness, nausea, vomiting, frequent urination, urinary system infections, heartburn, edema, varicose veins, constipation, sleep disturbances, leg cramps, and backache (Alden, 2016; Foxcroft, Callaway, Byrne, & Webster, 2013).

IPV is an important stress factor in pregnancy. As levels of stress rise, the adrenal hormones cortisol, norepinephrine, and epinephrine begin to be secreted at high levels. Continued stress causes physiological reactions, having an adverse effect on health. Stress leads to the weakening of the immune system and to cardiovascular, gastrointestinal, and neurological system problems (Kocatürk, 2000). Women who suffer from IPV display gastrointestinal, cardiovascular, neurological, urinary system, and mental health symptoms (Esposito, 2016; Özvarış et al., 2008). Studies have shown that anxiety and depression, rather than being affected by pregnancy-related factors, are more influenced by factors outside of pregnancy (Meijer et al., 2014) and that women exposed to IPV during pregnancy have higher levels of stress, anxiety, and depression than do those who have not been victims of IPV (Tomasdottir et al., 2016; WHO, RHR, 2011; WHO, WPRO, 2014). Researchers reported in one study that pregnant women diagnosed with anxiety/depression more frequently complain of physical and psychosomatic symptoms (nausea, stomach pain, headaches, shortness of breath, gastrointestinal symptoms, heart-pounding, dizziness) than do those not so diagnosed (Kelly, Russo, & Katon, 2001).

There are quite a number of studies in the current literature about the influence of IPV on reproductive health, women’s mental health, and childbirth outcomes (Arslantas et al., 2012; Hassan et al., 2014; Hoang et al., 2016; Karaoğlu et al., 2006; Makara-Studzinska, Lewicka, Sulima, & Urbanska, 2013; Murphy et al., 2001; WHO, RHR, 2011; Yanıkkerem et al., 2006). The current literature contains few studies conducted on the effect of IPV on pregnancy-related symptoms (Tomasdottir et al., 2016). Knowing the relationship between IPV and pregnancy-related symptoms may help health care professionals to recognize signs of IPV at an early stage.

Objective

The aim of this study was to explore the influence of IPV on pregnancy-related symptoms.

Hypothesis 1: Women exposed to IPV during pregnancy are more likely to experience pregnancy-related symptoms (gastrointestinal system symptoms, cardiovascular system symptoms, respiratory system symptoms dermatological symptoms, neurological system symptoms, mental health symptoms, urinary system symptoms, musculoskeletal system symptoms, tiredness or fatigue symptoms) than other pregnant women who did not expose to IPV during pregnancy.

Method

Design

This study of comparative, descriptive, and cross-sectional design was conducted over the period October 1, 2015, to March 15, 2016, at the antenatal care polyclinic of a state hospital located in the district of Uskudar in the province of Istanbul.

Participants

A total of 397 pregnant women presenting to the antenatal polyclinic during the mentioned period and carrying the inclusion criteria stated below were taken into the study. Twenty-seven pregnant women withdrew from the study because they did not wish to answer some of the questions. The study was concluded with 370 participants.

Inclusion criteria

The women included in the study were those consenting to participate in the research who were between the ages of 18 and 40 years, in their 36th to 40th gestational week of a singleton pregnancy, with no systemic disease diagnosed prior to pregnancy (e.g., thyroid disease, hypertension, diabetes, kidney disease, neurological problems, etc.) and without being at high risk in their current pregnancy (e.g., diagnosed with gestational diabetes, gestational hypertension, dermatitis of pregnancy, existence of threat of premature birth or premature rupture of membranes).

Data Collection

Data were collected using the Domestic Violence Against Women Screening Form (DVAWS), the Pregnancy Symptoms Inventory (PSI), and a descriptive questionnaire. Over the course of the data collection, the participants were interviewed in a setting in which they could comfortably express themselves. To increase data reliability, the data were collected via face-to-face interviews.

Instruments

Descriptive questionnaire

The descriptive questionnaire, prepared by the researchers in line with the literature, consisted of 10 questions assessing the women’s and their husbands’ sociodemographic characteristics (age, educational status, employment status), number of pregnancies, planning pregnancy, and type of family.

The DVAWS form

The DVAWS, developed by Özvarış et al. (2008), is aimed at determining whether a woman has experienced violence in the past year.

Each question on the form probes into a different type of violence. Respondents answer with a “Yes” or “No.” If the answer is “Yes,” the individual accepts that she has been subjected to the type of violence referred to in the question. The DVAWS form was modified to suit the purpose of the study, and consequently the term “in the past year” was replaced by “during your pregnancy.” The modified DVAWS form that we used in this study is presented in the appendix.

PSI

Developed by Foxcroft et al. (2013), the PSI aims to assess the frequency of symptoms experienced in pregnancy. The PSI assesses 41 of the most commonly experienced symptoms in pregnancy. Each symptom is evaluated on a 4-item Likert-type scale with ratings from 0 to 3 (0 = never, 1 = rarely, 2 = sometimes, and 3 = often). Possible total scores on the PSI range from 0 to 126. The higher scores on the PSI indicate that symptoms are experienced more frequently. The Turkish language equivalent of the PSI was drawn up and its content analysis performed by the researchers prior to the start of the study. After scoring by the experts, the total content validity index of the PSI was calculated and found to be 0.65. Following the content analysis of language equivalence, it was concluded that the Turkish version of the PSI could be used in the study. In our study, we found the PSI’s Cronbach’s Alpha coefficient to be 0.82.

Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS; Chicago, IL, USA). The data on the descriptive questionnaire belonging to the participants who experienced and did not experience IPV during pregnancy (age, duration of marriage, etc.) were analyzed using chi-square tests and t tests. When significant differences in the comparison of the three groups were found in the chi-square test, a post hoc Bonferroni test was performed to determine which groups were responsible for the differences.

As the data from the PSI were being analyzed, the symptoms appearing in the PSI were classified as below (Alden, 2016).

Increased vaginal discharge, changes in libido, breast pain, sore nipples, and changes in nipples constituted reproductive system symptoms.

Nausea, vomiting, reflux, constipation, hemorrhoids, dry mouth, food cravings, thrush, and taste/smell changes were classified as gastrointestinal system symptoms.

Painful veins in vagina, dizziness, fainting, heart palpitations, varicose veins, and swollen hands or feet were classified as cardiovascular system symptoms.

Snoring and shortness of breath were classified as respiratory system symptoms.

Greasy skin/acne, brownish marks on the face, itchy skin, and stretch marks were classified as dermatological symptoms.

Leg cramps, carpal tunnel (numb hands), sciatica/pain down the back of the legs, and headache constituted neurological system symptoms.

Poor sleep, restless legs, forgetfulness, feeling depressed, anxiety, vivid dreams, and altered body image constituted mental health symptoms.

Urinary frequency and incontinence/leaking urine were classed as urinary system symptoms.

Back, hip, or pelvic pains were classified as musculoskeletal system symptoms.

Because tiredness or fatigue symptoms were associated with many systems at once, they were assigned to a class of their own.

After all the symptoms were classified, the scores for the symptoms of each system were calculated. The score for the symptoms of a system was obtained by dividing the total score received for all symptoms associated with the system by the number of items.

In comparing the type of violence experienced in pregnancy with the system symptoms score, the data representing a normal distribution were analyzed with the t test while those that did not show a normal distribution were analyzed with the Mann–Whitney U test. The Kolmogorov–Smirnov test was used to assess normal distribution.

A p value of less than 0.05 was accepted as significant.

Ethics

During the planning stage of the study, permission to use the scale was obtained via email from Ms. Özvarış and Mrs. Foxcroft. The permission of the Ethics Committee of the hospital was also obtained (Date: 21.02.2014; No. 38). After written and oral explanations, informed consent forms were collected from those wishing to participate in the study.

When it was learned during the data collection phase that a pregnant woman had been a victim of violence, this was not entered into the hospital records because each participant had been given an assurance that the information she revealed would remain confidential. On the contrary, the researchers informed the women who were found to have experienced violence that IPV is a crime and that they had the legal right to file a complaint against their husbands; they were further informed as to which institutions they could apply if they chose to do so. It was explained to the women who were victims of violence that they could phone the number 183 (domestic violence hotline) whenever they needed help.

Results

The findings obtained from 370 participants were evaluated in the study. The mean age of the women exposed to IPV during pregnancy was 28.5 ± 5.8 years; the mean age of the women not exposed to IPV was 28.9 ± 5.5 years (Table 1). All were married (100%). Of the participants, 47% (n = 174) experienced at least one type of IPV during pregnancy. In addition, 18% (n = 67) of all participants experienced multiple types of IPV during pregnancy. The types of IPV the participants experienced during pregnancy were, in order of incidence, verbal violence (31.1%; n = 115), economic violence (25.9%; n = 96), physical violence (8.4%; n = 31), and sexual violence (5.9%; n = 22).

Table 1.

Factors Related to Exposure to Intimate Partner Violence During Pregnancy (n = 370).

Variable	IPV(n = 174)	Non-IPV (n = 196)	t	p ^a
Variable	M ± SD	M ± SD	t	p ^a
Women age (years)	28.5 ± 5.8	28.9 ± 5.5	−.61	.54
Duration of marriage (month)	76.6 ± 63	74.8 ± 69	.24	.80
Number of children	0.96 ± 0.9	0.87 ± 0.99	.94	.34
Partner age (years)	32.1 ± 5.4	33.1 ± 5.7	−1.5	.1
	n (%)	n (%)	χ²	p ^b
Women’s education
Primary school (4 years)	69 (39.7)	59 (30.1)
Middle school (8 years)	40 (23)	25 (12.8)	15.4	0 *
High school and above (12 years and above)	65 (37.4)	112 (57.1)
Women’s work status
Working	21 (12.1)	53 (27)	12.9	0 *
Not working	153 (87.9)	143 (73)
Partner’s education
Primary school (4 years)	52 (29.9)	51 (26)
Middle school (8 years)	48 (27.6)	29 (14.8)	12.7	.002*
High school and above (12 years and above)	74 (42.5)	116 (59.2)
Partner’s work status
Working	172 (98.9)	192 (98)	45	.49
Not working	2 (1.1)	4 (2)
Family type
Nuclear family	139 (79.9)	163 (83.2)	0.66	.41
Extended family	35 (20.1)	33 (16.8)
Planning pregnancy
Planned pregnancy	135 (77.6)	153 (78.1)	0.012	.913
Unplanned pregnancy	39 (22.4)	43 (21.9)

Note. IPV = intimate partner violence.

Variables were analyzed using t test.

Variables were analyzed using χ² test.

p < .01.

Statistically significant differences were found between the women’s educational status and their exposure to IPV in pregnancy (Table 1). The results of the post hoc Bonferroni test showed that there were significant differences between women who were primary school graduates and those who had a high school education or higher (xi – xj = −.17183; p = .008) and between women who had a middle school education and those with a high school education or higher (xi – xj = −.24,815; p = .002), demonstrating that as the women’s level of education rose, the rate of their exposure to IPV during pregnancy decreased.

Significant statistical differences were found between the level of education of the women’s partners and the women’s exposure to IPV during pregnancy (Table 1). In the post hoc Bonferroni test, it was observed that there were statistically significant differences between partners who had a middle school education and those with a high school education or higher (xi – xj = −.23390; p = .001), demonstrating that as the partners’ level of education rose, the women’s rate of exposure to IPV during pregnancy decreased.

The employment rate of women who had not experienced any type of IPV during pregnancy (27%; n = 53) was significantly higher than among women who had been exposed to IPV during pregnancy (12.1%; n = 21; Table 1).

The age, duration of marriage, number of children, age of partner, employment status of partner, type of family, and pregnancy planning status information of the women who had experienced any kind of IPV during pregnancy were similar to those of the pregnant women who had not experienced IPV (Table 1).

In the comparison of the system symptom scores of the pregnant women experiencing and not experiencing physical violence, among the women exposed to physical violence in pregnancy, their scores related to gastrointestinal system symptoms, cardiovascular system symptoms, mental health symptoms, neurological system symptoms, urinary system symptoms, tiredness or fatigue and total PSI scores were significantly higher than those of the women who had not experienced physical violence during pregnancy (Table 2).

Table 2.

Comparison of System Symptoms Scores by Type of IPV Experienced During Pregnancy (n = 370).

Symptoms	Physical Violence(+)(n = 31)Med (25-75 Quartel)	Physical Violence(–)(n = 339)Med (25-75 Quartel)	Z	p ^a
Gastrointestinal system	5 (3-8)	4 (1-7)	−1.98	.048*
Reproductive system	3 (2-6)	3 (1-5)	−.66	.507
Cardiovascular system	3 (1-5)	2 (0-4)	−2.36	.018*
Mental health	6 (5-11)	4 (2-7)	−3.66	.0**
Neurological system	4 (0-6)	2 (1-4)	−1.99	.047*
Dermatological	2 (0-3)	1 (0-3)	−.19	.84
Respiratory system	1 (0-3)	0 (0-2)	−1.75	.079
Urinary system	3 (2-5)	3 (2-3)	−3.11	.002**
Tiredness or fatigue	3 (2-3)	2 (1-3)	−3.67	.0**
Total score of PSI	38 (24-45)	24 (16-33)	−3.52	.0**
Symptoms	Sexual Violence(+)(n = 22)Med (25-75 Quartel)	Sexual Violence(–)(n = 348)Med (25-75 Quartel)	Z	p ^a
Gastrointestinal system	5 (3.7-7.2)	3.5 (1.2-7)	−1.20	.22
Reproductive system	4 (3-6)	3 (1-5)	−1.17	.24
Cardiovascular system	2 (0-3)	2 (0-4)	−.002	.99
Mental health	6 (3-7.2)	4 (2-7)	−2.20	.027*
Neurological system	4 (1.7-6)	2 (1-4)	−1.58	.11
Dermatological	2 (1- 3.2)	1 (0-3)	−1.57	.11
Respiratory system	0 (0-3)	0 (0-2)	−.52	.59
Urinary system	3 (2.7-4)	3 (2-3)	−1.85	.06
Tiredness or fatigue	2 (2-3)	2 (1-3)	−.94	.34
Total score of PSI	31.5 (22.5-42.5)	25 (16-34)	−2.10	.035*
Symptoms	Verbal Violence(+)(n = 115)M ± SD	Verbal Violence(–)(n = 255)M ± SD	t	p ^b
Gastrointestinal system	4.4 ± 3.5	4.7 ± 4.2	−0.61	.53
Reproductive system	3.7 ± 2.7	3.8 ± 3.1	−0.31	.75
Cardiovascular system	2.5 ± 2.3	2.4 ± 2.3	0.50	.61
Mental health	5 ± 4.1	4.7 ± 4	0.46	.64
Neurological system	3.1 ± 2.6	2.8 ± 2.5	1.2	.20
Dermatological	2 ± 2.1	2 ± 2.1	0.01	.98
Respiratory system	1.1 ± 1.3	0.9 ± 1.3	1.3	.17
Urinary system	2.5 ± 1.6	2.6± 1.4	−0.73	.46
Tiredness or fatigue	2 ± 1.07	1.8 ±1	1.2	.23
Total score of PSI	27.2 ± 13.1	26.5 ± 14.2	0.43	.66
Symptoms	Economic Violence(+)(n = 96)M ± SD	Economic Violence(–)(n = 274)M ± SD	t	p ^b
Gastrointestinal system	4.1 ± 3.8	4.8 ± 4.0	−1.31	.18
Reproductive system	3.5 ± 2.6	3.9 ± 3.1	−1.05	.29
Cardiovascular system	2.6 ±2.4	2.4 ± 2.3	0.59	.55
Mental health	5.6 ±4.5	4.5 ± 3.8	2.1	.02*
Neurological system	3.1 ± 2.7	2.8 ± 2.4	0.85	.39
Dermatological	2.1 ± 2.3	1.9 ± 2	0.88	.38
Respiratory system	1.03 ±1.3	1.04 ±1.3	−0.07	.93
Urinary system	2.7 ± 1.5	2.5 ±1.5	1.2	.19
Tiredness or fatigue	2.1 ± 0.96	1.8 ± 1.08	2.7	.007**
Total score of PSI	27.5 ± 14.8	26.5 ± 13.5	0.65	.51

Note. IPV = intimate partner violence; PSI = Pregnancy Symptoms Inventory.

Variables were analyzed using Mann–Whitney U test.

Variables were analyzed using independent sample t test.

p < .05. **p < .01.

The scores of the pregnant women exposed to sexual violence related to mental health symptoms, and their total PSI scores were significantly higher than those of the women who had not experienced sexual violence. The other system symptoms scores of women who had and who had not been exposed to sexual violence during pregnancy were similar (Table 2).

The total PSI scores and the other system symptoms scores of women who had and who had not been exposed to verbal violence during pregnancy were similar (Table 2).

The tiredness or fatigue scores of women experiencing economic violence during pregnancy (2.1 ± .96) and their mental health symptoms scores (5.6 ± 4.5) were significantly higher statistically than those of women who had not experienced economic violence (1.8 ± 1.08; 4.5 ± 3.8, respectively; Table 2).

Discussion

A review of the literature reveals studies that have examined the frequency of IPV, the effect of IPV on pregnancy outcomes, and the impact of IPV on women’s mental health during pregnancy and in the postpartum period (Arslantas et al., 2012; Hassan et al., 2014; Hoang et al., 2016; Karaoğlu et al., 2006; Khaironisak et al., 2017; Makara-Studzinska et al., 2013; Murphy et al., 2001; Tomasdottir et al., 2016; WHO, RHR, 2011; Yanıkkerem et al., 2006).

To the best of our knowledge, this study is the first piece of research that evaluates the impact of IPV on all kinds of pregnancy-related symptoms. The results of our study have shown that women who encounter violence during pregnancy, particularly violence of a physical kind, experience a significantly higher incidence of pregnancy-related symptoms than do those who do not experience violence. It is believed, therefore, that the results of the study will make a contribution to the literature.

An examination of the data belonging to the 370 participants in our study indicates that the demographic characteristics of the participants are similar to the demographic characteristics of participants in other studies (Arslantas et al., 2012; Hassan et al., 2014; Hoang et al., 2016; Yanıkkerem et al., 2006).

IPV during pregnancy threatens the health of both women and infants. While the rates of physical, verbal, and economic violence we obtained in our study are similar to the results reported in other research conducted in Turkey (Bağcıoğlu et al., 2014; Karaoğlu et al., 2006; RT, MFSP, DGSW, & HUIPS, 2015; Yanıkkerem et al., 2006), with regard to results obtained in other countries, they are similar to some but different from others (Castro, Peek-Asa, & Ruiz, 2003; Hassan et al., 2014; Hoang et al., 2016; Khaironisak et al., 2017; Makara-Studzinska et al., 2013; Perales et al., 2009). Besides, the rate of sexual violence during pregnancy in our study (5.9%) was found to be lower than that reported in other studies (Castro et al., 2003; Hassan et al., 2014; Hoang et al., 2016; Karaoğlu et al., 2006; Khaironisak et al., 2017).

The similarities and differences in the various studies suggest that this may be an effect of the different cultural characteristics of the countries and the degree to which their cultural characteristics are similar to our own. The cultural characteristics of a country determine the attitudes taken toward pregnant women as well as the general outlook toward gender equality. The WHO reports that in lesser-developed and developing countries, gender equality is an important issue and that violence toward women is at higher levels (WHO, WPRO, 2014).

In Turkey, women who are victims of IPV can file a complaint about their husbands, seek asylum at women’s shelters, and ask for economic and social support. Many women, however, do not file complaints in the belief that IPV is a family issue that requires privacy (Özvarış et al., 2008).

That our findings proved to be lower than those obtained in other countries may be an outcome of the strong belief of women in Turkey that violence experienced at home is a private matter and must remain secret and kept in the family (RT, MFSP, DGSW, & HUIPS, 2015). Another reason may be that the study was conducted in the hospital setting. Laws in Turkey require health care providers to draw up a judicial report to be filed with law enforcement authorities whenever they encounter a woman who is a victim of IPV. This is why many women keep their exposure to IPV secret (RT, MFSP, DGSW, & HUIPS, 2015; Özvarış et al., 2008).

The fact that there is a significant association between the status of women and IPV cannot be denied. Like the findings of other studies (Arslantas et al., 2012; Castro et al., 2003; Hassan et al., 2014; Karaoğlu et al., 2006; Khaironisak et al., 2017; Makara-Studzinska et al., 2013; Tomasdottir et al., 2016; WHO, WPRO, 2014; Yanıkkerem et al., 2006), the results of our study indicated that women with lower levels of education, with unemployed husbands, or with husbands with lower levels of education displayed higher rates of exposure to IPV during pregnancy. The results obtained showed that one of the major steps that can be taken to reduce IPV during pregnancy is to improve the socioeconomic level of both women and men.

Studies reveal that experiencing physical violence during pregnancy can lead to premature childbirth, miscarriage, and other similar outcomes (Donovan et al., 2016; Hassan et al., 2014; Hoang et al., 2016; Murphy et al., 2001; WHO, RHR, 2011; WHO, WPRO, 2014). IPV is a complex, stigmatizing problem that involves issues of emotional distress, personal safety, and social isolation (Esposito, 2016; Stadtlander, 2017).

The hypothesis in the present study was that women exposed to IPV during pregnancy are more likely to experience pregnancy-related symptoms compared with other pregnant women who did not expose to IPV.

Poor mental health (depression, anxiety, posttraumatic stress disorder, etc.) is among the most significant outcomes of IPV (Coker, Smith, Bethea, King, & McKeown, 2000; Esposito, 2016). It is known that exposure to IPV during pregnancy adversely affects women’s mental health and increases the incidence of depression and anxiety (Tomasdottir et al., 2016; WHO, RHR, 2011; WHO, WPRO, 2014). In this study, mental health symptoms reflecting anxiety, depression, and similar conditions were found to be more common in women who experienced physical, sexual, or economic violence than who did not exposed. The current study findings are consistent with the results of other studies (Coker et al., 2000; Tomasdottir et al., 2016).

Tiredness and fatigue are positively correlated with stress and anxiety (Bossuah, 2017; Stadtlander, 2017). Women who experience violence are more likely to suffer from unhappiness and depression than those who do not. Women who feel unhappy and depressive feel more tired and fatigued than those who do not feel unhappy and depressive (Bossuah, 2017). Tiredness and fatigue in turn reduce an individual’s energy, cognitive performance, and self-care abilities (Bossuah, 2017; Foxcroft et al., 2013). We found that women exposed to both physical and economic forms of violence displayed higher tiredness and fatigue scores than those who were not exposed to physical and economic forms of violence. Similarly, in a study conducted by Tomasdottir et al. (2016), it was reported that women exposed to violence during pregnancy suffered from more symptoms of tiredness, unhappiness, and depression than women who had not suffered violence. Our results support the conclusion that being exposed to physical violence and economic violence during pregnancy increases the frequency of complaints of tiredness and fatigue.

Many gastrointestinal, cardiovascular, neurological, and urinary system complaints are closely associated with stress. It is known that becoming the victim of physical violence is one of the most significant stressors for women (Esposito, 2016). The results of our study supported the assertion that pregnant women are adversely affected particularly in the case of physical violence.

These findings showed that the gastrointestinal, cardiovascular, neurological, and urinary symptom scores of the women who had experienced physical violence were significantly higher than those of the women who had not been subjected to violence. In the study of Tomasdottir et al. (2016), it was reported that women experiencing violence during pregnancy had more complaints of headache, backache, and incontinence than had women who were not subjected to violence; this supports the results of our study. Moreover, the results of studies with nonpregnant women indicating that women subjected to physical violence display a higher incidence of gastrointestinal complaints, chronic pain syndrome, and mental health issues (Coker et al., 2000; Özvarış et al., 2008) also support our findings.

The most interesting finding in the current study was that all of the system symptom scores of the women subjected to or not subjected to verbal violence were similar. Although the reason for this cannot be explicitly explained, we might venture to suggest that because verbal violence is a wide and common phenomenon in Turkey (RT, MFSP, DGSW, & HUIPS, 2015), the participants in the study may have internalized this form of violence such that it did not make a difference.

Limitations of the Study

One of the most important limitations to this study is that many women did not wish to participate in the research. The main reason for this was the women’s belief that because IPV is a crime in Turkey, legal action would be taken against their husbands if the women were to participate in the study and disclose what they had experienced. The fact that there were many women who did not wish to participate in our research raises the question of whether the rates of exposure to IPV during pregnancy that we found in our study are actually higher in the population. In future studies of a similar nature, different data collection methods (e.g., interviews at home, distributing and collecting data collection forms to and from the women in sealed envelopes) may be advisable so that more women can be encouraged to participate.

Another limitation to our study is that our evaluation did not cover the status of women who had been victims of violence before their pregnancy. It may be advisable for researchers who conduct similar studies to assess the status of women who are exposed to violence prior to pregnancy.

A further limitation is that no instrument of measurement has been developed for use in screening for IPV among pregnant women. Because of this, the DVAWS form was used in the study in a modified form. In terms of its benefit for future studies, it would be useful for researchers to engage in developing an instrument for measuring IPV during pregnancy. The findings of this study may not be generalized. It may be advisable for researchers engaging in future studies of a similar nature to conduct their research on a nationwide scale and with larger sample groups. It is also important in terms of raising awareness that all researchers of this subject share their findings with the authorities of the Ministry of Health.

Conclusion

According to the results of this study, it can be said that the rate at which women experience some form of violence during pregnancy is not negligible and that, in particular, women subjected to physical violence have a higher incidence of experiencing pregnancy-related symptoms than women who are not subjected to physical violence. The results have shown that the pregnancy symptoms women experience may vary according to the type of violence to which the woman has been subjected. In view of these results, it may be advisable for health care professionals to be more vigilant in evaluating women who suffer from significant pregnancy-related symptoms in terms of IPV and that the health team be equipped with the necessary knowledge and skills to enable them to conduct screening for IPV. Screening for IPV during antenatal care is an important responsibility of health care professionals (WHO, WPRO, 2014). Recognizing the existence of IPV in pregnancy early on and planning interventions to deal with the issue have a positive impact in terms of mother and infant health in both the short and long term. With the high rate at which pregnant women receive antenatal care in Turkey (97% receive care at least once during pregnancy; HUIPS, 2014), there is ample opportunity for health care professionals to engage in IPV screening.

It is important that antenatal clinics are set up appropriately, with screening forms on hand, and that protocols are formulated to indicate which interventions are to be made in the case of IPV victims.

Footnotes

Appendix

Domestic Violence Against Women Screening Form (Özvarış, Demirören, Şener, & Tümay, 2008).

1. During your pregnancy, did your husband ever display insulting, belittling, or humiliating behavior toward you?	❏ Yes	❏ No
2. During your pregnancy, did your husband ever kick, slap, beat, or strike you?	❏ Yes	❏ No
3. During your pregnancy, did you husband ever obstruct your work or behave in such a way as to cause you economic distress?	❏ Yes	❏ No
4. During your pregnancy, did your husband ever force you to have sexual relations against your will?	❏ Yes	❏ No
Assessment 1. If the answer to the question is “Yes” Verbal Violence (+) 2. If the answer to the question is “Yes” Physical Violence (+) 3. If the answer to the question is “Yes” Economic Violence (+) 4. If the answer to the question is “Yes” Sexual Violence (+)

Acknowledgements

The authors thank the pregnant women who were willing to participate in the study. They also thank statistics expert Abdurrahman Subas, PhD.

Authors’ Note

This study was presented as poster at The 14th Congress of The European Society of Contraception and Reproductive Health, May 4-7, 2016, Basel in Switzerland.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Özlem Can Gürkan, PhD, received a doctorate in 2005 from the Department of Obstetrics and Gynecology Nursing, Health Sciences Institute, Marmara University. She has been working since 1999 as an instructor at Department of Obstetrics and Gynecology Nursing, Health Sciences Institute, Marmara University. She has engaged in research in recent years on violence against women and teaches a class on domestic violence in the department in which she works.

Zübeyde Ekşi, PhD, received a doctorate in 2006 from the Department of Obstetrics and Gynecology Nursing, Health Sciences Institute, Marmara University. She has been working since 1997 as an instructor at Department of Obstetrics and Gynecology Nursing, Health Sciences Institute, Marmara University. She has engaged in research in recent years on pregnancy and maternity health in which she works.

Derya Deniz graduated in 2015 from the Marmara University, Health Sciences Faculty, Nursing Division. Currently, she works in the Intensive Care Unit of Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital. She was studying as a postgraduate student in the Institute of Health Sciences of Marmara University, Obstetrics and Gynecology Nursing Department. Currently, she conducts research on acupressure in labor.

Hasan Çırçır graduated in 2016 from the Marmara University, Health Sciences Faculty, Nursing Division. Currently, he works in the Intensive Care Unit of Acıbadem Altunizade Hospital and conducts research on web-based pregnancy education.

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