Objective. To determine the association between intimate partner violence and damage to health of pregnant women attending antenatal care in primary care level in 12 municipalities of Hidalgo Health Services in the period November 2008 to April 2009.
Material and Methods-. An analytical, cross-sectional epidemiological study with systematic random probability sampling was applied. It was carried out in the Health Centers of the Health Services in 12 municipalities. Data analysis began with obtaining descriptive statistics to estimate prevalence and outcome variables. The association between exposure variables of statistical significance (Pearson Chi Square) was explored. Measures of association that were obtained are the Prevalence Ratio with Confidence Intervals at 95%.
Results-. The 31.5% of the study population was about 15 to 19 years, 39.5% had completed secondary school, 91% were married or cohabiting. 80% were dedicated to home. 29% of women reported being abused in childhood, 30% of couples were beaten in childhood. 53% stated that in the last 12 months were the victims of some type of violence by their intimate partner. Violence during pregnancy was found: Psychological 52.6%, Physical 16.5%, Sexual 5.1% and Economic 25.4%. Association with psychological damage to physical and mental health, found that all were statistically significant (p < .001), the association with depression was 25 times more likely (PR 1.25, 95% CI 1.18-1.32), 16 times more nerve problems (PR 1.16, 95% CI 1.10-1.21), lack of appetite 15.5 times (PR 1.15, 95% CI 1.09-1.21) and have thought about suicide 9 times more (PR 1.09, 95% CI 1.04-1.14). Regarding psychological violence there was found association with threatened abortion 13.7% more likely (PR 1.13, 95% CI 1.08-1.18) in the rest there was no association. Regarding physical violence there was found an association with depression it was 28 times more (PR 1.28, 95% CI 1.21-1.35), trouble sleeping 20 times more (PR 1.20, 95% CI 1.13-1.26), anxiety 19% more likely (PR 1.19, 95% CI 1.13-1.25) and have thought suicide 11 times more (PR 1.11, 95% CI 1.06-1.16). It also was found an association with: bruises 3 times more (PR 1.03; 95% CI 1.00-1.05), threatened abortion 2 times more (PR 1.02, 95% CI .99-1.04) for the rest of the health damage there was no association. Regarding sexual violence there was found an association with depression 31 times more (PR 1.31, 95% CI 1.24-1.39), trouble sleeping 22 times more (PR 1.22, 95% CI 1.15-1.29), regarding anxiety 22 times more (PR 1.22, 95% CI 1.15 -1.29), has attempted suicide 12 times more (PR 1.12, 95% CI 1.08-1.16); as well there was found that: 6 times more bruising (PR 1.06%, 95% CI 1.02-1.10), threatened abortion 4 times more (PR 1.04, 95% CI 1.01-1.07) and vaginal bleeding 3 times more (PR 1.03, 95% CI 1.00-1.05%).
Conclusions: Intimate partner violence in pregnant women was present in the 4 types (psychological, physical, sexual and economic). The association was mainly present in damage to emotional health but it was also found association with damage to physical health commonly identified in pregnant women.
Keywords: Violence, emotional health damage, damage to physical health.
Family violence is a social problem that involves various areas such as human rights, social and legal justice, and public health, among others; it affects the living spaces of men and women, it comes from learning that occurs at home, school, through the media, and on the street; occurs in all cultures, in all social classes and in all stages of life.
Intimate partner violence is recognized as a public health problem in the world. In Mexico and in the Hidalgo State, as in many countries, its addition to the public agenda has been the product of a long journey whose central point has been the complaint, particularly made by the civil society organizations. However, after many socio-cultural, juridical and legal setbacks has been achieved that people see violence as a problem that affects health and that do exist possibilities to limit it.
Women are often victims of beatings and sexual abuse by the hands of their partners, family members, and in some cases, of neighbors or unknown people. However, it notes that most violent acts are not mortal, but it has immediate consequence such as physical and emotional injuries that can become mental disorders, reproductive health problems, most notably sexually transmitted infections. The pattern of continuous abuse can cause a permanent physical or mental disability to that who suffers them.
Pregnancy does not protect women against intimate partner violence; by contrast, it is a high risk period for the emergence or increasing of it in an already abusive relationship. 1
This research seeks to fill one of the many blank spaces, seeking to determine the association between intimate partner violence and damage to the health of pregnant women attending the Health Services of Hidalgo State.
Violence against woman cannot be attributed to individual diseases or mental disorders; not even alcoholism, unemployment, poverty or overcrowding are direct causes of violence, but only conditions attached to its practice, appearance, maintenance or intensity. 2
The World Bank estimated that annually there are nine million healthy life lost in the world by concept of rape and intimate partner violence.3 In a review made by the WHO (World Health Organization, 2005) among the different nations of women who report having been physically assaulted by an intimate partner, there were found results such as: 5.1% of women in the Philippines, 12.6% in Switzerland, 19.3% in Colombia, 20.8% in the Netherlands, 22.1% in the U.S.A, 29% in Canada, 34.4% were in Egypt , 47% and 67% respectively in villages of Bangladesh and Papua New Guinea. 4 Rate of mortality related to pregnancy and childbirth is from to two to five times higher among women under the age of 18 than among those who are about 20 to 29 years. 5
For European women aged 16 to 44 years, violence in the family is the leading cause of injury and death, between 25% and 50% are victims of this violence, said to be more lethal than road accidents and cancer.
Of medical appointments provided to women in Japan 13% and in Peru 61% suffered abuse by the hands of the man they lived with, the number rises to 75% when referring to emotional and psychological abuse, whose effects, according to its many victims, are even more difficult to overcome. Between 55% and 94% of abused women never receive any help. 6
The prevalence of violence in pregnant women ranges between 0.9 and 33.5% depending on the type of population studied. In India the number is 28.4%, in the United States 6.6%; in Canada ranges from 0.9 to 21.1%. It has been suggested that violence during pregnancy may be more common than diabetes or placenta previa. 7
PAHO (Pan American Health Organization) indicates that 19% of pregnant women in Mexico suffer violence especially in the third quarter of pregnancy 8. The National Institute of Public Health 9 found that 13% of the women interviewed reported having experienced violence (physical, psychological, sexual or economic) during any of their pregnancies.
On the National Survey on Violence Against Women (Spanish Encuesta Nacional sobre Violencia contra la Mujer-ENVIM 2006) 10 it was explored violence during pregnancy, 25% of surveyed said that suffered some type of abuse during pregnancy, being the most frequent: humiliations (8.4%), and being forced to have sex by her intimate partner 6.3% and 5.3% beatings.
Pregnancy does not protect women from violence, since 48.6% of abused women before pregnancy noted that violence remained the same during the period of gestation, and 25.8% of them, it even got worse. It is noteworthy that 4.4% of women, of all surveyed, said having been kicked and hit in the abdomen while pregnant. 11
Midwives and women recognize that often the abortion or fetal deaths are induced by the husband hits that his wife receives in the abdomen. Domestic violence plays a key role in the establishment of maternal risk, not only for the physical effect that may occur in the body of the pregnant woman, but by what is configured on the body and the psyche as a victim of violence since childhood to youth. 12
In a cross-sectional study of pregnant women in the states of Guerrero, Hidalgo, Oaxaca and Chiapas, 13% reported having experienced violence (physical, psychological, sexual and economic) during any of their pregnancies; one in three reported having been hit in the abdomen, 72% experienced more than one type of violence in the same period before the interview. These data as well as international level 91.4% the aggressor was the intimate partner. 13
Analytical cross-sectional epidemiological study was conducted in 12 priority municipalities using epidemiological indicators for maternal health, in units of primary care level of the Health Services of Hidalgo State.
Pregnant women went to the Observation Unit such women attended the antenatal care at the Health Centers of the Health Services of Hidalgo State, Jurisdiction One: Pachuca and Mineral de la Reforma; Jurisdiction Three: Tlahuelilpan, Tula de Allende, Tlaxcoapan and Tezontepec de Aldama; Jurisdiction Five: Zimapán; Jurisdiction Eight: Metztitlán; Jurisdiction Nine : Tepehuacán of Guerrero; Jurisdiction Ten: Huejutla and Yahualica and Jurisdiction Thirteen: San Bartolo Tutotepec, in the period between November 2009 and May 2010.
Of the 200 selected women, the average age was 24 years with a standard deviation of ± 6 years. The age range with the highest frequency was 15 to 19 years (34%), followed by 20 to 24 (24%), 25 to 29 was 21.0%, 30 to 34 years was 14% and 35 to more was 7%. Regarding schooling, 39.5% had completed high school and only 33.5% had higher education, noting that 91.0% were married or cohabiting.
80% of women were dedicated to home, 15.5% reported having some type of employment. No perceived economic income 84.5% and 4.5% they received less than twice the minimum daily wage. Regarding the right-holding the 100% of the population are responsible for the Health Services. Regarding alcohol consumption, 99.5% of women reported not having consumed alcoholic beverages.
Regarding the characterization of violence, 30.0% reported receiving violence (Fig.1) of which 16.5% reported physical violence (pushing or pulling hair, kicking, choking, or attempt to choke and hitting the abdomen); 52 .6% psychological violence (threats with gun, stopped talking, forbidden to work or study, they have felt ignored or not taken into account, have been embarrassed or belittled); 5.1% sexual violence (they have demanded unwanted sexual acts and forced sexual relations) and 25.8% economic violence, confirmed when they were asked if his partner complains about how she spends her money. The answer was affirmative (Fig. 2).
As a background of violence, 29% reported having experienced violence during childhood, 53.0% in the last 12 months were the victims of some type of violence by an intimate partner. Regarding experiences of violence experienced by her husband or partner during childhood 30% were beaten, the frequency was occasionally (17%).
In bivariate analysis, all tests were significant (p < .001) reflecting a dependence between the abuse performed and on its physical damage to health consequences. When crossed with indicators of psychological violence was observed that with the threat of abortion there is no association; when they are indicators of physical violence it was associated with bruising and swelling, followed with vaginal bleeding, threatened abortion and loss of the product; regarding economic violence there was association with the lack of medical care. (Table 1)
Dependence is seen between the different manifestations of violence and the impact they have on the psychological or emotional state of pregnant women, the main symptoms reported was anxiety, nervousness and lack of appetite. (Table No. 2)
Association between the violence and suicidal ideation was obtained, showed dependence (p < .001) mainly in variables of psychological and physical violence. The association of these same acts of abuse and attempted suicide showed only a slight dependence (p < .05) in some variables of psychological, physical and sexual violence (Table No. 3)
Crossing the variables of psychological violence, "has he stopped talking to you?" (PR .941 95% CI .911-.970); "Has he made you feel ashamed, belittled, told you that you are ugly or compared with other women?" (PR .974 95% CI .951-.997); "Does he ignore you; does he not take you into account; does he not show you affection?” (PR .973 95% CI .947-.999) and “Has he threatened you with a weapon?" (PR .998 95% CI .973-1.024) it was found that the risk for threatened abortion increases. No increased risk for vaginal bleeding or swelling and bruising to file was not found.
However, the PRs found were for the variables of mental health "lack of appetite" (PR1.093 95% CI 1.031-1.155) produced when the partner stops talking to you. On the other hand 10.3 times higher risk of anxiety (PR 1.103 95% CI 1.042-1.165); 10.4 times higher risk to have trouble sleeping (PR1.104 95% CI 1.039-1.169) and 3.5 higher risk for suicide thinking.
When the psychological variable "Has he made you feel ashamed, belittled, told you that you are ugly or compared with other women?" and the damage to emotional health were crossed it was found that for lack of appetite there is an increase of 11.8 times higher risk (PR 1.118 95% CI 1.063-1.173) in nerve problems was 11.8 (PR 1.068-1.169 95% CI 1.068-1.169), in anxiety it was found in 13.1 (PR 1.131 95% CI 1.075-1.186) in depression there is 21.8 ( PR 1.218 95% CI 1.152-1.285) in sleep problems was found 13.9 (PR 1.139 95% CI 1.078-1.201) and to the question regarding suicide was found 6.3 times the risk (PR 1.063, 95% CI 1.019-1.106).
The psychological variable "does he ignore you; does he not take you into account; does he nor show you affection?” was crossed. For damages to emotional health was found 11.8 more higher risk for lack of appetite (PR 1.118 95% CI 1.062-1.175) to nerve problems was 11.6 (PR 1.116 95% CI 1.065-1.166), anxiety was found to 13.3 (PR 1.133 95% CI 1.076-1.191), 21.3 for depression (PR 1.213 95% CI 1.147-1.280), 13.9 to have trouble sleeping (PR 1.139 95% CI 1.077-1.202) and regarding the question “have you thought of suicide?” it was found 6.3 times higher risk (PR 1.063 95% CI 1.018-1.109).
When the variable "has he threatened you with a gun?" was crossed with damage to emotional health it was found that lack of appetite had 15.5 times higher risk (PR 1.155 95% CI 1.096-1.214), 15.7 for nerve problems (PR 1.157 95% CI 1.103-1.212), 17 for anxiety (PR 1.170 95% CI 1.111-1.229) for depression it was found 25.8 (PR 1.188-1.328), for sleeping problems it was found 17.1 (PR 1.106-1.235) and 9.6 for suicidal ideation (PR 1.096 95% CI 1.048-1.144)
The association found with physical violence in the variable "has he pushed you or has he pulled your hair?" for damages to emotional health: there are 25.3 times higher risk to develop depression (PR 1.253 95% CI 1.184-1.321); 16.7 for trouble sleeping (PR 1.167 95% CI 1.104-1.229); 16 to suffer anxiety (PR 1.160 95% CI 1.103-1.217); 14.5 to present nerve problems (PR 1.145 95% CI 1.094-1.196); 13.8 to present lack of appetite (PR 1.138 95% CI 1.085-1.192) and 8.8 to think about suicide (PR 1.088 95% CI 1.041-1.134).
For the variable "has he kicked you?" in damage to emotional health it was found that there were 26.8 times higher risk to develop depression (PR 1.268 95% CI 1.199-1.337); 18.7 for sleep problems (PR 1.187 95% CI 1.121-1.252); 18 for anxiety (PR 1.18 95% CI 1.120-1.237); 16.6 for lack of appetite (PR 1.166 95% CI 1.106-1.225); 16.3 for nerve problems (PR 1.163 95% CI 1.110-1.216) and 10.3 to think of suicide (PR 1.103 95% CI 1.055-1.150)
The results of the variable “has he hit your abdomen?” it was found that there are 28.8 times higher risk to develop depression (PR 1.29 95% CI 1.218-1.359); 20.2 for trouble sleeping (PR 1.20 95% CI 1.136-1.267) and anxiety (PR 1.198% 95% CI 1.136-1.256); 18.1 for loss of appetite (PR 1.18 95% CI 1.121-1.241) and nerve problems (PR 1.18 95% CI 1.126-1.235); 11.5 to think of suicide (PR 1.115 95% CI 1.068-1.162).
When association of the variable representing sexual violence was searched, the results for the presence of edema and ecchymosis is 3.8 times higher risk (PR 1.038 95% CI 1.009-1.066), 2.1 for threatened abortion (PR 1.021 95% CI .993-1.049) and 1.0 time higher risk for vaginal bleeding (PR 1.010 95% CI .990-.1030).
When association with damage to emotional health was searched there was found 18.1 times more of presenting lack of appetite (PR 1.181 95% CI 1.121-1.241) for nerve problems it was found 18.3 (PR 1.183 95% CI 1.128-1.239) , 19.6 for anxiety (PR 1.196 95% CI 1.136-1.256), 28.8 for depression (PR 1.288 95% CI 1.218-1.359), 20.2 trouble sleeping (PR 1.202 95% CI 1.136-1.267) and 11.8 times more for suicide ideation (PR 1.118 95% CI 1.069-1.166).
Prevalence of intimate partner violence among pregnant women was 30%; lower than found in research conducted in 2006 in Mexico, which resulted in 38.8% 10, and in the investigation by Dr. Muñoz in the period from 2008 to 2009, where he obtained a prevalence of 35.37% 13. In psychological violence during pregnancy, the results of the National Survey on Violence Against Women10 were 12.74%, in the Hidalgo State (13) 48% was obtained; while in the present study was obtained 52.6%.
In terms of sexual violence, in the National Survey on Violence Against Women was obtained 8.43% 10 unlike 33.26% obtained in the research of Dr. Muñoz 13 while the results obtained in this investigation was 5.1%. As for physical violence, the result was 9.41% in the National Survey on Violence Against Women10, of which 5%, reported having been hit and / or kicked in the abdomen; while research in Hidalgo State13, a result of 27.11%(13), of which 8.6% reported having experienced abdominal trauma; in the present study 16.9% of this type of violence, of which 1.5%, said the attack aimed at the abdominal region, which shows that it can increase the risk to conclude pregnancy, threatening the product’s life and even the mother´s life.
In research conducted by PAHO 9 it was found that 16.9% of pregnant women suffered sexual violence, and of these, 1.5% were kicked or hit in the abdomen. In this same study it was found that extreme stress and anxiety caused by violence during pregnancy can lead to premature or delayed deliveries fetal growth.
In this study, significant association was found in all the variables of damage to mental health, which can be considered as a risk to present the abovementioned obstetric complications, so we consider the need for further research using more variables which allow supporting such premises.
Figure 1: Presence of Intimate Partner Violence at participating pregnant woman
Source: Survey “Explorador para identificar rasgos de violencia de pareja” (English: Explorer to identify features of intimate partner violence)
Figure 2: Percentage distribution by type of violence received by the participant pregnant woman
Source: Survey “Explorador para identificar rasgos de violencia de pareja” (English: Explorer to identify features of intimate partner violence)
Table Nº 1: Association among the violent acts and the physical damage in pregnant women of the Hidalgo State
|PHYSICAL DAMAGE /VIOLENT ACTS||Bruising or swelling||Threatened abortion||Vaginal bleeding||Medical attention||Product loss|
|Your partner has stopped talking to you||185.19***||185.60***||185.47***||185.47***||135.02***|
|Your partner has made you feel ashamed.||204.46***||206.34***||189.78***||191.67***||142.56***|
|Has forbidden you to go out||198.86***||192.39***||189.55***||189.55***||142.53***|
|Your partner ignores you||203.26***||194.12***||191.46***||201.49***||142.55***|
|Has threatened you with weapons||215.53***||215.67***||198.18***||203.64***||148.93***|
|Has stopped to give you money||208.58***||182.49***||200.31***||200.31***||150.59***|
|Has prohibited you to work or study||205.15***||179.72***||205.34***||205.34***||155.34***|
|Has pulled your hair||331.55***||185.09***||195.6***||214.97***||142.78***|
|Has kicked you||264.95***||175.37***||197.68***||225.55***||158.48***|
|Has hit your abdomen||254.20***||183.12***||210.56***||210.56***||158.42***|
|Has tried to strangulate you||226.18***||241.27***||189.94***||201.54***||158.45***|
|Has demanded you for sexual relations||195.55***||183.12***||189.9***||189.9***||158.42***|
|Has demanded you to perform non-conventional sexual acts||150.74***||138.66***||138.44***||140.42***||139.35***|
*** p < .001
Table Nº 2: Association among the violence acts and the psychological or emotional consequences in pregnant women.
|PSYCHOLOGICAL OR EMOTIONAL CONSEQUENCES /VIOLENT ACTS||Lack of appetite||Nerves||Anxiety||Sadness||No sleeping|
|Your partner has stopped talking to you||111.86***||123.03***||126.13***||119.16***||106.16***|
|Your partner has made you feel ashamed.||147.89***||160.36***||168.24***||153.67***||129.37***|
|Has forbidden you to go out||132.13***||147.98***||139.87***||130.32***||115.08***|
|Your partner ignores you||138.27***||157.17***||150.31***||156.88***||120.50***|
|Has threatened you with weapons||136.10***||132.06***||139.78***||122.22***||121.29***|
|Has stopped to give you money||122.39***||131.96***||137.82***||123.73***||103.27***|
|Has prohibited you to work or study||131.23***||143.55***||143.34***||137.01***||110.84***|
|Has pulled your hair||170.14***||146.69***||146.08***||122.85***||120.61***|
|Has kicked you||121.47***||135.09***||134.73***||124.43***||106.49***|
|Has hit your abdomen||120.92***||126.41***||126.41***||112.88***||106.11***|
|Has tried to strangle you||131.70***||125.78***||135.64***||118.59***||116.03***|
|Has demanded you for sexual relations||120.92***||117.22***||126.41***||112.88***||106.11***|
|Has demanded you to perform non-conventional sexual acts||86.34***||90.69***||91.38***||82.54***||74.96***|
***p < .001
Table Nº 3: Associations among the violence acts and the suicide attempts, possibility of change and pregnancy planning according to Pearson’s Chi-squared test (Pearson’s χ2).
|Has thought of taking her own life||Has tried to take her own life|
|Your partner has stopped talking to you||25.07***||2.67NS|
|Your partner has made you feel ashamed.||42.44***||3.26 NS|
|Has forbidden you to go out||35.40***||6.01 NS|
|Your partner ignores you||35.93***||12.94*|
|Has threatened you with weapons||31.37***||7.82 NS|
|Has stopped to give you money||27.11***||4.63 NS|
|Has prohibited you to work or study||31.20***||7.13 NS|
|Has pulled your hair||39.48***||11.20*|
|Has kicked you||33.84***||5.65 NS|
|Has hit your abdomen||36.05***||11.34*|
|Has tried to strangle you||40.33***||7.37 NS|
|Has demanded you for sexual relations||25.17**||5.03 NS|
|Has demanded you to perform non-conventional sexual acts||19.91**||10.65*|
***p < .001
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