The Effect of Intimate Partner Violence on Fear of Childbirth Among Pregnant Women

Abstract

This study was conducted to determine the effect of intimate partner violence on childbirth fear of pregnant women. This descriptive and cross-sectional study included 335 pregnant women who applied to pregnant outpatient clinics. The data of the study were collected with Questionnaire Form and Wijma Birth Expectation/Experience Scale A Version (W-DEQ-A). Descriptive statistical methods, t-test, one-way ANOVA, Mann–Whitney U-test, and Kruskal–Wallis test were used in the analysis of the data. W-DEQ-A scale score of pregnant women was found to be 69.34 ± 29.37. It was found that 15.2% of pregnant women experienced “mild level” childbirth fear, 28.4% had “moderate level” childbirth fear, 26.6% had “severe level” childbirth fear, and 29.9% had “clinical level” childbirth fear. It was determined that 49.3% of pregnant women were exposed to any type of violence by their partners. It was found that pregnant women were exposed to 46% verbal violence, 23.9% emotional violence, 13.7% economic violence, 8.7% physical violence, and 2.1% sexual violence. When pregnant women experiencing any type of violence (p = .000), verbal violence (p = .000), emotional violence (p = .000), and economic violence (p = .000) were compared with pregnant women who did not experience violence, W-DEQ-A scores were higher and differences were statistically significant. It was determined to be statistically significant differences of W-DEQ-A scores according to the age of the pregnant women (p = .044), family type (p = .004), place of residence (p = .026), and psychological problems before pregnancy (p = .026). As a result, the rate of violence exerted by their intimate partners against pregnant women was high. In addition, intimate partner violence during pregnancy had negative effects on the fear of childbirth of pregnant women.

Keywords

pregnant women pregnancy intimate partner violence childbirth fear domestic violence Turkey

Introduction

Intimate partner violence toward women is defined as “behavior within close relationships causing physical, sexual, or psychological harm including physical aggression, sexual pressure, psychological harassment and controlling behavior” (Kouyoumdjian et al., 2013). Though intimate partner violence against women is very common around the world, it is a poorly defined violation of human rights (Atman, 2003). People who are abusive toward women are generally the people close to them: their husbands or men they have been with for long periods (Polat, 2016). When causes of violence against women are examined, it appears individual factors are a focus, like problems due to the relationship between couples, various types of psychological distress, economic problems, the man’s bad habits, causes due to families of partners, jealousy, cheating, and use of violence as a “control tool” (Yüce Selvi & Karanfil, 2016). Types of abuse that women are victims of may be listed as emotional, physical, psychological, economic, and sexual violence (Öyekçin et al., 2012).

Intimate partner violence against women may be first observed during pregnancy, or existing violence may increase during pregnancy. Social, economic, biological, and environmental factors, difficulty dealing with partner problems due to biopsychological stress caused by pregnancy, and partner jealousy of the baby or women’s reduction in interest in the partner due to caring for the baby may affect exposure to violence in pregnancy (Sağkal et al., 2014). Despite the well-established relationship, it is still controversial whether pregnancy is a risk or a protective factor (Islam et al., 2018). Some researchers suggest that pregnancy may lead to better marital relationship and increased spousal support, thereby reducing the risk of intimate partner violence (Islam et al., 2018); others suggest that this may trigger stress and trigger the onset or increased use of Intimate partner violence (IPV) (Silva et al., 2011). Previous studies indicated that the prevalence of intimate partner violence among pregnant women was 15.9% in Japan (Kita et al., 2014), 6.5% in the United States (Beydoun et al., 2011), and 7.7% in Spain (Velasco et al., 2014). In a systematic review of studies from low- and middle-income countries, physical intimate partner violence was estimated at 2% to 35%, sexual intimate partner violence 9% to 40%, and psychological intimate partner violence between 22% and 65% (Halim et al., 2018). A study in rural regions of South Africa reported that the prevalence of domestic violence against pregnant women was 31%, whereas nearly one-quarter of women in Mexico were victims of abuse during pregnancy (Castro et al., 2003; Hoque et al., 2009). In Turkey, 8% of women with at least one pregnancy stated they experienced physical violence from partners or men they were with (T.C. Aile ve Sosyal Politikalar Bakanlığı, 2015). When compared with physical violence experienced before pregnancy, the incidence reduces during pregnancy, whereas 11% of women stating they were victims of physical violence during pregnancy were determined to live in the Northeast Anatolian region of Turkey (Turkiye’de Kadına Yonelik Aile Ici Siddet Arastırması, 2015). In a systematic review of intimate partner violence among pregnant women from Turkey, it was stated that the most common type of violence was emotional violence, followed by verbal, economic, physical, and sexual violence. The prevalence of emotional violence was 27%, the prevalence of verbal violence was 21.9%, the prevalence of economic violence was 21.4%, the prevalence of physical violence was 9.3%, and the prevalence of sexual violence was 8.5% (Boyacıoğlu et al., 2021).

In the pregnancy and perinatal period, women’s experience of violence is accepted as a risk factor for negative health outcomes for mother and neonate (Devries et al., 2010). A study by Campbell et al. (2002) identified that abused women had more headache, backache, sexually transmitted diseases, vaginal hemorrhage, vaginal infections, pelvic pain, painful sexual relations, urinary tract infections, loss of appetite, abdominal pain, and digestive problems. Women who are victims of violence have more gynecological problems, central nervous system, and health problems linked to chronic stress (Campbell et al., 2002). Partner violence during pregnancy may cause early labor and growth retardation of the fetus along with stress and anxiety (Şen et al., 2012). Pregnant cases experiencing violence have increased incidence of depressive symptoms, anxiety, and post-traumatic stress disorder (Topkara & Özerdoğan, 2020).

In spite of pregnancy and birth being physiological, fear of childbirth is important as it may have negative effects before, during, and after pregnancy (Aksoy, 2015). Fear of childbirth occurring before a first pregnancy is called “primary tokophobia,” whereas fear emerging after a previous traumatic birth is called “secondary tokophobia” and “tokophobia with depressive disease symptoms in pregnancy” (Kitapçıoğlu et al., 2008). Fear of childbirth was found to be associated with low educational level, inadequate social surroundings, young age, unemployment, smoking, and inadequate health levels (Laursen et al., 2009). Maternal psychopathology is a risk factor for fear of childbirth (Størksen et al., 2013). Increased fear of childbirth increases catecholamine levels and suppresses contractions, which may cause lengthened duration of labor (Çiçek & Mete, 2015). A study in Turkey found that 38.8% of women had excessive fear of childbirth, whereas 8.2% experienced clinical levels of fear of childbirth (Bülbül et al., 2016).

Fear of childbirth may affect all pregnancy cases, may make labor more difficult and lead to increases in cesarean births, and reduced amounts of oxytocin may cause lengthened labor (Størksen et al., 2013). Lengthened labor increases fear of childbirth while it may also cause excess hemorrhage in pregnant women (Scollato & Lampasona, 2013). Chan et al. (2021) indicated that the proportion of pregnant women who reported maintaining IPV throughout pregnancy was higher than that of women who reported termination of IPV during this period. More severe or longer-term IPV was associated with more severe maternal depression, lower levels of paternal involvement, and weaker perceived social support. Although intimate partner violence during pregnancy has been examined in the literature, the relationship between intimate partner violence and fear of childbirth has been studied in a limited number of studies. Evaluating this problem among pregnant women can assist government officials, policymakers, program designers, and nonprofits in designing prevention and control strategies. The aim of this research was to determine the incidence of partner abuse, level of fear of childbirth, and effect of partner abuse on fear of childbirth among pregnant cases.

The research questions are:

- What is the incidence of intimate partner violence in pregnancy?

- What are the levels of fear of childbirth among pregnant women?

- What is the effect of partner violence on fear of childbirth among pregnant women?

Method

Design and Participants

The population for this study, with descriptive and cross-sectional type, comprised pregnant cases attending a clinic in a university hospital located in the Black Sea region of Turkey and abiding by the research inclusion criteria. There were 1,749 births in the hospital in 2017.

The sample of the research was calculated according to the following known population formula. The rate of verbal violence (32.1%) determined in the study of S. Şahin et al. (2017) was used to determine the number of samples.

Formula:

N: Number in the population (1,749)

n: Number of individuals to be included in the sample

p: The frequency/probability of occurrence of investigated event (0.32)

q: Frequency of nonoccurrence of the investigated event (1−p = 0.68)

d: Standard error of the ratio to be determined in the study (0.05 for 95% confidence interval).

The desired ± deviation according to the frequency of the event

t: Theoretical value from the t table at a certain degree of freedom and detected error level

n = N \times p \times q \times t^{2} / (N - 1) \times d^{2}

n = 1,749 × 0.32 × 0.68 × (1.96)²/(1,749−1) × (0.05)²

Sampling of the study included 335 pregnant women who accepted participation and abided by the inclusion criteria for the research.

The inclusion criteria were being at gestational age is 28 weeks or more (by last menstrual date or Ultrasonography (USG)), being between the ages of 18 and 45, being at least primary school graduates, being married, and being volunteer to participate in the study.

Pregnant women with risky pregnancies, multiple pregnancies, any sensory, auditory, mental problems, chronic systemic disease, previous cesarean section, and fetal complications were excluded from the study.

Data Collection

Data for the research were collected from September 25, 2018 to March 15, 2019 with the personal information form and Wijma Delivery Expectancy/Experience Questionnaire version A (W-DEQ-A). Pregnant women with 28th gestational week and above were included in the study. Data were collected by face-to-face interview method. The pregnant woman was taken to a quiet room of the obstetrics outpatient clinic, and the personal information form and W-DEQ-A were filled in by the pregnant woman.

Personal information form

The personal information form included questions related to sociodemographic features like the age, educational level, habits, and partner characteristics of the pregnant cases; questions related to obstetric features like week of pregnancy, whether pregnancy was planned or not and psychological problems experienced in pregnancy; and questions related to experiences of partner abuse, frequency of abuse, and types of abuse (Ayrancı et al., 2002; Hossieni et al., 2017; Sağkal et al., 2014). The personal information form included 12 statements about physical violence, seven statements related to verbal violence, nine questions related to emotional violence, four questions related to economic violence, and six statements related to sexual violence.

Wijma delivery expectancy/experience questionnaire

With the aim of determining the level of childbirth fear experienced by pregnant women, the W-DEQ-A developed by Wijma et al. (1998) with Turkish validity and reliability determined by Körükcü et al. (2012) was used. The scale is a Likert-type scale with responses numbered from 0 to 5. The scale comprises 33 items with 0 points for “fully” and 5 points for “none” responses. Points from 0 to 165 can be obtained from the scale. The negatively charged questions (2, 3, 6, 7, 8, 11, 12, 15, 19, 20, 24, 25, 27, and 31) in the W-DEQ-A scale are calculated by inverting them in order to ensure consistency in the measurement. W-DEQ-A scores were collected in four subgroups including women with low fear of childbirth (W-DEQ-A score ≤ 37), women with moderate fear of childbirth (W-DEQ-A score between 38 and 65), women with severe fear of childbirth (W-DEQ-A score 66–84), and women with clinical fear of childbirth fear (W-DEQ-A score ≥ 85). High points show the woman is experiencing high fear of childbirth (Körükcü et al., 2012; Wijma et al., 1998). In the Turkish study, the Cronbach’s alpha reliability coefficient of the W-DEQ-A version was .89 (Körükcü et al., 2012). In this study, the W-DEQ-A Cronbach’s alpha reliability coefficient was found to be .92.

Ethical Dimension of the Research

Permission to use the W-DEQ in the research was obtained by email from Körükcü. After acceptance of the thesis proposal, in order to perform the research permission was granted by the provincial Directorate of Health (31.08.2018/66501263-799-E.75636468) and ethics committee permission was obtained from Ordu University Clinical Research Ethics Committee (Date: September 20, 2018 and decision number: 2018-197). Pregnant women accepting participation in the study were informed about the aims and benefits of the study and provided informed written consent. The research abided by the principles of the Helsinki Declaration.

Analysis of Data

A statistical program was used on a computer to analyze data. The study assessed frequency, percentage, arithmetic mean, and standard deviation as descriptive statistical methods. Differences in independent groups of parametric data were analyzed with the t-test and one-way ANOVA. The Scheffe test was used to analyze which group caused the difference in comparisons of more than two groups. For nonparametric data, the Kruskal–Wallis test and Mann–Whitney U-test were used. Statistical significance took p < .05 as the limit value.

Results

The mean age of pregnant women participating in the study was 27.06 ± 5.40 years (18–44), with mean marriage duration of 5.27 ± 4.75 years (1–22). Of cases, 39.1% were in the 23 to 27-year age group, 34.9% were middle school graduates, 76.5% were housewives, 73.4% lived in nuclear families, 57.3% lived in the provincial center, 84.2% had moderate-income level, and 64.5% were married from 1 to 5 years (Table 1).

Table 1.

Distribution According to Sociodemographic Characteristics of Pregnant Women.

Sociodemographic Characteristics	n (%)
Age
18–22 years old	69 (20.6)
23–27 years old	131 (39.1)
28–32 years old	76 (22.7)
33 years old	59 (17.6)
Education status
Primary school	53 (15.8)
Middle school	117 (34.9)
High school	110 (32.9)
University	55 (16.4)
Profession
House wife	256 (76.5)
Officer	34 (10.1)
Worker	45 (13.4)
Family type
Nuclear family	246 (73.4)
Extended family	89 (26.6)
Place of residence
Province	192 (57.3)
District	90 (26.9)
Village	53 (15.8)
Income level
High level	21 (6.3)
Intermediate	282 (84.2)
Low level	32 (9.5)
Duration of marriage
1–5 years	216 (64.5)
6–10 years	74 (22.1)
11 years and above	45 (13.4)

The mean number of pregnancies were 2.17 ± 1.18 (1–7), mean week of pregnancy was 35.88 ± 2.68 weeks (28–41), and mean number of surviving children was 1.04 ± 1.07 (1–3). Of pregnant women, 35.5% were in their first pregnancy, 42.7% had previous experience of childbirth, 75.2% had not had a miscarriage, 59.7% were 36 weeks or more pregnant, 68.1% had planned pregnancies, 55.8% had not received education in pregnancy, 16.1% experienced health problems during pregnancy, 9.3% had experienced psychological problems before pregnancy, 5.1% used medication during pregnancy, and 9.9% experienced psychological problems during pregnancy (Table 2).

Table 2.

Distribution of Pregnant Women According to Obstetric Characteristics (n = 335).

Obstetrics characteristics	n (%)
Number of pregnancies
First pregnancy	119 (35.5)
2 pregnancies	108 (32.3)
3 pregnancies	56 (16.7)
4 pregnancies and above	52 (15.5)
Number of births
No birth	143 (42.7)
1 birth	109 (32.5)
2 births and above	83 (24.8)
Miscarriage
No	252 (75.2)
Yes	83 (24.8)
Week of pregnancy
28–31 weeks	18 (5.4)
32–35 weeks	117 (34.9)
36 weeks and over	200 (59.7)
Planned pregnancy status
Yes	228 (68.1)
No	107 (31.9)
Education about pregnancy
Yes	148 (44.2)
No	187 (55.8)
Health problems during pregnancy
Yes	54 (16.1)
No	281 (83.9)
Psychological problems before pregnancy
Yes	31 (9.3)
No	304 (90.7)
Drug use during pregnancy (n = 30)*
Yes	17 (5.1)
No	13 (3.9)
Psychological problems during pregnancy
Yes	33 (9.9)
No	302 (90.1)

Percentages are based on the specified “n” value.

When the W-DEQ-A mean points were compared according to the sociodemographic characteristics of pregnant women included in the research, the mean W-DEQ-A points were higher for women in the 28 to 32-year age group (75.80 ± 27.03), who were primary school graduates (75.45 ± 28.40), living with extended family (77.04 ± 30.54), and living in villages. (77.71 ± 29.02). There were statistically significant differences for mean W-DEQ-A points according to age group (p = .044), family type (p = .004), and place of residence (p = .026) (Table 3).

Table 3.

Comparison of W-DEQ-A Scores According to the Sociodemographic Characteristics of Pregnant Women (n = 335).

Sociodemographic characteristics	n	W-DEQ-Ax̄ ± SD	Test and p-value
Age
18–22 years old	69	64.81 ± 30.40	F = 2.735
23–27 years old	131	66.12 ± 30.72	p = .044
28–32 years old	76	75.80 ± 27.03
33 years and older	59	73.50 ± 26.54
Education status
Primary school	53	75.45 ± 28.40
Middle school	117	69.44 ± 30.55	F = 1.193
High school	110	66.18 ± 29.07	p = .312
University	55	69.60 ± 28.12
Family type
Nuclear family	246	66.56 ± 28.49	t = 2.916
Extended family	89	77.04 ± 30.54	p = .004
Place of residence*
Province^a	192	69.52 ± 29.08	F = 3.680
District^b	90	64.04 ± 29.32	p = .026
Village^c	53	77.71 ± 29.02	*The difference between b–c

The difference between a,b,c was evaluated with the Sheffe test.

When W-DEQ-A mean points are compared in terms of obstetric characteristics of pregnant women, fear of childbirth was at higher levels for women with three pregnancies (73.26 ± 29.61), those who had not given birth (69.51 ± 31.63), those with miscarriages (70.71 ± 27.86), in 28 to 31 weeks of pregnancy (77.50 ± 30.58), with unplanned pregnancy (71.35 ± 29.33), receiving education during pregnancy (70.36 ± 30.88), experiencing psychological problems before pregnancy (80.51 ± 24.40), using medication during pregnancy (85.05 ± 22.80), and experiencing psychological problems during pregnancy. (76.24 ± 30.41). When W-DEQ-A points were compared according to obstetric characteristics, the difference in fear of childbirth levels was statistically significant for pregnant women who experienced psychological problems before pregnancy (p = .026), whereas the differences for other variables were not significant (p > .05) (Table 4).

Table 4.

Comparison of W-DEQ-A Scores According to Obstetric Characteristics of Pregnant Women (n = 335).

Obstetric characteristics	n	W-DEQ-A x̄ ± SD	Test and p-value
Number of pregnancies
First pregnancy	119	66.70 ± 31.14
2 pregnancies	108	71.75 ± 28.30	F = 1.095
3 pregnancies	56	73.26 ± 29.61	p = .351
4 pregnancies and above	52	66.19 ± 26.90
Number of births
No birth	143	69.51 ± 31.63	t = 0.85
One birth and over	192	69.22 ± 27.65	p = .932
Miscarriage
No	252	68.90 ± 29.89	t = −486
Yes	83	70.71 ± 27.86	p = .627
Pregnancy week
28–31 weeks	18	77.50 ± 30.58	F = 0.738
32–35 weeks	117	69.13 ± 27.27	p = .479
36 weeks and over	200	68.74 ± 30.46
Planned pregnancy
Yes	228	68.40 ± 29.41	t = −0.856
No	107	71.35 ± 29.33	p = .393
Education status during pregnancy
Yes	148	70.36 ± 30.88	t = 0.562
No	187	68.54 ± 28.18	p = .574
Having health problems during pregnancy
Yes	54	70.75 ± 31.81	t = 0.385
No	281	69.07 ± 28.93	p = .701
Psychological problems before pregnancy
Yes	31	80.51 ± 24.40	t = 2.235
No	304	68.21 ± 29.63	p = .026
Drug use during pregnancy (n = 30)*
Yes	17	85.05 ± 22.80	M-WU = 83.500
No	13	75.53 ± 26.94	p = .263
Psychological problems during pregnancy
Yes	33	76.24 ± 30.41	t = 1.422
No	302	68.59 ± 29.21	p = .156

The comparison of W-DEQ-A mean points according to type of intimate partner violence experienced during pregnancy is given in Table 5. The fear of childbirth was higher for pregnant women who experienced partner violence (77.67 ± 28.58), partner violence 1 to 2 times per week (81.88 ± 29.60), physical violence (79.06 ± 32.71), verbal violence (77.34 ± 28.83), emotional violence (81.18 ± 28.97), economic violence (83.97 ± 26.79), and sexual violence (72.71 ± 35.28). Although the difference in fear of childbirth levels were statistically significant for general intimate partner violence (p = .000), verbal violence (p = .000), emotional violence (p = .000), and economic violence (p = .000), the differences were not identified to be significant for the incidence of partner violence, physical violence, and sexual violence situations (p > .05) (Table 5).

Table 5.

Comparison of W-DEQ-A Scores According to Exposure Intimate Partner Violence of Pregnant Women (n = 335).

Intimate partner violence and types	n (%)	W-DEQ-Ax̄ ± SD	Test and p-value
Exposure to intimate partner violence
Yes	165 (49.3)	77.67 ± 28.58	t = −5.318
No	170 (50.7)	61.26 ± 27.90	p = .000
Frequency of partner violence (n = 165)*
1–2 times a week	61 (37.0)	81.88 ± 29.60	KW = 3.297*
1–2 times a month	80 (48.5)	73.72 ± 28.60	p = .192
1–2 times a year	24 (14.5)	80.16 ± 24.96
Physical violence
Yes	29 (8.7)	79.06 ± 32.71	t = −1.871
No	306 (91.3)	68.42 ± 28.92	p = .062
Verbal violence
Yes	154 (46.0)	77.34 ± 28.83	t = −4.740
No	181 (54.0)	62.54 ± 28.16	p = .000
Emotional violence
Yes	80 (23.9)	81.18 ± 28.97	t = −4.235
No	255 (76.1)	65.63 ± 28.55	p = .000
Economic violence
Yes	46 (13.7)	83.97 ± 26.79	t = −3.705
No	289 (86.3)	67.02 ± 29.13	p = .000
Sexual violence
Yes	7 (2.1)	72.71 ± 35.28	M-WU = 1015.500**
No	328 (97.9)	69.27 ± 29.37	p = .601

Kruskal-Wallis; **Mann -Whitney U test.

In this study, when all intimate partner violence types are considered, 49.3% of pregnant women were exposed to any type of violence and 48.5% experienced violence 1 to 2 times per month. It was found that 8.7% of pregnant women experienced physical violence, 46% verbal violence, 23.9% emotional violence, 13.7% economic violence, and 2.1% sexual violence (Table 5).

The total mean points for pregnant women on the W-DEQ-A scale were 69.34 ± 29.37; among pregnant cases, 15.2% had “mild” levels of childbirth fear, 28.4% had “moderate” levels, 26.6% had “severe” levels, and 29.9% had “clinical” levels of childbirth fear. According to level of childbirth fear, the mean W-DEQ-A points were 23.09 ± 9.46 for “mild” level, 52.77 ± 7.91 for “moderate” level, 74.42 ± 5.15 for “severe” level, and 104.16 ± 13.04 for “clinical” level (Table 6).

Table 6.

Classification of Fear of Childbirth According to W-DEQ-A Scores of Pregnant Women (n = 335).

Fear of childbirth levels	n (%)	W-DEQ-Ax̄ ± SD
Mild level (W-DEQ-A score ≤37 points)	51 (15.2)	23.09 ± 9.46
Moderate level (W-DEQ-A score 38–65 points)	95 (28.4)	52.77 ± 7.91
Severe level (W-DEQ-A score 66–84 points)	89 (26.6)	74.42 ± 5.15
Clinical level (W-DEQ-A score ≥85 points)	100 (29.9)	104.16 ± 13.04
Total	335 (100.0)	69.34 ± 29.37

Discussion

Intimate partner violence is a public health problem that is increasing around the world and may be observed in all periods of human life (Can-Gürkan & Coşar, 2009). Pregnancy is one of the riskiest periods for women and abuse during pregnancy increases this risk. Unfortunately, the problem of violence is generally ignored, and prenatal pregnancy check-ups do not investigate the violence problem (Şahin & Şahin, 2003). Intimate partner violence in pregnancy negatively affects the health of mother and fetus and may cause problems like early labor, low birth weight, early abruption of the placenta, prenatal hemorrhage, early membrane rupture, intrauterine growth deficiency, and perinatal death (Boy & Salihu, 2004; Coker et al., 2004; Janssen et al., 2003). In this study, it was identified that 46% of pregnant women experienced verbal violence, 23.9% emotional violence, 13.7% economic violence, 8.87% physical violence, and 2.1% sexual violence. The proportion of pregnant women who were victims of any of these types of intimate partner violence was found to be 49.3% (Table 5). The prevalence of partner violence in pregnancy was found to be 3.4% in England (Bacchus et al., 2004), 3.4% in the United States of America (Huth-Bocks et al., 2002), and 12.5% in Ireland (O’Donnell et al., 2000). Şahin et al. (2017) found that pregnant women experienced 1.3% physical violence, 32.1% verbal violence, 29.6% economic violence, 25.7% emotional violence, and 11.3% sexual violence. In this study, the incidence of physical violence against pregnant women was higher than the results of some studies (Bacchus et al., 2004; Huth-Bocks et al., 2002; S. Şahin et al., 2017) and lower than the results of others (O’Donnell et al., 2000). In this study, the low rate of physical violence in women can be interpreted as a result of women’s avoidance of expressing physical violence during pregnancy.

Fear of childbirth is a serious situation for women (Üst & Pasinlioğlu, 2015). Childbirth fear during pregnancy is known to negatively affect labor (Barut & Uçar, 2018). In this study, the mean W-DEQ-A points were found to be 69.34 ± 29.37. According to W-DEQ-A classification, 15.2% of pregnant cases had “mild” levels, 28.4% had “moderate” levels, 29.9% had “clinical” levels, and 26.6% had “severe” levels of childbirth fear (Table 6). Studies using the same scale in Turkey found similar results to our study, with W-DEQ-A mean points of 73.31 ± 16.84 found by Barut and Uçar (2018), 79.95 ± 17.33 found by Körükcü et al. (2012), and 85.63 ± 13.76 found by Şahin et al. (2009). Contrary to this, Güleç et al., 2014 identified lower levels of childbirth fear among pregnant cases with mean points of 46.4 ± 31.2. In a study using the same scale in Norway found the mean childbirth fear points were 56.66 ± 19.49 (Adams et al., 2012). Størksen et al. (2013) determined the mean fear of childbirth points were 53.8 ± 20.5. A study using the W-DEQ-A scale reported that 31% of women had low childbirth fear, 43% had moderate childbirth fear, and 18.8% had severe childbirth fear (Toohill et al., 2014). A study in Turkey by Bülbül et al. (2016) using the same scale identified that 38.8% of women had severe fear related to childbirth, whereas 8.2% had clinical levels of childbirth fear. The same study determined that as fear increased, decision-making styles varied and that women experiencing childbirth fear displayed more panic, avoiding and delaying behavior (Bülbül et al., 2016). The difference in mean childbirth fear points is considered to be due to personal and cultural differences of the pregnant women included in the research.

The mean W-DEQ-A points of women experiencing verbal violence, emotional violence, and economic violence during pregnancy were higher than the mean W-DEQ-A points of women not experiencing these types of violence, and the difference between the groups was found to be statistically significant (p = .000) (Table 6). A study by Hossieni et al. (2017) found that 73% of pregnant women in Iran experienced partner abuse at least once during pregnancy, 61% had fear of childbirth and that among all pregnant women, physical abuse during pregnancy increased fear of childbirth (Odd Ratio [OR] = 2.47; 95% Confidence Interval [CI], 1.01, 6.02). The same study found that for those in their first pregnancy, physical abuse significantly increased childbirth fear (OR = 12.15; 95% CI, 1.33, 110.96), whereas there was a negative correlation between emotional abuse and childbirth fear for multipara women (OR = 0.18%; 95% CI, 0.04, 0.73). Lukasse et al. (2010) found an increased risk of experiencing childbirth fear in women with a history of abuse in the past (Lukasse et al., 2010). Heimstad et al. (2006) found that women who were victims of physical or sexual abuse in childhood had higher W-DEQ-A rates than those who were not abused (Heimstad et al., 2006). A study stated that women with sexual abuse history during adult life had increased risk of excessive fear during childbirth (Eberhard-Gran et al., 2008). The results in this study are similar to the literature.

Study Limitations and Strengths

The small number of people included in the sample and the use of a survey-based technique limits the efficiency of this study. Additionally, it is possible that the participants in the research did not give accurate and reliable answers to questions. The strong aspects of this study are that it is one of the few studies researching intimate partner violence and fear of childbirth together for pregnant women in Turkey. There is a need to perform more comprehensive future research related to the topic.

Conclusions

In conclusion, 26.6% of pregnant women were identified to experience severe levels of childbirth fear, whereas 29.9% experienced clinical levels of childbirth fear. In addition, pregnant cases in the study experienced 46% verbal violence, 23.9% emotional violence, 13.7% economic violence, 8.7% physical violence, and 2.1% sexual violence, whereas 49.3% experienced any type of violence. It was found that those experiencing any type of violence, verbal violence, emotional violence, and economic violence experienced fear of childbirth more intensely than pregnant women who did not experience abuse.

Implications to Practice

Identification of intimate partner violence during pregnancy and fear of childbirth during antenatal check-ups and care will contribute to maternal and infant health by assisting in the provision of healthcare services, increasing adherence in pregnancy and ensuring a healthy pregnancy. Health professionals provide emotional support to reduce the physical and psychological problems of pregnant women and assist in a healthier pregnancy and labor. Understanding the effects of intimate partner violence against pregnant women and understanding the negative effects on reproductive health with early diagnosis may be effective in shaping intervention programs. Preventive actions and policies to reduce violence against girls and women, screening for fear of childbirth, and partner violence in obstetrics and gynecology clinics, and providing information about pregnancy, labor, and postnatal periods during labor preparation classes may increase family and social health by assisting to prevent other possible outcomes for maternal and infant health.

Footnotes

Acknowledgements

The authors thank to pregnant women who participated to this study. This study was produced from Mehtap Oğurlu’s master thesis.

Authors’ Note

This study was submitted as oral presentation in 1st National Women’s Health Congress, Halic University, September 12 and 13, 2020, Istanbul, Turkey.

Author Contributions

Concept: M.O. and N.E.; Design: M.O. and N.E.; Supervision: N.E.; Resources: M.O. and N.E.; Materials: M.O. and N.E.; Data Collection and/or Processing: M.O.; Analysis and/or Interpretation: M.O. and N.E.; Literature Search: M.O.; Writing Manuscript: M.O. and N.E.; Critical Review: M.O. and N.E.; Other: M.O. and N.E. Data Analysis and Drafting Article: M.O. and N.E.; Final Approval and Finalized Article: M.O. and N.E.

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

Nülüfer Erbil

Author Biographies

Mehtap Oğurlu graduated with a master’s degree from Nursing Programme of Institute of Health Sciences of Ordu University, Turkey in 2020. She is currently working as a nurse in a district of Ordu Province, Turkey.

Nülüfer Erbil is a full-time professor of Gynecology and Obstetrics Nursing who serves as a Dean of Faculty of Health Sciences of Ordu University, Turkey. She has published articles in the areas of women’s health problems, sexual dysfunction in pregnant and postpartum women, reproductive health, gynecological cancer, methodological studies, and nursing professionalism.

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