The Effect of Domestic Violence During Pregnancy on Cortisol Hormone Release,Breastfeeding,and Newborn

Abstract

This study was conducted to determine the effect of domestic violence during pregnancy on the cortisol hormone release, preterm birth, low birth weight, and breastfeeding status. The cross-sectional study was conducted with 255 pregnant women in a Family Health Centre in the Southeastern Anatolia Region of Turkey between October 2017 and August 2018. The questionnaire, DVWDS (Domestic Violence to Women Determination Scale) and Breastfeeding Self-Efficacy Scale were used to collect the data. In the present study, the pregnant women were followed up three times. The first follow-up was applied to the pregnant women in the second trimester, the second follow-up was applied to those in the third trimester, and the third follow-up was applied to the postpartum women. At each follow-up from newborn, cortisol hormone level was taken with saliva and evaluated. It was determined that 9.8% of the pregnant women participating in the study were exposed to violence by their partners. An important result was found that those who were exposed to domestic violence during their pregnancy gave birth in the 37th week (p < 0.05). It was seen that the babies of those exposed to domestic violence during pregnancy had a higher mean cortisol hormone level (p < 0.05). It was found that the mean score of the Breastfeeding Self-Efficacy Scale in the third follow-up was lower for those who were exposed to domestic violence during pregnancy than those who were not (p < 0.05). It was observed during the pregnancy that domestic violence affected cortisol hormone secretion, breastfeeding after birth and newborn health.

Keywords

pregnancy violence during pregnancy cortisol newborn breastfeeding

Introduction

In the family environment, where social relations are first shaped, globalization’s value judgments have entered into a kind of change process. As a result of this change, domestic problems have increased, and the failure to solve these domestic problems has revealed the concept of domestic violence (Tarhan, 2011). The concept of domestic violence is defined as the actions of individuals to their children, parents, siblings, or close relatives and partners that affect their physical, psychological, sexual, and economic independence (Kelly & Johnson, 2008). Women are exposed to domestic violence by their spouses and can also be exposed to violence by their lover, father, and brother (Paksoy & Akın, 2015). Violence against women, which is a violation of freedom based on social gender, causes women to be deprived of their rights to participate in social and economic life, and it is an essential concept due to deaths, disabilities, and many effects it causes on women’s health (Ellsberg et al., 2008).

A woman, who can be exposed to violence in every period of her life, is also exposed to violence during pregnancy, which has particular importance in her life (Jansen et al., 2009). However, adoption of pregnancy and motherhood roles by a woman and living in an environment where she will receive more humane care are essential not only for the woman but also for the baby to be healthy (Yılmaz & Kucuk, 2014). In some studies and the World Health Organization report, violence during pregnancy is reported to be an important public health problem that negatively affects both maternal and fetal health (Guler, 2010; Hammoury & Khawaja, 2007; WHO, 2005). In developing countries, violence during pregnancy is the most important reason for low birth weight in infants and infant deaths (Cardoza, 2005).

In Turkey, 8% of women who conceived at least one pregnancy stated that they were subjected to physical violence of their spouses or the men they were with during their pregnancy and four out of 10 women stated that the violence they were exposed to did not change during their pregnancy, and one out of 10 women expressed that the violence increased. In other words, pregnancy does not decrease violence for one in every two women who are violence victims (HUIPS Hacettepe University Institute of Population Studies, 2015). In their systematic review, Taillieu and Brownridge found physical violence between 0.9% and 30.0%, emotional violence between 1.5% and 36%, and sexual violence between 1% and 3.9% during pregnancy (Taillieu & Brownridge, 2009). In their systematic review and meta-analysis, Howard et al. reported that depressive symptoms, anxiety, and post-traumatic stress disorders were commonly seen in women exposed to violence (Howard et al., 2013).

Why is this research needed?

• As it has serious consequences for the health of both the pregnant woman and the baby to be born, exposure of pregnant women to domestic violence is an important public health problem.

• In many studies conducted in our country on this subject, it is observed that pregnant women are assessed for a single time during the pregnancy process in terms of violence, and the number of studies that encompass the entire pregnancy process and also assess the perinatal results and the postpartum period is low.

• With this study, the relationship between the hormone cortisol and the women who experienced domestic violence during pregnancy was assessed for the first time in our country. Perinatal outcomes due to domestic violence throughout pregnancy, postpartum period, and the attitude of the pregnant woman towards both prenatal and postnatal breastfeeding were also assessed. Besides, the cortisol hormone level of the newborn was examined for the first time in our country with this study.

• It is contemplated that the results acquired from the study will form the basis for future researchers who will do research on this subject and for the prevention of violence.

Being exposed to stress due to the mother’s violence during pregnancy also causes changes in hormonal balance (Valladares et al., 2009). The reason is that the stress-induced by violence limits the blood flow in the uterus and causes blood vessels to narrow and cortisol levels to increase (Nunes et al., 2010). Cortisol has a critical regulatory role in glucose metabolism and the stress response of the body. Plasma cortisol concentration elevates during pregnancy, hypoglycemia, stress conditions, obesity, depression, and hyperthyroidism (Koylu, 2017). A study determined that the cortisol hormone release increased in pregnant women depending on violence during pregnancy. In this study, partner violence during pregnancy was a stress factor, which caused cortisol levels to increase, and it was associated with a decrease in birth weight (Valladares et al., 2009), along with the hormonal changes in pregnancy, estrogen and progesterone levels after birth also cause a tendency to depression. Hormonal and genetic factors and stressful life events are effective in mood disorders (Ozorhan et al., 2014). A study found that the problems experienced by mothers during their pregnancy affected their breastfeeding self-efficacy (Ince et al., 2017). The concept of self-efficacy is described as one is evaluating the performance that she/he needs to do with his/her thoughts and turning it into behavior by acting according to the situation (Yesil, 2015). Breastfeeding Self-Efficacy perception is the competence that the mother feels about breastfeeding. This is also affected by the difficulties in different previous conditions perceived by the mother about breastfeeding (Dennis, 1999; Tokat, 2009). If the mother has good physical and mental health, she can better take care of her baby and breastfeed her for a long time (Ozkan et al., 2014).

The number of recent studies about violence during pregnancy is increasing. In many studies conducted on this subject in Turkey, pregnant women are only evaluated once during their pregnancy period in terms of violence. It is also seen that the number of studies covering the whole pregnancy period and evaluating the effects of violence during pregnancy on newborns and the postpartum period is low. It is believed that the results that will be obtained from this study will form a basis for the researchers who will conduct studies on this subject and the studies on preventing violence. This study was conducted to determine the effect of domestic violence during pregnancy on cortisol hormone release, preterm birth, low birth weight, and breastfeeding status.

Methods

Study Design and Ethical Issues

This cross-sectional study was conducted between October 2017 and August 2018 in a Family Health Centre in Gaziantep province located in Southeastern Turkey. The ethical approval required for conducting the study was obtained from the Ethics Committee of the Faculty of Health Sciences in Hasan Kalyoncu University. The study was conducted under the principles of the Declaration of Helsinki. Written permissions were also obtained from institutions. Verbal consent of pregnant women who agreed to participate in the study was obtained. Considering their privacy, the interviews with the pregnant women were held in a separate room. After the study, flyers prepared about relaxation exercises and legal rights in combating violence were delivered to the women exposed to violence.

Sampling

In the Family Health Centre, where the study was conducted, approximately 412 pregnant women were followed up. If the population size is 500 according to power analysis, then the sample size is 217 in ±0.05 sample error (p = 0.5 q = 0.5) in sample size calculation for α= 0.05 (Yazıcıoglu & Erdogan, 2004). However, by assuming that there may be data loss, 255 pregnant women were reached.

Data Collection Tools and Methods

The researchers developed the questionnaire, DVWDS (Domestic Violence to Women Determination Scale), and Breastfeeding Self-Efficacy Scale was used in the study to collect the data, and a saliva sample was taken for the cortisol hormone level. The questionnaire consists of five parts. The first part includes 31 questions about the sociodemographic characteristics of pregnant women’s fertility-related characteristics. The second part includes five questions and sub-questions about the presence of violence exposure during pregnancy, physical violence, emotional violence, sexual violence, and economic violence. The third part includes information about the mother’s delivery mode (normal delivery, cesarean), newborn (birth week, birth weight, etc.), and results about cortisol hormone level.

DVWDS, developed by Yanıkkerem and Saruhan, measures the types and degree of violence to women and has 87 questions (Yanıkkerem & Saruhan, 2005). The Cronbach’s alpha value of the scale is 0.98. In the present study, it is 0.95. Likert-type DVWDS is scored between 1–5 points. The lowest score on the scale is 87, and the highest score is 435. The increase in the scale score indicates that the violence to women increases.

By summing 9-factor scores determined from DVWDS, their averages were obtained, and the full scale means the score was obtained. The total raw score was divided to the highest top score taken from that factor and multiplied by 10. The scores obtained after standardization vary between 1–10 points. Scores after standardization are evaluated as; 0.00–2.00 very low, 2.01–4.00 low, 4.01–6.00 moderate, 6.01–8.00 high, and 8.01–10.00 very high (Yanıkkerem, 2002).

The Breastfeeding Self-Efficacy Scale is a 33-item scale developed by Dennis in 1999 (Dennis, 1999). Later in 2003, the scale was reduced to a 14-item scale, and Breastfeeding Self-Efficacy Short Form was developed (Dennis, 2003). Tokat, Okumus, and Dennis conducted its Turkish validity and reliability study in 2008 (Alus Tokat et al., 2010). The Cronbach’s alpha value of the scale is 0.86. The present study was determined as 0.84 in the first follow-up, 0.82 in the second follow-up, and 0.91 in the third follow-up. Breastfeeding Self-Efficacy Scale- Short Form is a 5-point Likert-type scale. The minimum score of the scale is 14, and its maximum score is 70. A high score indicates a high breastfeeding self-efficacy. It is stated that this scale is appropriate to apply in the postpartum period (Tokat, 2009).

It took approximately 30–35 minutes to apply the questionnaires.

The data were collected from pregnant women in the second trimester who voluntarily participated in the study and came for follow-up within the prenatal care service scope. After giving birth, the data were also collected from the mothers using face-to-face interviews within the context of both child health and postnatal care follow-up as in the pregnancy period. After taking saliva samples, questionnaires were applied. The data were collected between 08:00 and 12:00 in the morning.

In the study, three follow-ups were made during the data collection process. Figure 1 shows the application flow chart.

Figure 1.

Application flow chart.

Taking Cortisol Hormone Sample and Measurement of its Level

The cortisol hormone level was determined by taking saliva samples from pregnant women, mothers, and newborns. Ensuring that the pregnant women did not eat anything at least half an hour before giving the sample, 4–5 ml saliva sample was taken with a clean tube. In case of having materials such as blood, sputum, and lipstick in the sample, the sample was retaken.

Saliva sampling from the newborns was made with SIS (SalivaBio Infant’s Swab) tubes. Hands were washed, non-sterile gloves were worn, and a saliva sample was taken from the newborn. According to the instructions for using the SIS tube in newborns, one end of the pipe was securely held, and the other end was placed under the tongue, and it is necessary to keep the swab in place for 60–90 seconds to collect saliva. SIS was then placed into the storage device. However, since enough saliva could not be taken from the newborn by waiting for 60–90 seconds, the pipe was held for a total of 5–6 minutes, including 2.5–3 minutes for each end.

The tubes were labeled and stored at −20°C in the refrigerator at the Family Health Centre. As the number of samples increased, the samples were sent to Gaziantep University Biochemistry Laboratory within 15 minutes at the latest by considering the cold chain. The samples were centrifuged at 2000 rpm for 10 minutes in adults and 3 minutes in the newborn with a Turkish-made centrifuge device (NUVE NF 800R), and the supernatant was taken into clean tubes. In this supernatant, cortisol levels were measured within 1 month using ELISA [Enzyme Linked Immunosorbent Assay] method and studied using the commercial ELISA kit (DiaMetra, Italy).

Data Analysis

In preparing a database and analysis, SPSS (Statistical Package for Social Sciences) 23.0 Windows package program was used. The results were evaluated at a confidence interval of 95% and a significance level of p < 0.05.

In statistical analysis, the suitability of numerical variables to normal distribution was evaluated with the Kolmogorov-Smirnov test. In the pairwise comparison that did not fit the normal distribution, the non-parametric test Mann-Whitney U was performed. A Chi-square test was conducted for the number-percentage distributions of data concerning the pregnant women’s descriptive characteristics participating in the study and comparing the rates.

Correlation analysis was conducted to make a comparison between the mean scores on the Domestic Violence Against Women Scale and the mean scores on the Breastfeeding Self-Efficacy Scale.

Results

Table 1 shows the sociodemographic and fertility characteristics of pregnant women. The mean age of the pregnant women participating in the study was 28.57 (6.17) (minimum 17, maximum 46). The pregnant women’s average gravida was 2.78 (1.52) (minimum 1, maximum 7).

Table 1.

Sociodemographic and Fertility Characteristics of the Pregnant Women (n = 255).

Sociodemographic Characteristics of the Pregnant Women	n	%
Age group of the pregnant women
17–21	29	11.4
22–26	77	30.2
27–31	74	29.0
32–36	46	18.0
≥37	29	11.4
Educational status of the pregnant women
Primary school	112	44.0
Secondary school	83	32.5
High school	27	10.6
University	33	12.9
Working status of the pregnant women
Yes	22	8.6
No	233	91.4
Fertility characteristics of the pregnant women
Gravida including this pregnancy
Primigravida	63	24.7
Woman having ≥2 pregnancies	192	75.3
History of miscarriage
Yes	75	29.4
No	180	70.6
History of abortion
Yes	42	16.5
No	213	83.5
Planning type of the pregnancy
Yes	218	85.5
No	37	14.5
The number of follow-ups up to current pregnancy week
Between 1 and 3	71	27.8
Between 4 and 6	136	53.4
7 and more	48	18.8
Gender of the baby
Female	122	47.8
Male	110	43.1
Unknown	22	8.7
Twin (girl and boy)	1	0.4

Table 2 shows the distribution of violence during pregnancy and violence types expressed by pregnant women. It was found that 9.8% of pregnant women were exposed to violence by their spouses.

Table 2.

Distribution of the Pregnant Women’s Status of Being Exposed to Violence During Pregnancy and Violence types (n = 255).

	n	%
Status of exposure to violence during pregnancy
Yes	25	9.8
No	230	90.2
Types of violence being exposed during pregnancy ^a
Emotional violence	99	38.8
Physical violence	37	14.6
Economic violence	21	8.2
Sexual violence	19	7.4

^an multiplied.

Table 3 shows the distribution of pregnant women’s status to be exposed to domestic violence during pregnancy according to the newborn’s characteristics. It was detected that there exists a statistically significant difference between exposure to domestic violence during pregnancy and the birth week of babies (p < 0.05).

Table 3.

Distribution of the Status of being Exposed to Domestic Violence During Pregnancy According to the Newborn’s Characteristics.

	Exposure to Domestic Violence during Pregnancy
	Yes		No		Total		χ2	p
	n	%	n	%	n	%	χ2	p
Birth weight
<2500 Gram	2	7.7	24	92.3	26	100.0	0.043	0.836
≥2500 Gram	18	8.9	184	91.1	202	100.0	0.043	0.836
Birth week
<37 weeks	5	26.3	14	73.7	19	100.0	7.972	0.005
≥37 weeks	15	7.2	194	92.8	209	100.0	7.972	0.005

Table 4 shows the distribution of the Breastfeeding Self-Efficacy Scale mean scores of the pregnant women in the first, second and third follow-ups according to their status of being exposed to domestic violence during pregnancy and violence types. According to Table 4, breastfeeding self-efficacy scale mean scores in the third follow-up were lower in pregnant women exposed to domestic violence during pregnancy than those who were not (Z= −3.309, p < 0.05).

Table 4.

Distribution of Self-Efficacy Scale Mean Scores of Pregnant and Postpartum Women According to their Status of Being Subjected to Domestic Violence During Pregnancy and Violence Types.

	Breastfeeding Self-Efficacy Scale
	First follow-up (n=255)		Second follow-up (n=223)		Third follow-up (n=228)
	Yes	No	Yes	No	Yes	No
	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD
Being subjected to domestic violence during pregnancy	56.44 ± 7.68	56.84 ± 7.31	55.09 ± 10.35	58.08 ± 5.40	54.05 ± 13.95	62.53 ± 7.01
Being subjected to domestic violence during pregnancy	Z= −0.399	p = 0.690	Z= −1.352	p = 0.176	Z= −3.309	p = 0.001
Being subjected to physical violence	58.50 ± 5.66	56.73 ± 7.40	56.85 ± 4.87	57.83 ± 6.11	56.62 ± 13.95	61.97 ± 7.88
Being subjected to physical violence	Z= −0.512	p = 0.608	Z= −0.788	p = 0.431	Z= −1.320	p = 0.187
Being subjected to emotional violence	56.33 ± 7.82	56.85 ± 7.30	55.05 ± 10.62	58.07 ± 5.39	53.73 ± 14.26	62.52 ± 7.00
Being subjected to emotional violence	Z= −0.445	p = 0.656	Z= −1.238	p = 0.216	Z= −3.232	p = 0.001
Being subjected to sexual violence	6.09 ± 8.14	56.83 ± 7.31	51.77 ± 13.60	58.05 ± 5.46	49.80 ± 17.30	62.33 ± 7.12
Being subjected to sexual violence	Z= −0.341	p = 0.733	Z= −1.618	p = 0.106	Z= −3.033	p = 0.002
Being subjected to economical violence	56.09 ± 7.94	56.83 ± 7.32	54.10 ± 14.77	57.97 ± 5.35	60.70 ± 7.10	61.83 ± 8.24
Being subjected to economical violence	Z= −0.358	p = 0.721	Z= −0.463	p = 0.644	Z= −0.725	p = 0.469

Table 5 shows the correlation distribution between the factors obtained from DVWDS and the Breastfeeding Self-Efficacy Scale mean scores of the pregnant women in the first, second, and third follow-ups. Accordingly, it was observed that there was a low correlation that the breastfeeding self-efficacies of pregnant women in the second follow-up would decrease by the increased score of Factor 5, “disdaining female gender and threatening behaviors” of DVWDS (r= −.208, p < 0.01).

Table 5.

Distribution of the Correlations Between the Pregnant Women’s Factors Obtained from Domestic Violence to Women Determination Scale and the Breastfeeding Self-Efficacy Scale Mean Scores in the First, Second, and Third Follow-Ups.

Correlation Test Results	Breastfeeding Self-Efficacy Scale	Breastfeeding Self-Efficacy Scale	Breastfeeding Self-Efficacy Scale	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5	Factor 6	Factor 7	Factor 8	Factor 9
Correlation Test Results	1^st Follow-Up	2^nd Follow-Up	3^rd Follow-Up	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5	Factor 6	Factor 7	Factor 8	Factor 9
Breastfeeding self-Efficacy scale 1^st follow-up	1
Breastfeeding self-Efficacy scale 2^nd follow-up	.430**	1
Breastfeeding self-Efficacy scale 3^rd follow-up	.279**	.270**	1
Factor 1	-.016	-.068	-.246**	1
Factor 2	-.025	-.147*	-.199**	.815**	1
Factor 3	.102	-.155*	.017	.389**	.428**	1
Factor 4	.142*	-.009	-.106	.497**	.537**	.398**	1
Factor 5	-.065	-.208**	-.116	.713**	.680**	.503**	.418**	1
Factor 6	-.055	-.166*	-.194**	.645**	.669**	.203**	.289**	.504**	1
Factor 7	-.033	-.146*	-.081	.507**	.598**	.454**	.449**	.518**	.389**	1
Factor 8	-.050	-.123	-.104	.518**	.616**	.486**	.540**	.526**	.419**	.753**	1
Factor 9	-.101	-.146*	-.085	.450**	.504**	.462**	.322**	.422**	.476**	.427**	.506**	1

*p < 0.05 **p < 0.01.

Table 6 shows the distribution of mean cortisol hormone levels in the first, second, third follow-ups of pregnant women and newborns according to their status of being exposed to domestic violence during pregnancy and violence types. The cortisol level was found to be high in babies of mothers who were subjected to domestic violence during their pregnancy (p < 0.05).

Table 6.

Distribution of cortisol hormone levels of pregnant women, postpartum women, and newborn according to the status of being exposed to domestic violence and violence types.

	Cortisol Hormone Levels
	First Follow-Up		Second Follow-Up		Third Follow-Up		Newborn
	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD
Being exposed to domestic violence during pregnancy
Yes	17	14.88 ± 9.43	19	11.49 ± 5.38	19	10.26 ± 10.39	21	17.18 ± 8.46
No	174	14.67 ± 8.03	187	13.78 ± 6.84	175	8.44 ± 5.61	203	12.65 ± 8.32
	Z= −0.416	p=0.677	Z= −1.113	p=0.266	Z= −0.069	p=0.945	Z= −2.922	p=0.003
Being exposed to physical violence
Yes	7	11.17 ± 4.86	7	11.75 ± 5.97	8	8.06 ± 5.73	8	14.24 ± 7.12
No	184	14.82 ± 8.22	199	13.63 ± 6.77	186	8.64 ± 6.25	216	13.04 ± 8.47
	Z= −1.149	p=0.250	Z= −0.203	p=0.839	Z= −0.280	p=0.780	Z= −0.839	p=0.402
Being exposed to emotional violence
Yes	16	15.29 ± 9.58	18	11.80 ± 5.37	18	10.58 ± 10.59	20	17.26 ± 8.67
No	175	14.63 ± 8.02	188	13.74 ± 6.84	176	8.41 ± 5.60	204	12.67 ± 8.30
	Z= −0.13	p = 0.897	Z= −0.795	p = 0.427	Z= −0.337	p = 0.736	Z= −2.818	p = 0.005
Being Exposed to sexual violence
Yes	9	13.43 ± 8.83	9	11.30 ± 5.61	10	7.31 ± 3.66	10	17.31 ± 7.65
No	182	14.75 ± 8.12	197	13.67 ± 6.78	184	8.69 ± 6.33	214	12.88 ± 8.41
	Z= −0.865	p = 0.387	Z= −0.638	p = 0.524	Z= −0.364	p = 0.716	Z= −2.087	p = 0.037
Being exposed to economic violence
Yes	7	14.33 ± 5.61	7	11.35 ± 6.08	7	5.46 ± 2.02	9	14.73 ± 5.42
No	184	14.70 ± 8.23	199	13.65 ± 6.76	187	8.73 ± 6.30	215	13.01 ± 8.52
	Z= −0.286	p =0.775	Z= −0.419	p = 0.675	Z= −1.153	p = 0.120	Z= −1.431	p = 0.153

Table 7 shows the distribution of mean cortisol hormone levels in the first, second, and third follow-ups of pregnant women and newborns according to some factors of DVWDS. Accordingly, to Table 7, it was determined that there was a statistically significant correlation between the pregnant women’s cortisol hormone level in the second follow-up with the Factor 7 and Factor 8 factors of DVWDS. It was seen that there was a significant correlation between the cortisol hormone level of the newborn and Factor 5.

Table 7.

Distribution of cortisol hormone levels in pregnant women, postpartum women, and newborn according to some factors of DVWDS.

	Cortisol Hormone Levels
	First Follow-Up		Second Follow-Up		Third Follow-Up		Newborn
	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD
Factor 5 Disdaining female gender and threatening behaviours
Very low-low	183	14.80 ± 8.24	197	13.45 ± 6.47	183	8.69 ± 6.32	213	12.84 ± 8.38
Medium-high-very high	8	12.04 ± 5.06	9	16.22 ± 11.39	11	7.45 ± 4.27	11	17.72 ± 8.14
	Z = −0.849	p = 0.396	Z = −0.583	p = 0.560	Z= −0.514	p = 0.607	Z= −2.250	p = 0.024
Factor 7 Women’s negative affection for themselves
Very low-low	140	15.35 ± 8.52	155	13.96 ± 6.17	145	8.27 ± 4.88	165	13.09 ± 8.66
Medium-high-very high	51	12.86 ± 6.74	51	12.38 ± 8.19	49	9.63 ± 9.09	59	13.04 ± 7.77
	Z= −1.904	p = 0.057	Z= −2.303	p = 0.021	Z= −0.156	p = 0.876	Z= −0.257	p=0.797
Factor 8 concerns and fears about the partner
Very low-low	113	15.18 ± 8.84	128	14.12 ± 5.81	121	8.28 ± 4.55	136	13.25 ± 8.74
Medium-high-very high	78	13.97 ± 7.00	78	12.67 ± 8.00	73	9.17 ± 8.29	88	12.81 ± 7.83
	Z= −0.718	p = 0.473	Z= −2.510	p = 0.012	Z=−0.734	p = 0.463	Z= −0.107	p = 0.915

Discussion

This study was conducted to determine the effect of domestic violence during pregnancy on cortisol hormone release, preterm birth, low birth weight, and breastfeeding status. In this part, the data we obtained from our study were discussed by comparing them with the literature.

It was determined that 30.2% of the pregnant women participating in the study were in the age group of 22–26 years, and 29.0% were in the age group of 27–31 years. When the pregnant women’s education levels were examined, it was determined that they were mainly primary school graduates (44.0%).

When the pregnant women’s working status in the present study was examined, the majority (91.4%) of them were unemployed. According to TDHS 2018, 64% of women aged 15–49 are unemployed (TDHS 2018). The result obtained from the present study reflects this situation in Turkey.

When the status of being exposed to domestic violence in pregnant women participating in the study was examined, 9.8% of the pregnant women stated that they were exposed to domestic violence during pregnancy. According to a study conducted in Turkey, four out of every 10 pregnant women stated that the violence they were exposed to did not change during pregnancy, and one out of 10 women stated that the violence increased. When the violence rates that women are exposed to during the pregnancy period are examined in other Turkey studies, they vary between 0.8% and 71.4% (Ayrancı et al., 2002; Bolu et al., 2015; Gencer et al., 2018; Gogus & Yildiz, 2013; Guler, 2010; Karaoglu et al., 2005; Sahin et al., 2017). When the studies conducted worldwide regarding the frequency of women’s violence during the pregnancy period are examined, it is seen to vary between 0.9% and 52.4% (Abate et al., 2016; Pires de Almeida et al., 2013; Demelash et al., 2015; Finnbogadóttir et al., 2016; Hammoury & Khawaja, 2007; Katiti et al., 2016; Khaironisak et al., 2017; Valladares et al., 2009). It is hard to compare and evaluate domestic violence frequency during pregnancy in the present study with the other studies. The reason is that different sample types, study inclusion criteria, cultural differences, and different scales evaluating prevalence and severity of partner violence were used.

The violence type experienced by the pregnant women participating in the present study was emotional violence with a high rate (38.8%). According to a study in 2014, the violence type experienced by women at the highest rate was emotional violence (44%) (HUIPS 2015). In some studies conducted in Turkey, emotional violence from violence types was determined to be seen more frequently (Ayrancı et al., 2002; Bolu et al., 2015; Gogus & Yildiz, 2013; Guler, 2010; Sahin et al., 2017). The obtained study results were seen to be similar to these results. In the studies conducted in developed and developing countries on this subject, the frequency of emotional violence during pregnancy varies between 16.0% and 78.3% (Abate et al., 2016; Farid et al., 2008; Finnbogadóttir et al., 2016; Gao et al., 2008; Khaironisak et al., 2017; Taillieu & Brownridge, 2009; Valladares et al., 2009). High emotional violence is thought to be associated with a partner’s lack of knowledge about some mental changes occurring during pregnancy. Besides, the emergence of some behaviors that cannot be applied as physical violence during pregnancy as emotional violence can be interpreted as the cause of experiencing more emotional violence. On the other hand, having more emotional violence than the other violence types may also be caused by the fact that women can express this type of violence more comfortably.

It was determined that 14.6% of pregnant women were exposed to physical violence. In the studies conducted on domestic violence in Turkey, physical violence is high (HUIPS 2015). However, in Turkey’s studies on domestic violence during pregnancy, the rate of physical violence was determined to be less as in the present study (Ayrancı et al., 2002; Deveci et al., 2007; Guler, 2010; Mammadov, 2015; Sahin et al., 2017; Yanıkkerem et al., 2006). In the studies conducted in other developed and developing countries, the rate of physical violence during pregnancy was seen to vary between 4% and 33.8% (Abate et al., 2016; Farid et al., 2008; Finnbogadóttir et al., 2016; Garcia-Moreno et al., 2006; Gao et al., 2008; Khaironisak et al., 2017; Taillieu & Brownridge, 2009; Valladares et al., 2009). As can be seen, the rates vary from country to country depending on the cultural structure of society and the methods and samples used in the studies. According to the present study results, it can be interpreted as the fact that the fear of partners harming the fetus may be the cause of less physical violence experienced by pregnant women.

In the assessment made in the present study about exposure to domestic violence during pregnancy according to newborn-related characteristics, an important result was found to be associated with premature birth (p < 0.05). In the literature, it has been reported that the violence experienced during pregnancy increases the difficulties and risky conditions in adopting this process even more, negatively affect the health of mother and fetus, and could cause negative perinatal results (Howard et al., 2013; Mahapatro et al., 2011; Stöckl et al., 2012). In developing countries, the most crucial cause of babies with low birth weight and infant deaths was exposure to violence during pregnancy (Cardoza, 2005). A study found that all premature birth belonged to pregnant women who experienced violence during their pregnancy (Gogus & Yildiz, 2013). It was determined in another study that the possibility of having a newborn with low weight was three times greater for mothers who were exposed to all kinds of violence by their partners during pregnancy (Demelash et al., 2015). Many factors are defined in the etiology of preterm birth. The main ones are shown as mothers’ diseases, problems of the perinatal period, socioeconomic level, infections, etc. (Garcia et al., 2008; Moster et al., 2008; Slattery et al., 2008). While preterm births constitute a vital result of risky pregnancies, obstetric and perinatal causes such as hypertensive diseases, early membrane rupture, diabetes, multiple pregnancies, fetal distress, and oligohydramnios affect the fetus starting from the antenatal period (Kavuncuoglu et al., 2010). In the present study, it was found that there were risky situations in some pregnant women during the pregnancy period, and they had chronic diseases. Being exposed to domestic violence is believed to be effective on these factors causing preterm birth. Additionally, perinatal risks were seen less in the present study, and this may be associated with the fact that the pregnant women participating in the study were exposed to very low physical violence, increasing perinatal risk.

In the present study, pregnant women’s statuses to be exposed to domestic violence during pregnancy and violence types were also investigated in terms of their first follow-up, second follow-up, and breastfeeding self-efficacies in the third postpartum follow-up (Table 4). Breastfeeding Self-Efficacy perception is the thought of competence that the mother feels about breastfeeding. This situation is also affected by the mother’s difficulties regarding breastfeeding in different situations previously experienced (Dennis, 1999; Tokat, 2009). A high score obtained from the Breastfeeding Self-Efficacy Scale shows high breastfeeding self-efficacy (Tokat, 2009). According to Table 4, breastfeeding self-efficacy scale mean scores in the third follow-up were lower in pregnant women exposed to domestic violence during pregnancy than those who were not (Z= −3.309, p < 0.05). Besides, breastfeeding self-efficacy scale mean scores in the third follow-up were lower in mothers exposed to emotional and sexual violence during their pregnancies than the other mothers (Z= −3.232, p < 0.05; Z= −3.033, p < 0.05, respectively). In particular, it is believed that the mothers did not exhibit a positive attitude towards breastfeeding depending on the inability to cope with sadness and stress experienced by the mothers when they were alone with the baby in the third follow-up, namely postpartum period and since breastfeeding may remind the mother about sexual violence. The reason is that if the physical and mental health of the mother is good, then she can take care of her baby in a healthy way and breastfeed the baby for a long time (Ozkan et al., 2014). Furthermore, estrogen and progesterone levels after birth and the hormonal changes during pregnancy also cause a tendency to depression. Hormonal and genetic factors and stressful life events are effective in mood disorders (Ozorhan et al., 2014). The reason mothers, who were exposed to violence, could not exhibit a positive attitude towards breastfeeding is thought to be caused by hormonal changes and this stressful condition they experienced.

In the present study, correlation distribution between pregnant women’s breastfeeding self-efficacy scale means scores in the first follow-up, second follow-up, postpartum period, the third follow-up, and the factors obtained from DVWDS was investigated (Table 5). Accordingly, it was observed that there was a low correlation that the breastfeeding self-efficacies of pregnant women in the second follow-up would decrease by the increased score of Factor 5, “disdaining female gender and threatening behaviors” of DVWDS (r= −.208, p < 0.01). It was also observed that there is a weak relationship on that the increased scores of Factor 1 “Physical violence at a level that harms the body integrity of women,” Factor 2 “Insult, disdaining and emotional pressure to women,” Factor 6 “Sexual violence to women and respect requirement” in DVWDS would decrease their breastfeeding self-efficacies in the third follow-up (r= −.246, p < 0.01; r= −.199, p<0.01; r= −.194, p < 0.01, respectively).

When the cortisol hormone levels of pregnant women, postpartum women, and newborns were examined in terms of the status of being exposed to domestic violence and violence types, cortisol levels of those who were subjected to domestic violence during their pregnancy, in the first, second, and third follow-ups were in similar levels (p > 0.05), and the absence of any correlation between them suggests that women internalize and thus accept violence. However, the cortisol level was found to be high in babies of mothers who were subjected to domestic violence during their pregnancy. In addition, the mean cortisol hormone levels of the babies of mothers who were subjected to emotional and sexual violence during their pregnancy were seen to be higher than the mean cortisol hormone levels of the babies of mothers who were not subjected to emotional and sexual violence during pregnancy. Being exposed to stress due to the mother’s violence during pregnancy also causes changes in hormonal balance (Valladares et al., 2009). The reason is that the stress due to violence limits the blood flow in the uterus and causes blood vessels to narrow and increase cortisol levels (Nunes et al., 2010). A decrease in fetal growth or preterm birth can be seen as a result of vasoconstriction in placental vessels Depending on cortisol release. A study concluded that partner violence during pregnancy is a stress factor that causes cortisol levels to increase and is associated with a decrease in birth weight (Valladares et al., 2009). In another study, it was concluded that domestic violence during pregnancy could change some stimulating and inhibitory amino acids and endocrine function in the newborn (Zhang et al., 2008). The study conducted by Pico-Alfonso et al., in 2004 showed that partner violence had a significant effect on women’s endocrine systems both physically and psychologically. When the women who were subjected to partner violence were compared with the women who were not subjected to partner violence, it was found that morning and evening cortisol, and dehydroepiandrosterone was seen to be at higher levels. Conditions like depression, anxiety, and post-traumatic stress disorder were seen to be more (Pico-Alfonso et al., 2004). A study concluded that domestic violence during pregnancy might be associated with glutamate, r-aminobutyric acid, cortisol, and catechol-o-methyltransferase polymorphism gene, which are the increased plasma levels in newborns. They found that the plasma cortisol level in the newborn group of mothers who were exposed to domestic violence during pregnancy was higher than the newborn group of mothers who were not exposed to domestic violence during pregnancy, and this suggests that prenatal maternal stress may be associated with increased cortisol level in newborns (Zhang et al., 2013). In the study by Otten et al., it was determined that the mother’s cortisol level was increasing during stress passed from the placenta to the fetus, which will keep the fetus under stress and increase the neonatal plasma cortisol level (Otten et al., 2004). In other studies, for the newborn group of mothers exposed to domestic violence during their pregnancies, plasma cortisol levels increased, which suggests that more stress in the infancy period was associated with increased cortisol levels (Evans et al., 2008; Tollenaar et al., 2011). It is believed that depending on the stress emerging from the mother’s violence during her pregnancy, the stress reaches the baby from the uterus and increases the cortisol hormone level in the newborn, and this situation causes premature birth.

Accordingly, to Table 7, it was determined that there was a statistically significant correlation between the pregnant women’s cortisol hormone level in the second follow-up with the Factor 7 and Factor 8 factors of DVWDS (Z= −2.303, p < 0.05; Z= −2.510, p < 0.05, respectively). It was seen that there was a significant correlation between the cortisol hormone level of the newborn and Factor 5 (Z= −2.250, p < 0.05).

Conclusion

The information obtained from the study is valid for pregnant women in the Center where the study was conducted. Information obtained about violence against women was based on the women’s self-report. In addition, the fact that the researcher collected the data of the study through face-to-face interviews for 11 months required intensive work, and making groups in independent variables and organizing the study data took a long time. In addition, the fact that some consumables used in the study came from abroad caused a waste of time, and it took a long time to study and evaluate them in a laboratory environment.

In the study, an important result was found that exposure to domestic violence during pregnancy was an effect on the preterm birth of babies. Cortisol hormone levels of the babies of mothers exposed to domestic violence during their pregnancy were seen to be higher than the cortisol hormone levels of the babies of mothers who were not subjected to domestic violence during their pregnancy. In addition, it was also concluded that domestic violence during pregnancy affected breastfeeding after delivery. In accordance with the findings obtained from the research, it is observed that domestic violence not only damages the health of pregnant women but also increases the problems related to newborn health.

It can also be seen that it is also important for society that the health of both the pregnant woman and the baby to be born gets affected upon the exposure of the pregnant woman to domestic violence. In order to prevent the emergence of violence and to develop solutions in regard, it is necessary to thoroughly assess the perspective of health personnel working in primary care in our country against violence. Besides, in these matters, necessary training, support and encouragement should be provided to health personnel. It is recommended to conduct qualitative research on a smaller group of women who were exposed to violence during pregnancy.

Footnotes

Acknowledgments

We thank the women who participated in this study.

Author contributions

SA and TO were responsible for the study conception and design. SA performed the data collection. SA and TO performed the data analysis. SA was responsible for the drafting of the manuscript. TO provided statistical expertise. SA took cortisol hormone samples. The saliva samples stored in the refrigerator were brought to Gaziantep University Biochemistry Laboratory by SA. The cortisol hormone levels in saliva samples were measured by HU and SA. All authors met drafting the article or revising it critically for important intellectual content and final approval of the version to be published.

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.

ORCID iD

Sezer Avcı

Author Biographies

Sezer AVCI, PhD, is an Assistant Professor in the Faculty of Health Sciences Department of Nursing. It gives importance to personal development in the fields of Public Health Nursing and Maternal and Child Health. He has studies, publications and books related to his fields of interest.

Tulay ORTABAG, Professor, is an Professor in the Faculty of Health Sciences Department of Nursing. Her field is public health nursing. She has articles on reproductive health, adolescent health and maternal and child health in many national and international journals.

Hasan Ulusal, PhD, works at Gaziantep University Faculty of Medicine, Department of Medical Biochemistry. He is experienced in many subjects such as ELISA method, PCR method, electrophoresis, flowcytometry, spectrophotometric methods. In his research, he carries out studies to investigate the pathogenesis of the disease. He is working on the transport of cancer drugs with nanoparticle systems.

Seyithan Taysi, Professor, works at Gaziantep University Faculty of Medicine, Department of Medical Biochemistry. He is experienced in oxidative stress and antioxidant systems. He conducts studies to investigate the pathogenesis of the disease in her research. Obstetrics diseases, heart diseases and endocrine disorders are his main areas of interest.

References

Abebe Abate

Admassu Wossen

Tilahun Degfie

(2016). Determinants of intimate partner violence during pregnancy among married women in Abay Chomendistrict, Western Ethiopia: A community based cross sectional study. BMC Women's Health, 16(16), 16–18. https://doi.org/10.1186/s12905-016-0294-6

Aluş Tokat

Okumuş

Dennis

C.-L.

(2010). Translation and psychometric assessment of the breastfeeding self-efficacy scale short form among pregnant and postpartum women in Turkey. Midwifery, 26(1), 101–108. https://doi.org/10.1016/j.midw.2008.04.002

Ayrancı

Gunay

Unluoglu

(2002). Spouse violence during pregnancy: A research among women attending to primary health care. Anatolian Journal of Psychiatry, 3(2), 75–87. Retrieved from http://psikiyatridizini.net/articles.aspx?journalid=4&year=2002&volume=3&number=2

Bolu

Mayda

AS.

Yılmaz

(2015). Frequency and the factors affecting violence towards pregnant woman admitted to a university hospital pregnancy outpatient clinic. Nobel Medıcus, 11(1), 64–70. Retrieved from https://www.nobelmedicus.com/Content/1/31/64-70.pdf

Cardoza

(2005). Partner violence during pregnancy, psychosocial factors and child outcomes in Nicaragua, (Ph.D. thesis, Public Health and Clinical Medicine. Umea University. Retrieved from https://www.diva-portal.org/smash/record.jsf?pid=diva2%3A143845&dswid=7898

Demelash

Nigatu

Gashaw

(2015). A case-control study on ıntimate partner violence during pregnancy and low birth weight, Southeast EthiopiaObstetrics and Gynecology International. Article ID 394875. (pp. 1–6. https://dx-doi-org.web.bisu.edu.cn/10.1155/2015/394875

Dennis

(1999). Theoretical under pinnings of breastfeeding confidence: A self-efficacy framework. Journal of Human Lactation, 15(3), 195–201. https://doi.org/10.1177%2F089033449901500303

Dennis

C. L.

(2003). The breastfeeding self-efficacy scale: psycometric assesment of the short form. Journal of Obstetric, Gynecologic and Neonatal Nursing, 32(6), 734–744. https://doi.org/10.1177/0884217503258459

Deveci

Acik

Gulbayrak

Tokdemir

Ayar

(2007). Prevalence of domestic violence during pregnancy in a Turkish community. Southeast Asian Journal Tropic Medicine Public Health, 38(4), 754–760. Retrieved from https://www.tm.mahidol.ac.th/seameo/2007_38_4/24-3831.pdf

10.

Ellsberg

Jansen

H. A.

Heise

Watts

C. H.

Garcia-Moreno

(2008). WHO Multi-country study on women's health and domestic violence against women study team. Intimate partner violence and women’s physical and mental health in the who multi-country study on women’s health and domestic violence: an observational study. Lancet, 371(9619), 1165–1172. https://www-sciencedirect-com-443.web.bisu.edu.cn/science/article/pii/S014067360860522X

11.

Evans

Myers

Monk

(2008). Pregnant women’s cortisol is elevated with anxiety and depression-but only when comorbid. Archives of Women's Mental Health, 11(3), 239–248. https://doi.org/10.1007/s00737-008-0019-4

12.

Farid

Saleem

Karim

Hatcher

(2008). Spousal abuse during pregnancy in Karachi, Pakistan. International Journal of Gynecology and Obstetrics, 101(2), 141–145. https://doi.org/10.1016/j.ijgo.2007.11.015

13.

Finnbogadóttir

Dykes

A.-K.

Wann-Hansson

(2016). Prevalence and incidence of domestic violence during pregnancy and associated risk factors: A longitudinal cohort study in the south of Sweden. BMC Pregnancy and Childbirth, 16(1), 1–10. https://doi.org/10.1186/s12884-016-1017-6

14.

Gao

Paterson

Carter

Iusitini

(2008). Intimate partner violence and unplanned pregnancy in the Pacific Islands Families Study. International American Journal of Obstetrics and Gynecology, 100(2), 109-115. https://doi.org/10.1016/j.ijgo.2007.08.004.

15.

Garcia-Moreno

Jansen

Ellsberg

Heise

Watts

(2006). Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence. Lancet, 368(9543), 1260–1269. https://doi.org/10.1016/S0140-6736(06)69523-8

16.

García

Avendaño-Becerra

Islas-Rodríguez

(2008). Neonatal and maternal morbidity among adolescent and adult women. A comparative study. Rev Invest Clin, 60(2), 94–100. Retrieved from https://www.medigraphic.com/pdfs/revinvcli/nn-2008/nn082c.pdf

17.

Gencer

OnatBaser

T.E.

Kara

Yalvac

ES.

(2018). Prevalence of violence against pregnant women in Yozgat. Bozok Medical Journal, 8(2), 59–64. Retrieved from http://tipdergisi.bozok.edu.tr/dosyalar/tipdergisihaziran2018.pdf#page=64

18.

Gogus

Yildiz

(2013). Status of violence in pregnancy according to the trimesters, effecting factors and perinatal results. TAF Prev Med Bull, 12(6), 657–664. https://doi.org/10,5455/pmb.1-135177977110.5455/pmb.1-1351779771

19.

Guler

(2010). Physical, emotional, sexual, and economic violence by spouse during pregnancy and associated factors. E-journal of Dokuz Eylül University Nursing Faculty, 3(2), 72–77. http://hdl.handle.net/20.500.12397/4553

20.

Hammoury

Khawaja

(2007). Screening for domestic violence during pregnancy in an antenatal clinic in Lebanon. European Journal of Public Health, 17(6), 605–606. https://doi.org/10.1093/eurpub/ckm009

21.

Howard

Oram

Galley

Trevillion

Feder

(2013). Domestic violence and perinatal mental disorders: A systematic review and meta-analysis. PLOS Medicine, 10(5), 1–16. https://doi.org/10.1371/journal.pmed.1001452

22.

HUIPS (Hacettepe University Institute of Population Studies) (2015). Research on domestic violence against women in Turkey. [cited 2018 June 18] Retrieved from: http://www.hips.hacettepe.edu.tr/ING_SUMMARY_REPORT_VAW_2014.pdf

23.

Ince

Aktas

Aktepe

Aydın

(2017). Evaluation of the factors affecting mothers’ breastfeeding self-efficacy and breastfeeding success. Journal of Dr. Behcet Uz Children’s Hospital, 7(3), 183–190. https://dx-doi-org.web.bisu.edu.cn/10.5222/buchd.2017.183

24.

Jansen

H.A.F.M.

Yuksel

Cagatay

(2009). Prevalence of violence against women, Turkish republic prime ministry direcctorate general on the status of women. National Research on Domestic Violence Against Women in Turkey (pp. 45–69).

25.

Karaoglu

Celbis

Ercan

Ilgar

Pehlivan

Gunes

Genc

Egri

(2006). Physical, emotional and sexual violence during pregnancy in Malatya, Turkey. European Journal of Public Health, 16(2), 149–156. https://doi.org/10.1093/eurpub/cki161

26.

Katiti

Sigalla

Rogathi

Manongi

Mushi

(2016). Factors influencing disclosure among women experiencing intimate partner violence during pregnancy in Moshi Municipality, Tanzania. BMC Public Health, 15(715), 715–719. https://doi.org/10.1186/s12889-016-3345-x

27.

Kavuncuoglu

Ozturk

Aldemir

EY.

Ceylan

Ozbek

(2010). Early morbidity and mortality results of preterm babies born from mothers followed for risky pregnancy. Medical Journal of Istanbul Kanuni Sultan Süleyman, 2(1), 27–30. Retrieved from https://www.journalagent.com/iksst/pdfs/JOPP_2_1_27_30.pdf

28.

Kelly

J. B.

Johnson

M. P.

(2008). Differentiation among types of ıntimate partner violence: Research update and ımplications for ınterventions. Family Court Review, 46(3), 476–499. https://onlinelibrary-wiley-com-443.web.bisu.edu.cn/doi/pdf/10.1111/j.1744-1617.2008.00215.x

29.

Khaironisak

Zaridah

Hasanain

Zaleha

(2017). Prevalence, risk factors, and complications of violence against pregnant women in a hospital in Peninsular Malaysia. Women&Health, 57(8), 919–941. https://doi.org/10.1080/03630242.2016.1222329

30.

Koylu

(2017). Basic physiology for health sciences. (pp. 291–320). Istanbul Medical Bookstores.

31.

Mahapatro

Gupta

Kundu

(2011). Domestic violence during pregnancy in India. Journal of Interpersonal Violence, 26(15), 2973–2990. https://doi.org/10.1177%2F0886260510390948

32.

Mammadov

(2015). Assessment of domestic violence against pregnant women in Turkey Republic Northen Cyprus (Master’s thesis). East University, Health Sciences Faculty.

33.

Moster

Lie

Markestad

(2008). Long-term medical and social con- sequences of preterm birth. N Engl J Med, 359(3), 262–273. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1016/S0020-7292(02)00250-3

34.

Nunes

Camey

Ferri

Manzolli

Manenti

Schmidt

(2010). Violence during pregnancy and newborn outcomes: A cohort study in a disadvantaged population in Brazil. European Journal of Public Health, 21(1), 92–97. https://doi.org/10.1093/eurpub/ckp241

35.

Otten

Kanitz

Tuchscherer

Schneider

Brüssow

(2004). Effects of adrenocorticotropin stimulation on cortisol dynamics of pregnant gilts and their fetuses: implications for prenatal stres studies. Theriogenology, 61(9), 1649–1659. https://doi.org/10.1016/j.theriogenology.2003.09.009

36.

Özkan

Üst

Z. D.

Gündoğdu

Çapık

Şahin

S. A.

(2014). The relationship between breast feeding and depression in the early postpartum period. The Medical Bulletin of Sisli Etfal Hospital, 48(2), 125–132. https://doi.org/10.5350/SEMB.20140206061410

37.

Ozorhan

EY.

Ejder

AS.

Sahin

AO.

(2014). Mental health in pregnancy. Yıldırım Beyazıt University Journal of Nursing, 2(3), 33–42.

38.

Paksoy

E.N.

Akın

(2015). Violence against women. In Guler

Akın

(Eds.), Public health basics (3rd ed., pp. 362-367). Hacettepe University Press.

39.

Pico-Alfonso

Garcia-Linares

Celda-Navarro

Herbert

Martinez

(2004). Changes in cortisol and dehydroepiandrosterone in women victims of physical and psychological intimate partner violence. Biological Psychiatry, 56(4), 233–240. https://doi.org/10.1016/j.biopsych.2004.06.001

40.

Pires de Almeida

Sá

Cunha

Pires

E. P.

(2013). Violence during pregnancy and it seffects on mother–baby relationship during pregnancy. Journal of Reproductive and Infant Psychology, 31(4), 370–380. https://doi.org/10.1080/02646838.2013.822058

41.

Sahin

İlçioğlu

Unsal

(2017). Domestic violence, depression and anxiety during pregnancy. Journal of Education and Research in Nursing, 14(3), 204–211. https://doi.org/10.5222/HEAD.2017.204

42.

Slattery

Geary

Morrison

(2008). Obstetric antecedents for preterm delivery. Journal of Perinatal Medicine, 36(4), 306–309. https://doi.org/10.1515/JPM.2008.045

43.

Stöckl

Filippi

Watts

Mbwambo

(2012). Induced abortion, pregnancy loss and intimate partner violence in Tanzania: A population based study. BMC Pregnancy and Childbirth, 12(1), 12. Retrieved from. http://www.biomedcentral.com/1471-2393/12/12

44.

Taillieu

TL.

Brownridge

DA.

(2009). Violence against pregnant women: prevalence, patterns, risk factors, theories, and directions for future research. Aggression and Violent Behavior, 15(1), 14–35. https://doi.org/10.1016/j.avb.2009.07.013

45.

Tarhan

(2011). Women's psychology (p. 181). Generation Publications.

46.

Tokat

AM.

(2009). The effect of antenatal education on mothers breastfeeding self -efficacy and breastfeeding success. PhD thesis. Dokuz Eylul University Nursing School.

47.

Tollenaar

Beijers

Jansen

Riksen-Walraven

de Weerth

(2011). Maternal prenatal stres and cortisol reactivity to stressors in human infants. Stress: the International Journal on the Biology of Stress, 14(1), 53–65. https://doi.org/10.3109/10253890.2010.499485

48.

Turkey Demographic and Health Survey (2018). Retrieved from http://www.hips.hacettepe.edu.tr/tnsa2018/rapor/sonuclar_sunum.pdf

49.

Valladares

Peña

Ellsberg

Persson

Högberg

(2009). Neuroendocrine response to violence during pregnancy impact on duration of pregnancy and fetal growth. Acta Obstetricia et Gynecologica, 88(7), 818–823. https://doi.org/10.1080/00016340903015321

50.

WHO (2005). World Health Report: Multi-country study on women’s health and domestic violence against women: Initial results on prevalence, health outcomes and women’s responses. WHO. Retrieved from http://www.who.int/gender/violence/who_multicountry_study/Introduction.pdf

51.

Yanıkkerem

(2002). The investigation on the opinion married women between the age of 15-49 on inner domestic violence and the circumtances they exposed to violence (Master’s thesis). Ege University Institute of Health Sciences Nursing Department.

52.

Yanıkkerem

Karadas

Adıgüzel

Sevil

(2006). Domestic violence during pregnancy in Turkey and responsibility of prenatal healthcare providers. American Journal of Perinatology, 23(2), 93–103. https://doi.org/10.1055/s-2006-93180210.1055/s-2006-931802

53.

Yanıkkerem

Saruhan

(2005). The investigation on the opinion married women between the age of 15-49 on inner domestic violence and the circumtances they exposed to violence. Journal Of Clinical Sciences & Doctor, 11(2), 198–204. Retrieved from http://www.medicalnetwork.com.tr/2005/konu.asp?goster=1&Metin=755

54.

Yazıcıoglu

Erdogan

(2004). Spss applied scientific research methods (pp. 49–50). Detail Publishing.

55.

Yesil

(2015). The effect of individual and group breast feeding training of future mother and father at postpartum period on breast feeding self-efficacy and attitude (Master’s thesis). Ege University Institute of Health Sciences Midwifery Department.

56.

Yılmaz

EB.

Kucuk

EE.

(2014). Evaluation of psychosocial health of pregnant women according to their violence and pregnancy-related characteristics (17, pp. 1080–1081). National Public Health Congress Book.

57.

Zhang

Zou

Zhang

Cao

Yang

(2008). Correlation between domestic violence in pregnancy and the levels of plasma amino acids and cortisol in theneonates. [Zhonghua Nei Ke Za Zhi Chinese Journal of Internal Medicine], 47(3), 209–212. https://europepmc.org/article/med/18785504

58.

Zhang

Zou

Zhang

(2013). Correlation of domestic violence during pregnancy with plasma amino‐acid neurotransmitter, cortisol levels and catechol‐o‐methyltransferase V al(158) M et polymorphism in neonates. Asia‐Pacific Psychiatry, 5(1), 2–10. https://onlinelibrary-wiley-com-443.web.bisu.edu.cn/doi/pdf/10.1111/appy.12021