Abstract
This grounded theory study found that Nicaraguan mothers exposed to intimate partner violence (IPV) during pregnancy eventually acted to protect their children and themselves. They experienced ending abuse as an empowerment process characterized by a cognitive change in women’s attitudes toward partner abuse and the emergence of help-seeking strategies that lead to ending violence with or without ending the relationship. This process was facilitated by a supportive environment that challenged abusive behaviors as well as being asked about abuse during their last pregnancy. Although environmental changes can facilitate ending abuse, Nicaragua’s public institutions must be strengthened to reach women in need.
Around the world, millions of women have experienced intimate partner violence (IPV) at some point in their lives. However, IPV prevalence varies in different cultural settings. The World Health Organization (WHO) multi-country study on women’s health and domestic violence found that lifetime physical or sexual IPV prevalence varied from 15.4% in a Japanese urban setting to 70.9% in an Ethiopian rural setting (García-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006).
Pregnancy does not protect against IPV and IPV may have devastating mental and somatic consequences for the woman (Sarkar, 2008) as well as putting children at risk with increasing infant and child mortality in low-income countries (Åsling–Monemi, Peña, Ellsberg, & Persson, 2003; Deyessa, 2010). IPV exposure during pregnancy may be higher in low-income countries than high-income countries (Campbell, García-Moreno, & Sharps, 2004). In Latin America, a recent Peruvian study of 2,392 women delivering at a clinical facility found an 11.9% prevalence of physical abuse and a 3.9% prevalence of sexual IPV during their current pregnancy (Perales et al., 2009). While IPV can start during pregnancy, it is often a continuation of previous IPV. One recent longitudinal study in Nicaragua found that 53% of the women experiencing IPV before pregnancy also were abused during their current pregnancy (Salazar, Valladares, Öhman, & Högberg, 2009).
Although exposure to IPV is frequent, ending IPV is a complex process that takes time. This process usually begins with an internalization phase (Enander & Holmberg, 2008) or not recognizing the abuse (Burke, Gielen, McDonnell, O’Campo, & Maman, 2001), where IPV is sometimes defined as temporary, survivable, or reasonable (Kearney, 2001). As the process continues, the IPV seems less reasonable, leading to a phase where the women gather enough resources and personal strength to end the abusive partner relationship (Burke et al., 2001; Enander & Holmberg, 2008; Kearney, 2001; Landenburger, 1998).
The transition between the different phases can be triggered by specific events or circumstances that permanently change the women’s notions about the abusive relationship and how they react to it (Chang et al., 2010). Increased IPV severity and the need to protect others from the abuser (Campbell, Rose, Kub, & Nedd, 1998; Chang et al., 2010; Enander & Holmberg, 2008; Patzel, 2001) have been identified as crucial points in the process of ending IPV. Outside interventions that increased the women’s independence and self-esteem (Kearney, 2001) and an increase in the awareness of access to support and resources (Chang et al., 2010) also have been reported as important turning points in the abusive relationship.
Women’s perceptions of the violent relationship are also important factors influencing the ending IPV process. Women’s cognitive shift—when they started to perceive the relationship as violent—has been described as one of the most essential factors that lead to the final breakup (Campbell et al., 1998; Enander & Holmberg, 2008). In addition, women’s interactions with health-care providers may help change women’s perceptions of IPV (Chang et al., 2010). The health sector, through IPV screening during pregnancy, can help raise awareness about IPV and can be a source of information about services and support resources in the community (Chang et al., 2005; Edin & Högberg, 2002).
The ending of IPV process is strongly influenced by women’s life situation and the sociocultural context in which they live (Kearney, 2001). Important individual factors include women’s economic independence (Anderson & Saunders, 2003; Davis, 2002; Landenburger, 1998), their age (Coker et al., 2007), how many children or other dependants they have (McCarroll et al., 2000), and the women’s self efficacy/perceived power (Cluss et al., 2006). Pregnancy may weaken their ability to deal with the abuse, forcing them to endure and adapt to their partner’s violence to protect the fetus (Edin, Dahlgren, Lalos, & Högberg, 2010), while child rearing might accelerate the end to an abusive relationship. In addition, community and societal factors, such as the cultural norms and values about gender roles and IPV, the level of social support (Barnett, 2000, 2001; Krug, Dahlberg, Mercy, & Lozano, 2002; Valladares, 2005; Wuest & Merritt-Gray, 1999), and the degree of state/institutional support (Heise, 1996) can either facilitate or hinder the IPV ending process.
Women as active subjects use and combine many different strategies to end IPV (Campbell et al., 1998). These strategies can vary according to what phase the woman is in with respect to ending IPV and their personal and sociocultural context (Kearney, 2001). They may range from private efforts to stop the violence to seeking help when their private efforts are unsuccessful (Goodman, Dutton, Weinfurt, & Vankos, 2005). The strategies used in the private realm can be classified as placating strategies, resistance strategies, and safety planning, whereas those used in the public realm can be categorized as formal or informal network use and legal action (Goodman, Dutton, Weinfurt, & Cook, 2003).
IPV is endemic in Nicaragua. Five out of 10 partnered/married women have experienced physical/sexual IPV at some point in their lives (Ellsberg, Peña, Herrera, Liljestrand, & Winkvist, 1999). Nicaraguan women also experience IPV during pregnancy. One population-based study in this setting found a 13% prevalence of physical abuse and a 7% prevalence of sexual abuse during the current pregnancy (Valladares, Peña, Persson, & Högberg, 2005).
Previous qualitative research with pregnant women experiencing IPV in this setting found that these women experience IPV as a process that consists of four stages: (a) the “introduction stage,” in which women blame themselves for the abuse and use submissive strategies to cope; (b) the “establishment stage,” in which women started to label the relationship as abusive and looked for support; (c) the “accommodation stage,” in which women were hopeless due to their inability to cope with the abuse; and (d) the “crossroad stage,” in which women realized that they were not alone and started to look for external support (Valladares, 2005). This study also showed that pregnancy in itself may be an obstacle to ending IPV. In addition, gender norms regarding the woman’s role as the one responsible for keeping the family together limited the support family, friends, and society could provide.
In Nicaragua, one in four women who experience IPV will leave the abusive relationship within the first four years after the IPV started (Ellsberg, Winkvist, Peña, & Stenlund, 2001). In addition, a longitudinal study in this setting found that no or diminishing controlling behavior by a partner and high or improved social resources were associated with ending IPV (Salazar et al., 2009). However, the processes and strategies of women successfully ending IPV after experiencing it during pregnancy have not yet been explored. This study explores the process and successful strategies involved in ending IPV after pregnancy in a municipality in Nicaragua and how they are influenced by other factors present in the women’s environment.
Method
Setting
The study setting was León, Nicaragua. In the last two decades, the Nicaraguan civil society and the government have made efforts to end violence against women. In 1992, a coalition of women’s groups created the Network of Women against Violence (Ellsberg, Liljestrand, & Winkvist, 1997), a group whose public and legal lobbying contributed to the reform of Law 150. In 1992, this law changed the Nicaraguan Criminal Code to allow for a more severe punishment for sexual offenders. In 1996, the Family Violence Law (Law 230) was passed to protect victims and to sanction offenders.
In 1994, the Women and Children Police Station (WCPS), which provides services in 32 locations around the country, was created to handle family violence and child abuse cases within the police department. Higher rates of women reporting IPV have been described as a positive outcome of this effort (Ellsberg et al., 1997). However, other authors have pointed out that their effectiveness is limited by insufficient financial and human resources. In addition, their impact on IPV cessation is difficult to evaluate due to lack of reliable information on the outcome of the women’s reports (Jubb et al., 2008).
More recently, women’s and nongovernmental organizations have conducted media campaigns challenging the cultural norms that define gender, sexuality, and HIV. One example of these efforts is a mass media campaign applied by Puntos de Encuentro NGO. Their approach combined a weekly television series broadcasted on a national commercial cable station, a call-in radio show, and a youth leadership capacity building program (Solórzano et al., 2008).
Data Collection and Informants
A qualitative emergent design was adopted in which data were gathered through individual research interviews (Dahlgren, Emmelin, & Winkvist, 2004). Data were collected during the first six months of 2008 focusing on the informants’ end of IPV experiences between 2002 and 2007.
A semistructured interview guide with open-ended questions was used to collect information. An interview guide can have two dimensions: a thematic dimension that explores the general topics of relevance for a research question and a dynamic dimension that promotes a positive interaction between the interviewer and the informant (Kvale, 1996). Thus, a literature review was conducted to identify relevant aspects of the research question to explore in-depth with the informants. Six main aspects were identified: (a) women’s general perception of the partner relationship; (b) women’s experiences ending IPV; (c) self-esteem; (d) access to social support and resources; (e) perception of community norms on IPV; and (f) women’s perception about previous IPV inquiring during pregnancy three to four years before. After identifying the aspects to explore, colloquial open-ended questions for each aspect were developed to promote spontaneous descriptions. During the interview, follow-up and probing questions were used to try to obtain a complete description of the informant’s experience and actions. Table 1 describes the interview guide.
Semistructured Interview Guide.
Informants were identified from 398 women who participated in a community-based panel study assessing factors associated with ending IPV after experiencing it during pregnancy in León, Nicaragua (Salazar et al., 2009). In the quantitative study, women were asked about their IPV experiences during pregnancy and at follow-up three to four years after delivery. To be eligible to participate in the present qualitative study, women must have reported physical or sexual IPV during pregnancy but not at follow-up in the quantitative study. Fifty-seven women reported physical/sexual IPV during pregnancy, but only 32 met the selection criteria. Furthermore, four women could not be located and one woman declined to participate. Thus, 27 women were eligible to be interviewed.
From those women eligible, 13 consecutive in-depth interviews were conducted until women were no longer providing new information; saturation was reached (Glaser, 1978). Urban and rural women in the sample were purposively included in the sample. The emergent design is an interactive process of data collection and analyses (Dahlgren et al., 2004). Thus, the interviewing process developed as follows. An initial interview was conducted with a woman living in an urban setting. It was then transcribed and analyzed. From the analysis, we identified additional topics to explore, which led us to modify the interview guide so we could explore further the emerging results with the next informant. This process continued until 10 interviews were conducted with urban women. To explore possible differences with women living in rural settings, three additional interviews were conducted. Also, three reinterviews were performed to further clarify and elaborate on specific issues raised in the previous interviews.
The 13 interviews were conducted in private in the informants’ houses by the first author (MS) and a woman research assistant. The interviews’ average length was 1 hr, varying from 45 to 120 min. They were tape-recorded with an audio device and transcribed verbatim. Field notes were written and used in the final analyses. The age of the informants ranged from 19 to 43 years. The women had one to six children. Women’s education level varied from primary school to college level. Four women did not have a partner at the time the data were collected, two had a new partner, and seven reported the same partner as during pregnancy. Nine women were employed at the time of the interview. No income information was collected (Table 2).
Characteristics of Women Ending Abuse After Pregnancy.
The informants experienced several acts of physical IPV that ranged from moderate to severe violence according to the WHO classification (García-Moreno et al., 2006). Slaps and pushes were considered moderate IPV. Punches, kicks, and strangulations were considered severe IPV. Sexual violence was also present and was described as incidents of forced sex. Most women presented a continuous IPV pattern, reporting that the violence started before pregnancy. Two women reported having experienced IPV with a previous partner.
To increase trustworthiness, we used researcher triangulation and peer debriefing (Lincoln & Guba, 1985). In practice, the researcher triangulation meant that we were researchers from different fields of knowledge: public health, maternal health, and gender research. By making use of our different expertise, we were able to view the material from different perspectives, thus broadening understanding. Peer debriefing was obtained through seminars with our colleagues, where preliminary results were presented and discussed.
Data Analysis
The interviews were analyzed with the grounded theory method of constant comparison (Glaser, 2001). Data collection and analysis were performed in parallel in accordance with grounded theory. Emerging results were negotiated among the four researchers. The analysis process started with a separate open coding of the interview text to identify open codes that characterize the main content. Thereafter, selective coding was performed to group the codes into categories (Dahlgren et al., 2004). In this process, one core category emerged. Finally, categories were linked with each other in a model that represents the processes, strategies, and factors related to ending IPV. The software OpenCode 3.4 (UMDAC & Epidemiology Department of Public Health and Clinical Medicine Umeå University, 2001) was used for coding and categorizing.
Ethical Considerations
The study was approved by the ethical committee at UNAN-Leon Faculty of Medicine, Nicaragua, in February, 2008. WHO Ethical and Safety Recommendations for Research on Domestic Violence Against Women (García-Moreno, 2001) were followed. Participation was voluntarily. Study objectives were explained to all participants and written informed consent was obtained. The interviewer was accompanied by a woman field assistant to enhance rapport. Both were extensively trained to interview women with sensitivity, empathy, and without expressing judgment. The women have been identified using aliases to ensure anonymity. The women were informed that they could withdraw from the study whenever they wanted without any further explanation. Referral services were available for women who needed support of any kind.
Results
From the grounded theory analyses, one core category and three related categories emerged. The core category, “A process of change,” represents the process that the women described as the way out of IPV. The process contains three phases: “I came to a turning point,” “I changed,” and “The relationship ended or changed.” The three related categories represent the factors facilitating the end of the violence. The category labeled, “Less tolerant of intimate partner violence and supportive environment” represents the most important feature that the women identified with respect to ending IPV. It contains three subcategories: “family support,” “social support,” and “community intervention.” The category, “Abuse inquiring,” reflects how the women felt about and perceived being exposed to abuse inquiring during pregnancy and its effects on ending the violence. The category, “Police and health system involvement,” represents the women’s perceptions and feelings about the role of the police and health system in ending the IPV. The three phenomena represented in the categories described contributed to the women’s process of change. The core category and the categories are presented in Figure 1.
Process and factors related to ending IPV after pregnancy.
In the following section, we will present the results by first describing the core category, that is, the process of change as described by the women. Then we will present the related categories and their content.
Process of Change
Phase “I came to a turning point.”
The starting point of the process is mainly triggered by an increase in the severity and the frequency of the IPV experienced by the women and their children. For many women, reaching a “boiling point” meant having survived a severe threatening episode of physical violence that put their life and/or their children at risk.
Once he came drunk and mistreated my little girl just because she complained. He slapped her in the face and my older boy got involved to defend his sister. It became a big problem. My daughter started to cry and cry and cry and she was becoming very thin. That made me see that I could not continue; he could hit me but not them. So, that made me say, enough! (Juana, 43 years, Urban).
These strong emotional experiences generated deep feelings of fear for themselves as well as concern for their children’s safety and well-being. These experiences also triggered a starting point from which they reflected on their own experiences with IPV. This “awakening,” as described by many informants, meant accepting that they were experiencing violence and labeling their partner’s violence as such. “Julia” describes her experience as follows: One of the many times he hit me, he told me . . . “I can kill you” . . . and I was thinking, and thinking and thinking for my son’s life and also for my own life, because it was my life that was in danger! So that was the moment I decided that I was not going to put up with him anymore. (Julia, 29 years, Urban).
Recognizing the violence and labeling it as such also lead to an emotional turning point. Women started to shift from feelings of denial, self-blame, frustration, resignation, and fear to feelings of disappointment, anger, fury, and even revenge. Also, a main cognitive change in this phase is that informants realized that they could not prevent or control the violence: I said, not anymore, not anymore, I can’t continue like this. Every time he drinks I am going to be avoiding him? Every time? No, not anymore, not anymore. I can’t withstand this! (Lorena, 25 years, Urban).
This emotional turning point also implied a modification in the strategies women used to prevent or avoid the violence. For example, after realizing that they were not to blame for the abuse, they shifted from strategies aimed to prevent the violence by adjusting to the batterer’s demands (acting submissive and changing her own behavior) to more assertive methods such as defending themselves verbally or physically. However, such tactics were generally ineffective, leading to a more violent partner response, especially for women who were isolated from their families, lived in a nonsupportive environment, or experienced more severe forms of IPV.
As a result of the low effectiveness of the strategies described earlier, women started to reveal the IPV to friends initially and family later. This strategy was a turning point in itself, because it signified a behavioral change in the woman’s response to their partner’s violence. It meant they recognized that they had exhausted their own private efforts to end the abuse and that they needed external help to cope with it: The last time we fought he pushed me down the stairs of my house. I had to go to the hospital . . . the doctor told me that I had sprained a disc in my spine and I had to use a wheelchair for 15 days . . . when I left the hospital I went to my mother’s house. Initially, I told my mother that I had fallen. Later on I started to think, “I do not need to lie anymore, I did not fall, he pushed me!” After two more weeks, I told my mother . . . “Mom, I can’t continue like this anymore, I don’t want anything to do with that man, can I move here with my children?” (Gloria, 36 years, Urban).
However, this transition from early coping strategies, such as hiding the violence, was difficult. All women struggled to overcome feelings of shame, self-blame, and the perception that IPV was a private issue. In addition, some women had to battle with depression and anxiety that limited their ability to respond assertively to their partner’s violence: When he was abusing me, I felt humiliated, like I couldn’t do anything. I never had a home like this; I didn’t know what to do; I felt so humiliated. Sometimes, I just cried and cried and cried because I couldn’t figure what to do. Finally, I told him, “Control yourself, I don’t want to live like this anymore”. (Karen, 32 years, Urban).
Women moved through this phase at a different pace. Breaking the silence by involving friends and family allowed women to access emotional support, diminished their isolation, and improved their self-esteem. Although all women had access at some level to the support of family and friends, accessing it depended on the degree of partner control, isolation, and the level of trust and communication between the woman and her environment.
In addition, variations in the properties and dimensions of social support could facilitate or decelerate this stage. For example, family support was not always expressed directly by the woman’s family. This property was named “expression.” It ranged from explicit to implied support. When it was implied, women did not expect much support from their families even if it were available. Moreover, when family support was tied to demands and conditions, the women were more reluctant to accept it. This property was named “conditional.” It varied from unconditional to highly conditional support. Therefore, for some women, the fact that support was implied rather than explicit, and conditional rather than unconditional, might have delayed its usefulness to end IPV.
The last time he hit me, I decided to leave him. I left him and went to my family house. I told my mother that I wanted to stay, and she said I could. But my father warned me: “If you go back to him, you are not allowed to come back the family house again.” (Julia, 29 years, Urban).
Phase “I changed”
As a consequence of the enhanced access to social and family support, women emerged to a strengthened position and with improved self-esteem. This new stage allowed them to start the shift from feelings of powerlessness and impotence to being more assertive, less permissive toward abuse, and empowered to challenge their partner’s control. However, reaching this phase was described as difficult—a struggle to build the courage and strength to end the violence.
Challenging partner control meant the rise of new strategies. Women started using temporary separations from their partner. This new strategy was commonly triggered by new episodes of physical violence, and it was made possible by the material support (access to a secure shelter) provided by the women’s family. This meant that for a certain amount of time, the informants and their children would move from a setting where the partner had higher authority and control, to a generally more favorable and supportive setting such as the woman’s own family house. This time away from the partner’s controlling and violent behavior allowed women to continue building their own personal resources, diminish their isolation, and increase their social networks. In addition, it acted as an indirect form of pressure on the partner to end the violence, shifting the couple’s power balance toward the woman: The last time we fought, I left to my mother’s house. Afterwards, one friend told me that he started to drink and when he was drunk he went to my mother’s house. We fought again, and he took and threw my clothes onto the patio; he said, “I am going to throw you out of this house,” and I told him, “You are in my house now, and I can throw you out now!” Afterwards, he apologized. (Carol, 26 years, Rural)
As part of the women’s own efforts to build their own resources, improving their economic independence represented another important strategy to challenge and escape partner control. For some women who were unemployed, searching for a source of income became a priority. Working was described as providing economic stability and emotional fulfillment, as well as an important space to increase their social networks. In addition, less economic dependency contributed to a more balanced power relationship between the couple.
I used to endure his violence because he was the only one supporting myself and my daughters. Now that I am working, I can support myself and my children on my own. Now, I think that if he wants to leave, well, he can leave. (Maria, 30 years, Urban)
As a consequence of the changing environmental factors described earlier, at the end of this phase, women finalized the transition from a powerless position to a more assertive and empowered one. Nevertheless, progression to this state was not homogeneous. For example, the benefits generated by being employed differed according to the type of job (formal/informal), the amount of money earned, and the number of dependants.
However, the capacity to execute the temporary separations strategy successfully was mediated by the intensity of partner control and the geographical distance between the woman and her family. The duration and intensity of the material support were also influenced by the woman’s family economic conditions. Temporary separations might have been executed several times before the woman gathered enough resources and support to end the abuse.
Phase “The relationship ended or changed.”
This stage was reached within four years after pregnancy. The positive change in women’s personal and social conditions generated two final responses that also seem to be influenced by the severity of the IPV experienced, the women’s educational level, and employment status. Women who experienced more continuous, severe, and controlling IPV patterns reported ending the relationship as the only way to end the abuse. For them, the process was longer and more difficult. Also, women who had an educational level higher than primary school and those with an independent income reported ending the relationship more often than those with a primary school level or who were unemployed.
Women who experienced moderate IPV ended the violence without ending the relationship. This group described an improvement in the relationship characterized by better communication with their partners and their partner being more respectful to the woman’s wishes. For these women, an important contextual factor influencing the partner’s behavioral change was the family and community pressure placed on the man to end the violence. The informants noted that these actions also resulted in a decline in the partner’s alcohol use: An NGO brought a women’s project to my community. The community leader was looking for women in my neighborhood to go to the workshops. She asked, so I went. I told one of the women giving the workshop about the situation I was living and they asked my permission to talk to my husband and they did. (Mayra, 21 years, Rural)
The informants also claimed that some men were afraid of the negative consequences of being identified as violent, which, in turn, seemed to discourage further abuse: I told him that I had gone to his workplace, and that if he hits me again, they are going to fire him. Afterwards, when he got angry and wanted to hit me, he would not do it when I reminded him of that. (Lorena, 27 years, Urban)
The way urban and rural women experienced ending IPV differed somewhat. Women living in the rural area were more isolated from sources of support, which seemed to be a significant factor slowing the progress in the “I reached a turning point” phase. Their path to economic independence was also hindered by their limited access to jobs and by lower wages. Also, they seemed to have less access to health care and police services than urban women. However, the degree of social and family support perceived by the informants did not vary by their place of residency.
Reflecting on this phase, the informants described this as a period of “peacefulness,” “ease,” and “happiness” associated with less emotional stress. This “new life” also translated into feelings of personal improvement, maturity, higher self-esteem, and greater autonomy. The process of ending IPV did not occur in isolation, but was strongly influenced by the woman’s environment. Three major factors emerged from the data: “less tolerant of intimate partner violence and supportive environment”; “abuse inquiring”; and “police and health system involvement.” The interaction between the process and these categories is described in the following section.
Less Tolerant of Intimate Partner Violence and Supportive Environment
A supportive and less tolerant of IPV environment emerged as the most important contextual factor influencing the end of the violence. The less tolerant of IPV aspect arose from the informants’ description of the attitudes toward IPV expressed by people in their environment (acquaintances, friends, and coworkers); these attitudes mainly rejected traditional values that encouraged women’s self-sacrifice and endurance as the norm in a violent partner relationship. In addition, through the entire process of ending IPV, docility (a traditional value expected of women in this context) was frequently questioned and criticized.
In this environment, expectations on women’s behavior while in a violent partner relationship also seemed to differ from traditional expectations. Women were repeatedly encouraged to carry out actions to end the violence, such as seeking help, involving other people to end abuse, defending themselves physically, pressing charges against the violent man, or even ending the relationship.
My sister-in-law found that he had hit me. She told me, “Come on! You have to throw him in jail! Don’t worry; I am going to support you! Don’t let him lay a hand on you, don’t let him mistreat you.” She was very supportive. (Ana, 26 years, Urban)
Variations in the degree of encouragement were also found. While women noted that the overwhelming sentiment among young people and women in their environment was to reject IPV and that these people encouraged them to leave the relationship, there were some older individuals who would advise them to stay.
The less tolerant of abuse context seemed to have facilitated the availability of social and family emotional and material support. As described in the category “Process of change,” support was one of the key elements influencing the outcomes of the process itself. Emotional support from friends and community members played a large role by helping women recognize the violence and provided comfort and hope, while material support was key in the effectiveness of the “Temporary separation” strategy.
Variations on the sources of support were also discovered. Although family and friends’ support was predominant, to a lesser extent women also obtained help from institutions such as nongovernmental organizations and religious organizations. For example, one woman who participated in gender workshops sponsored by an NGO community intervention recalled that it helped her to be less isolated and was an important source of emotional support.
While I was going to the gender workshops, I started to feel freer, more at ease. It was good to know that they were listening to me. Afterwards, I felt that I had changed. I felt that I was important; I felt that I had the right to talk about things with less fear. (Mayra, 21 years, Rural)
Abuse Inquiring
The informants participated in a previous panel study assessing IPV exposure during pregnancy and three to four years after delivery. Twice during pregnancy, trained women interviewers asked them about their IPV experiences. In general, women perceived these encounters as positive, although recounting their stories was painful. They related that the confidential and trustful interview environment created by the interviewer provided a unique opportunity to share their stories. This opportunity also contributed to improve their mental health by allowing them to break their silence and express their feelings, sometimes for the first time, without the fear of being judged. In addition, they noted that the information provided and the interaction with the interviewer allowed them to start reflecting on the abuse and later to start labeling it as violence.
Researcher: How did you feel when you talked about the violence with the interviewer that visited you when you were pregnant? Informant: I felt good because that was the first time I talked about it. Afterwards, I realized that there was a problem and after that I decided to move on. (Martha, 25, Urban)
Police and Health System Involvement
Informants’ use of formal network strategies such as involvement of the police or health system was in general limited; only one woman reported the abuse to the police. Accessing police services was limited because often the women believed that looking for help would have negative consequences for them, such as harassment by the partner’s family and loss of their partner’s economic support. Also, shame and a deep distrust of the ability of the police to support ending IPV played a significant role in not using police services: My friends used to tell me, “Go to the police, go to get help.” I didn’t go because I thought they were not going to help, I am just going to waste my time filling a lot and a lot of paperwork. (Lucia, 19 years, Rural)
Women identified several barriers to disclosing the violence in the health care system. They mentioned the lack of inquiring about possible IPV, saturated services, and poor privacy as factors discouraging them from sharing their stories. Although the use of these institutions was limited, some women also reported benefits from this interaction. For example, after a health-care provider identified one woman as experiencing IPV, she was given psychological treatment, which she identified as an important step in her end of IPV process. In addition, harassment by a violent partner was prevented when one informant brought her case to the police.
Discussion
This study shows that women exposed to IPV during pregnancy experience ending abuse as an empowering process with three distinct phases: (a) “I came to a turning point”; (b) “I changed”; and (c) “The relationship ended or changed.” The duration of these phases and the transition between them were influenced by women’s individual characteristics (IPV awareness, severity of the abuse, safety consideration for their children and themselves, shame, mental health issues, and economic independence) and facilitated by external factors (abuse inquiring and a less tolerant of abuse supportive environment). To end IPV, women used a variety of strategies. Successful strategies involved mainly the use of informal networks; formal networks were rarely used. Ending IPV was not always related to ending the relationship.
Significant factors influencing IPV are the social and cultural norms and values associated with it (Krug et al., 2002). For example, one study in India found that in communities where there was a higher acceptance of IPV the protective influence that women’s higher education had on lower IPV occurrence was undermined (Boyle, Georgiades, Cullen, & Racine, 2009). Thus, one major finding from this study is that the supportive environment in which women interacted was strongly critical of traditional gender relations—a subordinate relationship to men—and the patriarchal discourses tolerant of IPV previously reported in this setting (Ellsberg et al., 2001; Valladares, 2005; Wessel & Campbell, 1997).
Gender relations are not static and can be reshaped by social processes (Connell, 2009). In Nicaragua, a revolutionary social process during the 1980s brought positive changes in women’s access to public life and activism (Isbester, 2001) that led to a strong independent women’s movement addressing the issue of violence against women in the public sphere (Ellsberg et al., 1997). Thus, in environments like this, where normative attitudes in gender relations are changing, the individual and collective empowerment for women are more likely to have an effect on reducing violence (Koenig, Ahmed, Hossain, & Mozumder, 2003). These findings are also consistent with previous research conducted in this setting. Solórzano et al. (2008) found a change in norms and values on gender relations in a population exposed to a mass media campaign challenging patriarchal gender roles.
Empowerment implies enhancing the individual’s capacity to make choices and to transform those choices into desired actions and outcomes (Alsop & Heinsohn, 2005). Thus, the transition to a more supportive environment facilitated the women’s empowerment process by allowing more access to social support and resources, a vital step in ending the IPV (Kasturirangan, 2008). Clearly, the emotional and material support provided the conditions to end IPV by strengthening their self-esteem, reducing isolation, and diminishing their dependency. Social support and social resources have been described as keys factors to end IPV (Goodman et al., 2005; Jewkes, 2002; Lown & Vega, 2001; Salazar et al., 2009).
In this context of less tolerance of IPV, the women’s help-seeking process was also facilitated. As previously described in this setting (Ellsberg et al., 2001), informal network strategies (involving family or friends, temporary separations, and setting change) were the most effective and used actions to end partner abuse. The success of informal network strategies is related to an improvement in women’s access to material support (a secure shelter and economic resources). This change in availability of resources has also been described as a key factor influencing women’s decision to end IPV (Sleutel, 1998). Our results are consistent with studies in developed countries reporting informal network use among the most effective strategies ranked by women to end IPV (Goodman et al., 2003; Riddell, Ford-Gilboe, & Leipert, 2009).
Formal network strategies (getting help from a domestic violence program or the health system) and legal action, although only somewhat effective, were used to a lesser extent. Liang, Goodman, Tummala-Narra, & Weintraub, 2005 point out that women whose private strategies had failed to end IPV did not always look for support when they needed it. In this study, shame, perceived institutional barriers, and perceptions of formal network effectiveness to end abuse significantly influenced women’s decisions to use these services. These results are in line with previous research showing that women’s decisions to seek help and their source of support selection are strongly influenced by the quality of institutional responses in their community (Sagot, 2005). In addition, women may avoid services that fail to acknowledge the specific realities of their lives (Baker, 1997).
A recent longitudinal study of this population reported that women expressed more positive attitudes toward accepting help to end IPV from people other than their family (Salazar et al., 2009). However, to capitalize on this attitudinal change and make a deeper impact on IPV reduction, formal network effectiveness must be strengthened. The Nicaraguan government must make efforts to diminish the barriers women face at police and health services by providing training, material resources, and human resources.
This study shows that mental health suffering and shame negatively influenced women’s responses to IPV. Depression prevalence is high in this population (Waldrop & Resick, 2004). The WHO multi-country study on women’s health and domestic violence showed that emotional distress was significantly higher in women exposed to IPV than those not exposed (Ellsberg, Jansen, Heise, Watts, & García-Moreno, 2008). The interaction between IPV and depression has devastating consequences for child survival (Deyessa, 2010). In addition, women who are ashamed and who fear judgment have difficulty finding support (McCauley, Yurk, Jenckes, & Ford, 1998). Thus, interventions aimed to end IPV must implement actions to improve women’s mental health and diminish feelings of shame to facilitate their access to resources and improve child survival.
Child bearing and the norms and values regarding motherhood may hamper the process of ending IPV by limiting women’s responses and access to support (Edin et al., 2010; Valladares, 2005). Results from the present study showed that during childrearing, concerns about the children’s safety were key factors triggering the IPV ending process. Practitioners working with pregnant women might take these results into consideration when designing interventions to end IPV.
This is the first study in this setting that explores the effect that previous IPV inquiring had on ending of IPV. One study in Sweden (Lundgren, Heimer, Wasterstand, & Kallioski, 2001) described that women living with violent men experience a process of normalization: They internalize the abuser’s norms and values of IPV and reinterpret violence as a normal part of their lives. Many researchers have noted that recognizing the violence is a key step in ending IPV (Burke et al., 2001; Landenburger, 1998; Moss, Pitula, Campbell, & Halstead, 1997). In line with this, our findings showed that asking the informants about their experiences with IPV when they were pregnant played an important role in helping the women “denormalize” the violence by breaking down isolation, providing information, and facilitating a cognitive shift from accepting IPV to resisting IPV. The benefits of emotional support (the opportunity to talk about the violence freely and the information provided) are consistent with previous results from a control trial that evaluated the impact of an empowerment program on IPV reduction in pregnant women (Tiwari et al., 2005).
Ending IPV was not always related to ending the relationship. Our results are consistent with previous qualitative research showing that ending IPV is a complex process that does not always involve ending the relationship (Campbell et al., 1998). However, a cautious interpretation of our results is demanded. Attaining economic independence has been described as a key factor influencing a woman’s decision to leave (Anderson & Saunders, 2003). In our sample, women who stayed were mainly those who did not have an independent source of income; thus their dependency might have been a factor influencing their decision to stay in the relationship. In addition, they experienced sporadic and less severe violence than those leaving a violent relationship.
Data from our interviews suggest that some violent men ended their abusive behavior. Changes in violent men’s social circumstances might influence them to change their violent behavior toward their partners (Hearn, 1998). Therefore, our findings might be related to an environmental normative change in Nicaraguan society toward not tolerating IPV. However, further research is needed to explore this finding in-depth.
Quality of the research process was preserved in all steps through a thorough use of methods from qualitative methodology to creating an environment of trustworthiness. To explore the variety of women’s experiences, the informants were purposively selected from a community population and not from shelters. In addition, privacy was ensured during data collection. A woman research assistant was present during all interviews to help build trust between the informants and the main researcher.
The findings from this study are based on a sample size that is acceptable for a qualitative study. The 13 in-depth interviews generated richness in data and we believe that we met saturation; that is, no new information was provided. The results cannot be generalized to a larger population based on any statistical generalization. Instead, the qualitative research tradition in which it is assumed that findings from small samples analyzed with grounded theory can be generalized through theoretical generalization, transferability (Lincoln & Guba, 1985), was followed. The results from this study can be transferred to similar social contexts from a theoretical point of view. To map the magnitude of the findings from this study, a quantitative population-based study is needed.
Conclusions
IPV continues to be an endemic and paramount event in Nicaraguan women’s lives. This study showed that women exposed to IPV during pregnancy experience ending abuse as an empowering process with three phases (“I came to a turning point,” “I changed,” and “The relationship ended or changed”). The duration of these phases was influenced by women’s individual characteristics (IPV awareness, shame, mental health issues, and economic independence) and external factors (less tolerant of abuse, a supportive environment, and abuse inquiring). Successful strategies used to end IPV involved using informal networks.
Being in a supportive and less tolerant of IPV environment was the main factor facilitating IPV cessation. Thus, community interventions challenging traditional norms and values toward IPV and violence against women in general as a sign of masculinity must continue in this setting to enhance family and social support accessibility. However, to further the reduction of IPV, the effectiveness of formal networks (legal and health system) must be strengthened. It is paramount that state-managed shelters are created, especially for women who do not have access to material support from their social networks.
IPV inquiring was found to facilitate women’s cognitive shift from accepting IPV to resisting IPV. Thus, IPV inquiring implementation in public health care settings might further facilitate the ending of IPV process by providing information and resources to women in need. Further research is needed to understand how changing social circumstances might influence men’s violent behaviors toward their partners.
Footnotes
Acknowledgements
We thank all the informants for their participation in this study. We also wish to thank Umeå Centre for Gender Studies for financial support.
Authors’ Note
The sponsors of this study had no role in the study design, data collection, analysis, interpretation, writing of the report, or the decision to submit for publication.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this project was provided by Swedish-Nicaragua research collaboration supported by Sida International Development Cooperation Agency/Swedish Agency for Research Cooperation and from Umeå Centre for Global Health Research with support from the Swedish Council for Working Life and Social Research (grant no. 2006-1512).