1 International Peer Reviewed JournalVol. 15 · January 2014 Print ISSN 2012-3981 • Online ISSN 2244-0445 doi: http://dx.doi.org/10.7719/jpair.v15i1.262 JPAIR Multidisciplinary Research is produced by PAIR, an ISO 9001:2008 QMS certified by AJA Registrars, Inc. Nurse(s) make a Difference on Early Detection of Intimate Partner Violence (IPV) in Pregnancy: A Study Case AYNUR UYSAL TORAMAN ORCID No. 0000-0002-9140-7396 aynur.uysal@ege.edu.tr Ege University Bornova-Izmir, Turkey SAFAK DAĞHAN ORCID No. 0000-0003-2768-2737 safak.ergul@ege.edu.tr Ege University Bornova-Izmir, Turkey ABSTRACT Violence against women in the perinatal period is common and leads to negative health outcomes for women and infants. This case presentation demonstrates the value of home visit interventions and nursing implications for abused pregnant woman. A single case study was utilized in this research. The only participant in this study was Canan K.*, a 20 year-old pregnant living in Izmir, Turkey. Home visiting interventions addressing intimate partner violence in perinatal period have been effective in minimizing intimate partner violence and improving outcomes. In this case, the nursing educators and primary health care nurse served as an advocate for the abused woman, supporting her in her decision-making and providing necessary resources and referrals. 2 JPAIR Multidisciplinary Research Keywords - Health education, intimate partner violence (IPV), pregnancy, home visit, nursing intervention, case study, Turkey INTRODUCTION Given the high rates of IPV in the perinatal period (Garcia-Moreno et al., 2006) and the associated negative health outcomes, health care providers should routinely screen women for IPV; without such screening, few IPV cases are likely to be detected, and women cannot be appropriately referred to resources such as home visitation. Additionally, nurses and other health care professionals play an important role in identifying and preventing public health problems. They have an opportunity to help the victims of IPV as they work in a variety of health and community settings, and they often are the first ones, outside the family, to know about the abuse especially for nurses who serve as advocates for abused women, supporting them in their decision making and providing necessary resources and referrals (Sharps et al., 2008). FRAMEWORK Research conducted over the past two decades has demonstrated that many women, including those who are pregnant, are victims of physical abuse perpetrated by intimate partners in both developed and developing countries (Bohn et al.; 2004, Deveci et al., 2007; Bhandari et al., 2008). A summary of studies examining violence against pregnant women found that the prevalence ranges from 9% to 25%, with most studies in the 0.9% to 20.1% range (Arslantaş et al., 2012; Bohn, Tebben & Campbell, 2004; Schoening et al., 2004). Deveci et al. (2007) found that in Turkey, 28.9% of the pregnant women were exposed to physical violence. Studies have shown that domestic violence exposure to pregnant women is more prevalent than pregnancy related complications such as preeclampsia, and gestational diabetes that have detrimental effects on both the physical and mental health of the mother, as well as presenting risks for the baby (Deveci et al., 2007). Health consequences of intimate partner violence during the perinatal period noted in the literature include miscarriage, vaginal and cervical infections, sexually transmitted diseases, abruptio placentae (placental abruption), chrioamnionitis, preterm labor, low birth weight and intrauterine fetal death (Bhandari et al., 2008; Bohn et al., 2004; Durham et al., 2006; Schoening et al., 2004; Sharps 3 International Peer Reviewed Journal et al., 2008). Many of the negative effects of IPV during pregnancy are indirect, including inadequate perinatal care, poor maternal weight gain, substance abuse, suicide attempts, depression, the increased use of alcohol, tobacco, less social support and lower self-esteem (Bohn et al., 2004; Deveci et al., 2007; Durham et al., 2006; Sharps et al., 2008). While not all abused women have access to health care services, it is estimated that approximately 80% see physicians or health care providers during a one-year period and that abused women who use health care services do so at a higher rate than women who are not abused. Thus, health care professionals have the opportunity to assist the majority of abused women (McNutt et al., 1999). The International Council of Nurses (ICN, 2001), the American Medical Association (AMA, 2002) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN, 2007) recommend that practitioners screen all patients for IPV, regardless of the reason for which they are seeking health care. Women are four times more likely to report abuse if they are simply asked (Schoening et al., 2004). Nurses are in a key position to screen women for IPV. However, investigators found that many nurses lacked knowledge regarding IPV (Schoening et al., 2004). Home visiting historically has been an essential component of public health nursing practice. Perinatal home visiting interventions have been used to reduce risks for poor pregnancy outcomes, improve parenting skills, and enhance infant development. Current economic slowdowns and under funding of a variety of health initiatives and interventions have forced many public health departments to eliminate home visiting interventions. Some literature suggests that public health nurses be uniquely suited to be home visitors because of their advanced training in maternal and infant health and parenting and their ability to gain insight on family functioning (Arslantaş et al., 2012; Minsky-Kelly et al., 2005; Sharps et al., 2008). Early detection, supportive education, effective referral and ongoing support, and follow up for abused women could eventually reduce the prevalence of abusive injury. Until recent times, medical personnel is tended to ignore the violence towards women even if they have come across such women among their patients who are subjected to violence, and they have stayed away from the idea of the fact that this problem is their basic responsibility (Berkowitz, 2005; Griffin & Koss 2002; McCauley et al., 2003; Thurston et al., 1998). It is suggested that nurses’ attitudes have been effective on their intentions to screen patients for intimate partner abuse (Han, 2008; Schoening et al., 4 JPAIR Multidisciplinary Research 2004). In the research which Woodtli (2000) carried on with 13 experts who work on care related to violence, they indicate that nurses experience anger, disappointment, tenderness and empathy as well as sorrow while working with the victims of violence. There is a dearth of studies dealing with these topics and dimensions from the perspective of nursing students. While recent researches have been planned for students of social sciences and behavioral sciences to indicate the manners directed towards beaten women and beating men, very few researches have been carried out for students of the school of nursing and faculty of medicine (Coleman & Stith, 1997; Haj Yahia & Uysal, 2008; Haj-Yahia & de Zoysa, 2007). It is pointed out that people’s beliefs about wife beating appear and improve in the childhood, adolescence and young adulthood periods (Gerbert et al., 2002; Haj-Yahia & Uysal, 2008; Woodtli, 2000; Woodtli & Breslin, 1996). Lack of appropriate knowledge base contributes to an inability to identify and effectively care for victims of partner abuse, much could be done to educate nursing students. Content on domestic violence could easily be incorporated whenever women’s health issues are addressed on nursing curriculum (Coleman & Stith, 1997). Early detection, supportive education, effective referral and ongoing support, and follow up for abused women both at the social and practice level would be important. OBJECTIVE OF THE STUDY The purposes of this study are to: 1) define IPV in pregnancy; 2) share the experience of one abused pregnant woman; and 3) demonstrate the value of home visit interventions and nursing implications for abused pregnant woman. METHODOLOGY A single case study was used in this research. Case studies use in-depth data collection techniques that allow for the detailed study of all aspects of the case and the exploration of perspective that may have been missed when using other methods. Case study design focuses on the data analysis of one phenomenon, which the researcher selects to understand in depth regardless of the number of sites, participants or documents for the study and provides a detailed description and analysis of processes of themes voiced by participants in a particular situation (Polit & Beck, 2008). The case study has been described as being simultaneously 5 International Peer Reviewed Journal descriptive, exploratory and explanatory. However, it is acknowledged that a frequent criticism of case study methodology, incapable of providing a generalizing conclusion (Yin, 2009). Data was collected using a semi-structured interview form during the home visits by student nurse and educators-researchers. The only participant in this study was Canan K.*, a 20 year-old pregnant living in Izmir, Turkey. Assurances were provided regarding the confidential nature of the interview. *The names used in this case are pseudonyms. RESULTS AND DISCUSSION The case determined the value of home visit interventions and nursing implications for abused pregnant woman via the home visits conducted by the fourth year nursing school student during public health practices under the guidance of nursing educators and district nurse. 1.CASE 1.1. Detection In the first home visit, the student nurse posed the case descriptive questions concerning the family relations included in the family identification form. Canan K. is a primary school graduate who is 20 years old. A psychosocial history reveals that Canan lives in a rural district where low-income families reside and relocated to the region one year ago. She was employed as a worker at a textile factory until her pregnancy. Her husband is 25-year-old worker at a textile factory. It has been their first year of marriage, and she is 24 weeks pregnant. When asked about social relationships, Canan states that she is somewhat lonely because she is new to the region and has not formed any friendships. Besides, she adds “I left all my family and friends where we used to live.” My husband says, “we have each other, so we do not really need anyone else.” She states that her husband is very jealous and because of that he does not keep a telephone at home to limit her communication with others. On the other hand, he does not leave her any money for not enabling her to go out. The anxious appearance of Canan, her contradictory statements concerning family relations and her complaints concerning the negative impacts of her pregnancy on her relationship with her husband drew the attention of the student nurse. 6 JPAIR Multidisciplinary Research After completing the psychosocial history, student nurse and nurse educator performs general examination of the pregnant woman and assess vital signs, and measure height and weight. The physical examination is normal to inspection and palpation. The student nurse set a date for the second home visit in the short run. One week later, in the second home visit, the case expressed to the student nurse that she was exposed to violence perpetrated by her spouse. The student nurse did not come across any finding indicating that physical violence was perpetrated. She wrote down the story of the case by taking her permission and gave her feedback by telling her that she would help and support her. 1.2. Situation assessment The first case of physical violence occurred on the eighth day after the wedding. Following this incident, the case lived separately for a while but then she was persuaded by her spouse to come back home. As no cases of violence occurred for a while, thinking that her spouse changed, the case stated that they decided to have a baby. However, she stated that their life changed along with pregnancy and the furious behaviours of her spouse increased which led to the onset of violence. She stated that her husband pulled her hair to drag her way, mostly punched her in the stomach not to reveal the violence and sometimes she was even hit in the face. She also stated that right after her spouse perpetrated violence, he started caressing her face and then forced her to have sexual intercourse with him. Furthermore, the case expressed that her spouse showed excessive interest and affection to her and the baby in her abdomen one day after he perpetrated violence. The case is worried that her family would hear about her story. In this regard, the student nurse promised to keep the information confidential and only share it with the authorities of the health center in the district. After she had left the house, she shared this information about the case with the educators who is guiding her in the public health practice program conducted within the health center in the district. Together with the student nurse, the educators made an interview with the nurse and the doctor who are in charge of watching the pregnancy of the case. Following this interview, a plan regarding the case of violence was made. The legal and social procedures concerning domestic violence was analyzed by this team. 7 International Peer Reviewed Journal 1.3. Intervention /Case Management Guidelines prepared ICN, ANA and AWHONN for nurses and health professionals were used for case management. According to this plan, the student conducted another home visit with the district nurse and researchers. First, whether there was a life threat for the woman and the baby was assessed, and the case expressed that such a threat did not exist. The district nurse did not notify forensic institutions of the case as there was not any sign violence-related injuries at the time of the interview made with the case. However, the woman was informed about her medical and legal rights when she was exposed to violence and was asked what she preferred to do at that moment. The woman stated that she would not file a legal application and that she did not want to leave the house or make the case known to her family. Accordingly, the health crew offered solutions regarding domestic violence. By giving support and courage, the woman was motivated to fight with this problem. In accordance with the plan designed, the district nurse and researchers worked as a consultant for the case. Within the scope of the consultancy, her medical and legal rights were explained to the case. At the same time, help resources from which the case could benefit were listed, and information on social support systems and communication network were also given. The women’s consultation center of the local management was contacted, and the case was provided a connection with a psychologist employed at the center. The case was given a booklet which could guide her when necessary as it includes the cases and indicators that might magnify the danger, increase the cycle of violence and its impacts on herself as well as the baby. After the case had started seeing a psychologist, another home visit was conducted. The case stated that she demonstrated the behavior pattern that was suggested to her by the psychologist. Accordingly, she told her spouse about the legal procedures that would be followed in case of violence and added that the situation in the house was being watched by both the health center of the district and women’s consultation center. The case expressed that her spouse became uneasy by what she told him and that he brought her flowers while coming home for the last three weeks, adding that he did not perpetrate any violence. Furthermore, her husband rejected seeing the psychologist on his behavior of violence. The case continued her weekly phone interviews with the psychologist. The case expressed that she did not experience an act of violence within the one-month period in which the home visit was conducted. The advanced follow-up and consulting services of the case were provided by the district nurse, and a repetitive case of violence was not observed in the pregnancy process. 8 JPAIR Multidisciplinary Research This case example demonstrates how a nurse can help women who have experienced IPV during pregnancy. Low socio-economic and educational status, early marriage, alcohol and substance abuse habits of the partner, immigration, and unemployment are among the main risk factors for domestic violence (Bhandari et al., 2008; Bohn et al., 2004, Deveci et al., 2007; Van Hightower & Gorton, 1998). The risk factors for increased domestic violence found in this case was consistent with the literature. These factors can be defined as the sociodemographic characteristics of the case such as her age, early marriage and the fact that she settled in the district through migration from another region. In the study conducted by Bohn et al. (2004), it was determined that the most significant predictor that increased the risk of violence during pregnancy was the woman’s level of education. In the same study, it was also determined that the rate of being exposed to violence was higher in women who had an educational level below high school. The low level of education was considered a significant risk factor in this case, as well. The sociocultural analysis of spouse abuse views sex-role socialization, which results in aggressive, dominant, authoritarian men and passive, dependent, self-sacrificing women, as one vital social mechanism for the creation and legitimization of an ideology that supports male dominance and the need to maintain power through whatever means are deemed necessary (Bhandari et al., 2008; Coleman & Stith, 1997). Patriarchal norms are still predominant in the Turkish society, particularly inside the family; having strong impact on relations between husbands and wives. This popular local saying is a reflection of norms that sanction domestic violence: “After all, he’s your husband; he can both love you and beat you”. This patriarchal structure seems dominant in the family life of the case. The social relations and expenditure of the pregnant woman are controlled by her spouse. A striking finding is that the case considered the situation usual and the case did not render the experience a problem until physical violence occurred. It is stated in the literature that some forms of violence and force should be tolerated and accepted physical violence occurs more frequently in the first years of marriage (Martin et al., 2004). Similarly, the case was exposed to violence in the first days of marriage. The story of violence was experienced in a typical cycle of violence (tension, acting-out phase, separation and the honeymoon phase caused by the spouse’s regret). In a period without violence the woman decided to become pregnant thinking that her spouse changed. However, acts of violence were repeated in the period of pregnancy as well. Most victims will not spontaneously disclose that they are victims of wife abuse (Han, 2008). It is difficult to explain domestic violence to persons, other 9 International Peer Reviewed Journal than family members, due to the cultural and traditional structure in the Turkish population. Therefore, women do not admit that they have been exposed to abuse or violence, and do not give any information about details (Deveci et al., 2007). In the same way, the case did not apply to a legal or institutional mechanism in order to receive help until the home visit was conducted by the student nurse. Researchers are of the opinion that violence could be decreased by up to 75 % through its definition and intervention by professionals working in primary health care centers (Glaister & Kesling, 2002; Arslantaş et al., 2012). A recent study also identified health care provider characteristics that may hinder disclosure of abuse. These include the woman’s fear that she will be judged or blamed for the abuse and perceptions that the provider was uncaring, rushed, too busy, uncomfortable or not really listening (Bohn et al., 2004). Therefore, the home visit conducted by the nurse in the woman’s own environment reduces these negative barriers to the minimum. During home visits, the following points are suggested to be taken into consideration and carefully analyzed; the medical history of the persons that are suspected to be exposed to violence, chronic complaints and physical injuries observed during pregnancy. Furthermore, while diagnosing through appropriate questions and examination methods, all records should be kept in full (Atan & Şirin, 2005; Sharps et al., 2008). The student developed trust in the case and she confided the abuse she experienced during home visits period. Developing a trusting relationship with health care providers is important in intimate partner violence. In the study conducted by Mcnutt et al. (1999), it was determined that being asked questions concerning domestic violence, being listened to, being believed and not being judged when they tell the violence they experienced were the expectations of the domestic violence victims from health professionals. Besides, they want information about domestic violence and reference to community resources to be provided when needed. The aforementioned approaches were taken into consideration and confidentiality was provided with the case. The educators, nurse, doctor and student nurse in charge at the health center all abided by the legal arrangements and the domestic violence case management guidelines. Within this framework, the conditions of the pregnant woman were evaluated, the process of guiding and education was conducted, and the woman was informed about her medical and legal rights as well as the legal and institutional mechanisms she could apply for support. The experimental studies put forward the fact that the guidance and education conducted with home visits reduced the frequency of the physical violence the pregnant women experienced, led the women to utilize help resources more, and 10 JPAIR Multidisciplinary Research increased their self-confidence. (Olds et al., 2004; Sharps et al., 2008; Sullivan & Bybee, 1999). In the case in question, the advocacy, support and the information provided by the nurse made the pregnant woman gain confidence and encouraged her. She started receiving guidance on family relations from the psychologist at the Local Women’s Consultation Center. The limitation of this study concerns the limited generalizability due to limited sample. If more samples were obtained, the patterns of IPV abuse and preferred interventions could have been determined. CONCLUSIONS Nurses and other health workers have intimate knowledge of homes and other settings where violence takes place and they must take actions to break the cycle. Health professionals who work in the community may suspect or detect signs of violence during home visits or when the victim seeks health care. Although the knowledge of intimate partner violence in Turkey has recently increased, knowledge and research on pregnant abused women is still limited. While descriptive studies portraying the frequency and prevalence of spouse violence towards pregnant women are recently observed, case presentations in which acts of violence are discussed are limited. This study puts forward the effect of home visiting conducted in the perinatal period on the early diagnosis of IPV and in avoiding negative health outcomes for women and infants. This case is significant for the nurses working in primary health care centers to determine the case of violence which is not considered primary in terms of mother and infant health during perinatal follow-up and it constitutes an example for case management. ACKNOWLEDGMENT The authors would like to thank the nursing student and district nurse for their collaboration and support to the case. LITERATURE CITED American Medical Association 2002 October is domestic violence awareness month. Retrieved January 12, 2009 from http://goo.gl/QEN8MR 11 International Peer Reviewed Journal Association of Women’s Health, Obstetric and Neonatal Nurses 2007 Opposition to mandatory reporting of intimate partner violence. Retrieved January 13, 2009, from http://goo.gl/PY9jx1 Arslantaş, H., Adana, F., Ergin, F., Gey, N., Biçer, N., & Kıranşal, N. 2012 Domestic Violence During Pregnancy in an Eastern City of Turkey A Field Study. Journal of interpersonal violence, 27(7), 1293-1313. 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