الفهرس 
Etiology and Risk factors
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Abstract
Recently IPV against pregnant women has been increasingly recognized as an extremely important public health issue with severe adverse consequences. It has a direct impact on the health, well being, survival and quality of life of women, family and children worldwide. PIPV is associated with poor birth outcomes as well as numerous physical and mental sequelae. It also affects the capacity of women to act as equal and productive partners in their society and economy.
The aim of the present work was to study the prevalence of violence against pregnant women and its relationship with post-partum depression and post-traumatic stress disorder. Specific objectives included: estimating the prevalence rate of intimate partner violence against pregnant women, whether physical, emotional or sexual; identifying the relationship of intimate partner violence against pregnant women with the birth outcome in the post-partum period (gestational age, birth weight, type of delivery, admission to NICU); and investigating the relationship of violence against pregnant women with post-partum depression and post-traumatic stress disorder.
A cross-sectional study design was conducted in Family Health Centers in Alexandria, targeting post-partum women attending the above mentioned settings. The sample size was determined to be at least 544 based on a prevalence estimate of 15%, using 3% desired degree of precision and 95% confidence limits. Cases were recruited from FHCs representing each district of the seven districts of Alexandria. The previously determined sample was proportionally allocated on the seven FHCs based on daily attendance, where women who were in the post-partum period attending the selected FHCs during the visits were invited to participate in the study after taking their verbal consent.
Participants were subjected to:
1. Structured interview using a predesigned questionnaire to collect socio-demographic, personal history including husband-wife relationship, medical and psychiatric history of the woman and her family, history of smoking and drug intake by the female and her husband, reproductive history and history of birth outcome.
2. Psychological testing using the modified Arabic version of AAS. In addition to the Arabic version of each of the following; PSS4, SWLS, EPDS and PCL-C. All the tests were translated into Arabic in the preparatory phase of the present study except for the EPDS.
The study revealed the following important results:
• The Arabic version of PSS4 showed satisfactory test re-test reliability (r=0.93 at 0.01 level) and internal consistency (α=0.96).
• The Arabic version of SWLS showed satisfactory test re-test reliability (r=0.98 at 0.01 level) and internal consistency (α=0.99).
• The Arabic version of AAS showed satisfactory test re-test reliability (r=1 at 0.01 level) and internal consistency (α=1).
• Reliability and validity of the Arabic Version of PCL-C:
- Satisfactory test re-test reliability (r=0.99 at 0.01 level) and internal consistency (α=0.99)
- Factor analysis revealed that three factors were extracted in concordance with DSM-IV three clusters of symptoms; reflecting recurrent re-experiencing of events, arousal and avoidance.
• The prevalence of IPV:
- Ever experiencing psychological IPV was 87.6%, during the year preceding the study was 55.1% and during pregnancy was 46.2%.
Prevalence of ever experiencing physical IPV was 71.6%, during the preceding year was 22.4% and during pregnancy was 19.1%.
Prevalence of sexual IPV during the preceding year was 7.6% and during pregnancy was 7.4%. All the previous results were based on the modified Arabic version of AAS.
- Ever exposure to psychological IPV alone was 16.0%, combined psychological and physical IPV was 71.6%.
The preceding year exposure to psychological IPV alone was 31.9%, combined psychological and physical IPV was 15.1%, all three types of IPV combined (psychological, physical and sexual) was 7.6%.
During pregnancy IPV alone was 26.9%, combined psychological and physical was 11.9%, all three types of IPV combined was 7.4%.
- The percentage of postpartum mothers who experienced abuse for the first time during pregnancy was estimated to be 44.3%, the percentage of postpartum mothers who reported a decrease in the rate of abuse during pregnancy was 41.5%. About 33.0% reported the same rate of abuse and 25.5% reported an increase in the rate of abuse during pregnancy. About 16% stopped being abused during pregnancy.
• Postpartum mothers in the age groups “18 to less than 27 years” and “36 to less than or equals to 45 years” were significantly more exposed to abuse during pregnancy than those in the age group “27 to less than 36 years” (55.4%, 55.3% and 34.8% respectively).
• The group of age difference between the husband and wife “6 to less than 16 years” had significantly more exposure to abuse during pregnancy, followed by the age difference group “less than 6 years”, while the least percentage of abuse was in the age difference group “16 to less than 26 years” (52.5%, 42.1% and 10.0% respectively).
• Higher education of the mother was significantly associated with lower abuse during pregnancy (primary, preparatory, secondary and university/postgraduate 69.6%, 67.0%, 50.5% and 30.7% respectively).
• Higher education of the husband was significantly associated with lower abuse during pregnancy (primary, preparatory, secondary and university/postgraduate 83.3%, 74.1%, 52.7% and 26.7% respectively).
• The group of postpartum mothers who were married since more than 10 years were significantly more abused during pregnancy, followed by the group married since 1 to less than 5 years, while those married since 5 years to less than 10 years were the least abused (55.0%, 49.2% and 29.8% % respectively).
• Postpartum mothers with low and moderate socio-economic level were at higher risk of exposure to pregnancy IPV than those with high socio-economic level (OR=4.8 and 2.4 respectively).
• Postpartum mothers with bad and moderate marital relation were at significantly higher risk of exposure to pregnancy IPV than those with good marital relation (OR=58 and 5.1 respectively).
• Postpartum women who always and sometimes had marital conflict were at a significantly higher risk of being abused during pregnancy than those who never had marital conflict (OR=204.0 and 16.1 respectively).
• The highest causes of marital conflict in relation to abuse during pregnancy were wife’s parents, financial issues and husband’s parents respectively.
• Husbands who smoked cigarettes were at a significantly higher risk of abusing their wives during pregnancy IPV than husbands who did not smoke (OR=1.6).
• Husbands who were substance abusers were at a significantly higher risk of abusing their wives during pregnancy IPV than husbands who were not (OR=44.4).
• Postpartum mothers who smoked cigarettes were significantly more abused during pregnancy than wives who did not smoke (90.0% and 45.6% respectively).
• Mothers who smoked cigarettes during pregnancy were significantly more abused during pregnancy than wives who did not smoke cigarettes during pregnancy (100.0% and 49.5% respectively).
• Mothers who were substance abusers were significantly more abused during pregnancy than wives who were not (77.8% and 45.8% respectively).
• Mothers who were substance abusers during pregnancy were significantly more abused during pregnancy than wives who were not (66.7% and 46.1% respectively).
• Husbands who preferred boys significantly abused their wives during pregnancy more than those who had no sex preference (OR=2.6), while husbands who preferred girls were significantly less abusive to their wives during pregnancy than those who had no sex preference (OR=0.5).
• Mothers who were intending to be pregnant were significantly less abused during pregnancy than those who were not (OR=0.5).
• Mothers with history of psychiatric problems were significantly more subjected to abuse during pregnancy than those with no history (76.3% and 40.9% respectively).
• Mothers who had history of depression and anxiety were significantly subjected to more abuse during pregnancy than those who had history of OCD ((81.9%, 60% and 0% respectively).
• Women with family history of psychiatric problems were significantly more exposed to abuse during pregnancy than those with no history (69.1% and 43.6% respectively).
• Postpartum mothers who were exposed to abuse during pregnancy had a significantly higher rate of bleeding in pregnancy than those who were not exposed to abuse (42.3% and 27.2% respectively).
• Postpartum mothers who were abused during pregnancy were at significantly higher risk of having LBW infants than wives who were not abused (OR=2.9).
• The mean score of perceived stress of the post-partum wives abused during pregnancy was significantly higher than the mean score of perceived stress of the post-partum wives who were not abused (13.4 ± 3.4 and 10.9 ± 3.2 respectively).
• The mean score of satisfaction with life of the post-partum wives abused during pregnancy was significantly less than the mean score of satisfaction with life of the post-partum women who were not abused (12.9 ± 5.7 and 19.0 ± 4.6 respectively).
• Post-partum depression was significantly higher among post-partum women who were abused during pregnancy than those who were not abused (81.2% and 42.9% respectively, OR= 5.7).
• Post-traumatic stress disorder was significantly more prevalent among post-partum women exposed to abuse during pregnancy compared to those who were not exposed (51.8% and 14.8% respectively, OR= 5.4).
• Co-morbidity between PPD and PTSD was significantly higher among post-partum women subjected to abuse during pregnancy compared to those who were not subjected (45.2 % and 13.1% respectively, OR= 5.5).
• On logistic regression analysis, the presence of PIPV was significantly associated with the following variables: age of the wife (OR=0.79), marriage years (OR=0.68), marital conflict (OR=0.11), intending to be pregnant (OR=0.47), marital relation (OR=2.25), socio-economic level (OR=0.55), husband substance abuse (OR=0.06), husband sex preference (OR=0.75), mother history of psychiciatric problems (OR=0.38) and family history of psychiciatric problems (OR=0.31).
Accordingly, the following recommendations are suggested:
• PHC centers and FHCs play a vital role in the prevention of IPV, because females always pay several visits to these centers during pregnancy and in the post-partum period. PHC staff and obstetricians should be trained on identifying IPV and its underlying risk factors by proper history taking from all females attending these settings.
• On job training should be regularly offered to health care workers in the PHC centers to familiarize them with screening tools of PIPV and some of its common consequences (such as PPD and PTSD). Such training program should include signs and symptoms related to IPV (especially during pregnancy).
• PHC staff should periodically apply routine IPV screening for pregnant women and women in the post-partum period. Screening should take place in a private and safe setting with the woman alone.
• The routine medical history should incorporate IPV screening by including pertinent questions on intake forms. On identification of IPV (in general or during pregnancy), support and prevention should be provided and referral options should be discussed.
• The modified Arabic version of AAS is recommended as a valid screening tool for IPV by health care workers dealing with pregnant women in primary care settings.
• Provision of screening PIPV exposed wives for PPD by EPDS and PTSD by PCL-C, also PSS4 and SWLS are recommended to find out perceived stress and satisfaction with life respectively.
• Developing educational manuals about IPV for women in general, pregnant women and their families in particular. These should be available in the waiting areas of PHC settings.
• Need assessment of females exposed to IPV, especially those who are exposed to IPV during pregnancy, should be multi-dimensional involving psychiatric, psychological, social and educational services.
• Psycho-education should be an integral part of any IPV intervention program for women exposed to IPV, especially during pregnancy, including educating pregnant females about risk and protective factors of IPV, communicating skills, problem solving skills and how to deal with depression and perceived stress.
• For targeting violence in general, we should address the three main pillars affecting its occurrence (i.e. community, school and family). Educational material about violence in the form of pamphlets or brochures should be properly prepared by experts and made available in any community service, PHC setting and in all school grades.
• Teachers should be subjected to proper awareness and training to deal effectively with the problem of violence in schools.
• Violence in families, wrong family norms and gender issues should be addressed by heath care workers. These should be discussed with the couples during the premarital counseling (family life education).
• Community awareness should start with advocacy for gender equality and women’s human rights by raising the status of women through education and employment. Political and religious leaders can play an important role in this awareness.
• Periodic evaluation of the implemented programs against violence in general and IPV in particular.
• Future research on IPV against pregnant women is greatly needed to illuminate gaps in our understanding.