Abstract

This study analyzes the association between violence against women during pregnancy and intimate partner socioeconomic and behavioral characteristics. We conducted an analytical cross-sectional study with 327 postpartum women admitted to a maternity hospital in a city in Espírito Santo, Brazil using a questionnaire to collect data on intimate partner socioeconomic and behavioral characteristics. Intimate partner violence was assessed using questions based on the World Health Organisation instrument “Violence against Women (WHO VAW STUDY)”. Associations were tested using crude and adjusted Poisson regression. The prevalence of psychological violence during pregnancy was higher among women whose partners consumed alcohol, refused to use condoms, and were not the infant’s biological father. Physical violence was associated with women whose partners did not work and refused to use condoms. The prevalence of sexual violence during pregnancy was more than nine times higher among women with partners who refused to use condoms. The findings demonstrate that antenatal care is an opportune time to approach partners about health care and address violence. It is necessary to promote the utilization of health services by men in order to address risk factors for violence during pregnancy.

Key words:
Intimate partner violence; Violence against women; Spouse abuse; Masculinity; Pregnancy

Introduction

The World Health Organisation report “The World Report on Violence and Health” defines Intimate partner violence (IPV) as any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors¹.

National and international studies show that victims of IPV are predominantly women and that women experience more serious forms of violence than men²2 Lindner SR, Coelho EBS, Bolsoni CC, Rojas PF, Boing AF. Prevalência de violência física por parceiro íntimo em homens e mulheres de Florianópolis, Santa Catarina, Brasil: estudo de base populacional. Cad Saude Publica 2015; 31(4):815-826.^,33 Smith SG, Zhang X, Basile KC, Merrick MT, Wang J, Kresnow M, Chen J. The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 Data Brief - Updated Release. Atlanta: Centers for Disease Control and Prevention (CDC); 2018.. Data from the United States reveal that 36.0% of American women have experienced IPV during their lifetime³3 Smith SG, Zhang X, Basile KC, Merrick MT, Wang J, Kresnow M, Chen J. The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 Data Brief - Updated Release. Atlanta: Centers for Disease Control and Prevention (CDC); 2018.. In Brazil, a study undertaken in 15 state capitals and the Federal District reported that the prevalence of psychological violence ranged from 61.7% in Campo Grande to 85.6% in Belo Horizonte, while physical violence ranged from 13.2% in João Pessoa to 34.7% in Belém⁴4 Reichenheim ME, Moraes CL, Szklo A, Hasselmann MH, Souza ER, Lozana JA, Figueiredo V. The magnitude of intimate partner violence in Brazil: portraits from 15 capital cities and the Federal District. Cad Saude Publica 2006; 22(2):425-437.. The prevalence of lifetime psychological, physical and sexual IPV in Vitória was 57.6%, 39.3%, and 18.0%, respecitvely⁵5 Santos IB, Leite FMC, Amorim MHC, Maciel PMA, Gigante DP. Violência contra a mulher na vida: estudo entre usuárias da atenção primária. Cien Saud Colet 2020; 25(50):1935-1946..

In light of the above, it is important to investigate gender asymmetry in relationships, as although social changes have taken place over time, we continue to witness the reproduction of inequalities in intimate relationships⁶6 Bandeira LM. Violência de gênero: a construção de um campo teórico e de investigação. Soc Estado 2014; 29(2):449-469.. Traditionally the hegemonic concept of masculinity has been used to refer to ideas of men’s domination over women, virility, strength and power, characteristics that counterpose the attributes of femininity, such as fragility and submission. These characteristics are part of the social construction of masculine identity, demarcating expected and socially legitimate conduct, such violent behavior⁷7 Paixão GPN, Gomes NP, Diniz NMF, Couto TM, Vianna LAC, Santos SMP. Situations which precipitate conflicts in the conjugal relationship: the women's discourse. Texto Contexto Enferm 2014; 23(4):1041-1049.^,88 Silva AF, Gomes NP, Pereira A, Magalhães JRF, Estrela FM, Sousa AR, Carneiro JB. Atributos sociais da masculinidade que suscitam a violência por parceiro íntimo. Rev Bras Enferm 2020; 73(6):e20190470..

With regard to perpetrators of IPV against women, a number of characteristics are associated with acts of violence. Women whose partners are unemployed, have a low level of education, consume alcohol, and are controlling, are more likely to experience violence⁹9 Leite FMC, Luis MA, Amorim MHC, Maciel ELN, Gigante DP. Violência contra a mulher e sua associação com o perfil do parceiro íntimo: estudo com usuárias da atenção primária. Rev Bras Epidemiol 2019; 22:e190056.. Other factors that are precipitators of violence include jealousy, suspicions of infidelity, refusal to have sex, different approaches to raising children, and unplanned fatherhood⁸8 Silva AF, Gomes NP, Pereira A, Magalhães JRF, Estrela FM, Sousa AR, Carneiro JB. Atributos sociais da masculinidade que suscitam a violência por parceiro íntimo. Rev Bras Enferm 2020; 73(6):e20190470.^,1010 Lírio JG S, Pereira A, Gomes NP, Paixão GPN, Couto TM, Ferreira AS. Elements which precipitate conjugal violence: the discourse of men in criminal prosecution. Rev Esc Enferm USP 2019; 53:e03428..

It is important to highlight that violence is a reality in the life of women and manifests itself throughout all stages of life, including pregnancy. There is no consensus in the literature as to whether pregnancy is a risk factor or protective factor against violence. Silva et al.¹¹11 Silva EP, Ludermir AB, Araújo TVB, Valongueiro SA. Frequência e padrão da violência por parceiro íntimo antes, durante e depois da gravidez. Rev Saude Publica 2011; 45(6):1044-1053. point out that different types of violence can overlap, with around 11.0% of women experiencing psychological, physical and sexual violence during pregnancy. Other studies show that the prevalence of violence is similar before and during pregnancy, but during pregnancy there is a pronounced increase in psychological violence and reduction in physical violence. Another study showed that the incidence of IPV during pregnancy was 9.7%.

The consequences of IPV during pregnancy are greater as it directly affects the health of both the mother and infant. Studies show that pregnant women who experience IPV are more likely to develop symptoms of depression and post-traumatic stress disorder and have an increased risk of early cessation of breastfeeding and misscarriage¹²12 Mendoza VB, Harville EW, Savage J, Giarratano G. Experiences of intimate partner and neighborhood violence and their association with mental health in pregnant women. J Interpers Violence 2018; 33(6):938-959.

13 Madsen FK, Holm-Larsen CE, Wu C, Rogathi J, Manongi R, Mushi D, Meyrowitsch DW, Itoft TG, Sigalla GN, Rasch V. Intimate partner violence and subsequent premature termination of exclusive breastfeeding: A cohort study. PLoS One 2019; 14(6):e0217479.^-1414 Nur N. Association between domestic violence and miscarriage: a population-based cross-sectional study among women of childbearing ages, Sivas, Turkey. Women & Health 2014; 54(5):425-438.. Violence is also associated with newborn health outcomes, including prematurity, low birth weight, and fetal and neonatal death¹⁵15 Leite FMC, Gabira FG, Freitas PA, Lima EFA, Bravim LR, Primo CC. Implicações para o feto e recém-nascido da violência durante a gestação: revisão sistemática. J Res Fundam Care Online 2019; 11(spec.):533-539..

In view of the complexity and impacts of violence against women, including violence during pregnancy, combined with the fact that men are the main perpetrators of IPV, the aim of the present study was to explore the association between violence against women during pregnancy and the socioeconomic and behavioral characteristics of the intimate partner.

Methodology

We conducted an analytical cross-sectional study with postpartum women admitted to a public maternity facility in Cariacica in the state of Espírito Santo between August and October 2017.

The eligibility criteria for participants were as follows: postpartum women admitted to the maternity facility for at least 24 hours after birth with a live baby (weighing > 500 grams) who had had an intimate partner during pregnancy. Intimate partner was defined as the woman’s partner/ex-partner, regardless of whether or not there was a formal commitment, and boyfriends, provided they had sexual relations.

The sample size was calculated using a prevalence of IPV violence during pregnancy of 20%¹⁶16 Oliveira LCQ, Fonseca-Machado MO, Stefanello J, Gomes-Sponholz FA. Violência por parceiro íntimo na gestação: identificação de mulheres vítimas de seus parceiros. Rev Gaucha Enferm 2015; 36(spe.):233-238., adopting a 5% sampling error and 95% confidence interval, and adding 10.0% to account for sample losses and 30.0% for confounding factors, resulting in a final sample of 327 postpartum women.

We used a standardized questionnaire developed for the study with closed-ended questions devised to collect information on intimate partner socioeconomic (age, race/color, level of education, paid work) and behavioral (alcohol consumption, smoking, drug use, jealous behavior, controlling behavior and refusal to use a condom) characteristics, and whether the partner was the father of the newborn. The variables controlling behavior and jealousy were assessed using the following dichotomous question (yes/no): “Is he jealous?” and “Is he controlling?”

Information on the dependent variables (psychological, physical, and sexual violence during pregnancy) was collected using questions based on the World Health Organisation instrument “Violence against Women (WHO VAW STUDY)”. The instrument characterizes these different types of violence as follows: physical violence - physical aggression or the use of objects to cause injury; psychological violence - threatening behavior, humiliation and insults; and sexual violence - physically forced sexual relations or threats and humiliating acts. Victimization was classified according to type of violence based on yes answers to specific questions relating to each type of violence¹⁷17 Schraiber LB, Latorre MRDO, França Junior I, Segri NJ, D'Oliveira AFPL. Validade do instrumento WHO VAW STUDY para estimar violência de gênero contra a mulher. Rev Saude Publica 2010; 44(4):658-666..

The eligible postpartum women were invited to participate in the study and those who accepted signed an informed consent form. A copy of the form was given to the participant and another copy remained with the interviewer for filing. In the case of underage mothers, one of the parents or guardians signed the informed consent form. The interviews were conducted in a private area by previously trained interviewers, who undertook a pilot study in the same maternity facility a month before data collection. The training emphasized guidance on ethical aspects such as the appropriate application of the questionnaire.

The data were inputted into Microsoft Office Excel version 2010 by a previously trained digitizer. Data entry was crosschecked for possible inconsistencies. The data were analyzed using STATA 13 and the following descriptive statistics: raw frequencies, relative frequencies, and 95% confidence interval. To identify the distribution of violence during pregnancy and partner socioeconomic and behavioral characteristics we used the Pearson’s chi-squared test or Fisher’s exact test. To examine the association between the outcomes and exposures we ran a multivariate Poisson regression model including all variables with a p-value of < 0.20 and maintaining variables with a p-value of < 0.05. The results are presented using crude and adjusted prevalence ratios and their respective 95% confidence intervals.

The study protocol was approved by the research ethics committee (approval code 2.149.430).

Results

The majority of the partners were aged up to 40 years (89.3%) and were predominantly brown (44.8%) and had completed at least nine years of education (60.5%). Almost one- quarter (23.8%) did not have paid work. With regard to behavioral characteristics, 56.0% did not drink and 89.6% did not use drugs. Over half of the partners were reported to be jealous (51.4%), while 36.1% were considered controlling. Finally, 27.2% of the partners refused to use a condom and 95.7% were the father of the newborn (Table 1).

The results of the bivariate analysis presented in Table 2 show that the frequency of psychological, physical and sexual violence during pregnancy was higher in women whose partners refused to use a condom, while the prevalence of psychological and physical violence was higher among women whose partners did not have paid work. The frequency of psychological violence was higher in women with partners who consumed alcohol, were controlling, and were not the father of the newborn (p < 0.05).

After adjustment for possible confounding variables, the results show that the prevalence of psychological violence was 1.72 times higher in women whose partners consumed alcohol (PR: 1.72; 95%CI: 1.05-2.83) and 1.77 times higher among women whose partners refused to use a condom (PR: 1.77; 95%CI: 1.10-2.86) (Table 3).

Table 4 shows that the prevalence of physical violence during pregnancy was higher in women whose partners did not have paid work (PR: 2.70; 95%CI: 1.27-5.72) and refused to use a condom (PR: 2.22; 95%CI: 1.04-4.71).

Prevalence of sexual violence during pregnancy was 9.36 times higher among women whose partners refused to use a condom (PR: 9.36; 95%CI: 1.97-44.31) (Table 5).

Discussion

Our findings show that the prevalence of violence during pregnancy was higher among women whose partners consumed alcohol, did not work, refused to use a condom, and were not the father of the newborn. The variables race/color, use of illicit drugs, and having a jealous and/or controlling partner did not maintain their association after adjusted multivariate analysis.

Although women report experiencing violence in various life stages, violence during pregnancy is particularly worrying because it can have health consequences for both the mother and infant¹¹11 Silva EP, Ludermir AB, Araújo TVB, Valongueiro SA. Frequência e padrão da violência por parceiro íntimo antes, durante e depois da gravidez. Rev Saude Publica 2011; 45(6):1044-1053.. Faced with changes in routine, ambivalent feelings and the possibility of an unplanned pregnancy, pregnancy is period of profound change in which couples can either come closer together or grow apart¹⁸18 Cecílio MS, Scorsolini-Comin F. Relações entre conjugalidade e parentalidades adotiva e biológica. Psico 2013; 44(2):245-256.. Evidence shows that an unwanted pregnancy on the part of the partner is a factor that triggers marital conflict and violence⁷7 Paixão GPN, Gomes NP, Diniz NMF, Couto TM, Vianna LAC, Santos SMP. Situations which precipitate conflicts in the conjugal relationship: the women's discourse. Texto Contexto Enferm 2014; 23(4):1041-1049..

In the present study, the prevalence of psychological violence during pregnancy was 1.72 times higher in women whose partners consumed alcohol, which is similar to the findings of previous studies¹⁹19 Audi CAF, Segall-Corrêa AM, Santiago SM, Andrade MGG, Pérez-Escamilla R. Violência Doméstica na gestação: prevalência e fatores associados. Rev Saude Publica 2008; 42(5):877-885.^,2020 Vieira EM, Perdona GSC, Santos MA. Fatores associados à violência física por parceiro íntimo em usuárias de serviços de saúde. Rev Saude Publica 2011; 45(4):730-737.. A study undertaken in Campinas in the state of São Paulo with pregnant women using primary health care services found that alcohol consumption in women whose partners consumed alcohol at least twice a week were more than twice as likely to experience psychological, physical violence, and/or sexual violence during pregnancy¹⁹19 Audi CAF, Segall-Corrêa AM, Santiago SM, Andrade MGG, Pérez-Escamilla R. Violência Doméstica na gestação: prevalência e fatores associados. Rev Saude Publica 2008; 42(5):877-885.. A study using data from the 1st Nationwide Survey on Alcohol Consumption Patterns in Brazil showed that the prevalence of alcohol consumption was four times higher in men who commit IPV²¹21 Zaleski M, Pinsky I, Laranjeira R, Ramisetty-Mikler S, Caetano R. Violência entre parceiros íntimos e consumo de álcool. Rev Saude Publica 2010; 44(1):53-59..

The association between alcohol consumption and intimate partner violence is therefore recognized⁹9 Leite FMC, Luis MA, Amorim MHC, Maciel ELN, Gigante DP. Violência contra a mulher e sua associação com o perfil do parceiro íntimo: estudo com usuárias da atenção primária. Rev Bras Epidemiol 2019; 22:e190056.^,2222 Oliveira JB, Lima MCP, Simão MO, Cavariani MB, Tucci AM, Kerr-Corrêa F. Violência entre parceiros íntimos e álcool: prevalência e fatores associados. Rev Panam Salud Publica 2009; 26(6):494-501.^,2323 Birkley EL, Giancola PR, Lance CE. Psychopathy and the prediction of alcohol-related physical aggression: the roles of impulsive antisociality and fearless dominance. Drug Alcohol Depend 2013; 128(1-2):58-63.. Alcohol consumption can lead to tension between the couple, aggravating and intensifying violence. Alcohol consumption by the partner can act as a factor that externalizes an impulsive and aggressive personality and predisposition to violence²²22 Oliveira JB, Lima MCP, Simão MO, Cavariani MB, Tucci AM, Kerr-Corrêa F. Violência entre parceiros íntimos e álcool: prevalência e fatores associados. Rev Panam Salud Publica 2009; 26(6):494-501.^,2323 Birkley EL, Giancola PR, Lance CE. Psychopathy and the prediction of alcohol-related physical aggression: the roles of impulsive antisociality and fearless dominance. Drug Alcohol Depend 2013; 128(1-2):58-63.. However, it is known that violence is a complex and multifactorial phenomenon and that alcohol is not the only explanatory factor¹1 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, organizadores. World report on violence and health. Geneva: WHO; 2002..

Another characteristic that was associated with higher prevalence of physical violence during pregnancy was the partner not having paid work, which is similar to the findings of a study in Maringá in the state of Paraná, which reported that physical violence during pregnancy was more frequent among women with partners who were unemployed²⁴24 Sgobero JKGS, Monteschio LCV, Zurita RCM, Oliveira RR, Mathias TAF. Violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados. Aquichan 2015; 15(3):339-350.. A study with 1,379 pregnant women in Campinas found that women whose partners were unemployed were more likely to experience physical/sexual violence during pregnancy¹⁹19 Audi CAF, Segall-Corrêa AM, Santiago SM, Andrade MGG, Pérez-Escamilla R. Violência Doméstica na gestação: prevalência e fatores associados. Rev Saude Publica 2008; 42(5):877-885., while research with patients in primary care centers in Vitória in the state of Espírito Santo observed that the prevalence of physical IPV was 1.11 times higher in women whose partners did not have paid work⁹9 Leite FMC, Luis MA, Amorim MHC, Maciel ELN, Gigante DP. Violência contra a mulher e sua associação com o perfil do parceiro íntimo: estudo com usuárias da atenção primária. Rev Bras Epidemiol 2019; 22:e190056..

The social norms that establish gender roles assign men the role of provider. Men who do not have a job or source of income are more likely to make threats and commit physical violence as a way of dominating and exercising power over the woman and family⁸8 Silva AF, Gomes NP, Pereira A, Magalhães JRF, Estrela FM, Sousa AR, Carneiro JB. Atributos sociais da masculinidade que suscitam a violência por parceiro íntimo. Rev Bras Enferm 2020; 73(6):e20190470.^,1010 Lírio JG S, Pereira A, Gomes NP, Paixão GPN, Couto TM, Ferreira AS. Elements which precipitate conjugal violence: the discourse of men in criminal prosecution. Rev Esc Enferm USP 2019; 53:e03428.^,2525 Novaes RCP, Freitas GAP, Beiras A. A produção científica brasileira sobre homens autores de violência - reflexões a partir de uma revisão crítica de literatura. Barbarói 2018; 1(51):154-176.. In a study interviewing men being prosecuted for IPV, the respondents emphasized that providing for the family is a male activity and that women should not do paid work. Working women living with unemployed men may therefore be more likely to experience episodes of violence, including physical violence⁸8 Silva AF, Gomes NP, Pereira A, Magalhães JRF, Estrela FM, Sousa AR, Carneiro JB. Atributos sociais da masculinidade que suscitam a violência por parceiro íntimo. Rev Bras Enferm 2020; 73(6):e20190470.^,2020 Vieira EM, Perdona GSC, Santos MA. Fatores associados à violência física por parceiro íntimo em usuárias de serviços de saúde. Rev Saude Publica 2011; 45(4):730-737..

In addition, pregnancy leads to an increase in the number of family members. For men who perpetrate violence against women, this factor may act as a threat to their masculinity, as they may find themselves unable to carry out the socially-conditioned function of partner/provider and father. The lack of policies that provide women and couples with the enabling conditions to perform the roles of motherhood and fatherhood in a responsible and safe manner may also act as an aggravating factor²⁶26 Berger SMD, Giffin KM. Serviços de saúde e a violência na gravidez: perspectivas e práticas de profissionais e equipes de saúde em um hospital público no Rio de Janeiro. Interface (Botucatu) 2011; 15(37):391-405..

Our findings also show that the prevalence of psychological, physical, and sexual violence was also higher among women whose partners refused to use a condom. Schraiber et al.²⁷27 Schraiber LB, D'Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, Valença O, Couto MT. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saude Publica 2007; 41(5):797-807. found that women whose partners had refused to use a condom were 0.62 times more likely to experience violence during pregnancy. This association was also observed by a study with patients in Porto Alegre in the state of Rio Grande do Sul, which showed that the frequency of physical violence was greater in women whose partners refused to use a condom²⁸28 Kronbauer JFD, Meneghel SN. Perfil da violência de gênero perpetrada por companheiro. Rev Saude Publica 2005; 39(5):695-701..

Although sex in an intimate relationship is seen as obligatory by both men and women, the sexual desires of men tend to override those of women and the latter often find it difficult to negotiate sex, condom use and contraceptive methods. However, this conduct can lead to unwanted pregnancy. Women with less control over their sexual and reproductive health, where the man holds the decision-making power, experience privation and are prevented from deciding what is best for themselves²⁶26 Berger SMD, Giffin KM. Serviços de saúde e a violência na gravidez: perspectivas e práticas de profissionais e equipes de saúde em um hospital público no Rio de Janeiro. Interface (Botucatu) 2011; 15(37):391-405.^,2828 Kronbauer JFD, Meneghel SN. Perfil da violência de gênero perpetrada por companheiro. Rev Saude Publica 2005; 39(5):695-701.^,2929 Miller E, Decker MR, McCauley HL, Tancredi DJ, Levenson RR, Waldman J, Schoenwan P, Silverman JG. Pregnancy coercion, intimate partner violence and unintended pregnancy. Contraception 2010; 81(4):316-322..

A study with health professionals showed that on occasions pregnant women go to the clinic accompanied by their partners with excessive doubts and concerns about sex during pregnancy, indicating difficulties in negotiating sex and the occurrence of sexual violence during pregnancy²⁶26 Berger SMD, Giffin KM. Serviços de saúde e a violência na gravidez: perspectivas e práticas de profissionais e equipes de saúde em um hospital público no Rio de Janeiro. Interface (Botucatu) 2011; 15(37):391-405.. It is also worth highlighting that men are more likely to neglect their health than women as self-care is conventionally associated with women, exposing themselves and their partners to a series of risks³⁰30 Machin R, Couto MT, Silva GSN, Schraiber LB, Gomes R, Figueiredo WS, Valença OA, Pinheiro TF. Concepções de gênero, masculinidade e cuidados em saúde: estudo com profissionais de saúde da atenção primária. Cien Saude Colet 2011; 16(11):4503-4512..

The findings of the present study show that the prevalence of psychological violence during pregnancy was 2.87 higher among women whose partners were not the biological father of the newborn. A study in two public maternity facilities showed that postpartum women with children from other relationships were 3.4 time more likely to experience physical violence during pregnancy²⁴24 Sgobero JKGS, Monteschio LCV, Zurita RCM, Oliveira RR, Mathias TAF. Violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados. Aquichan 2015; 15(3):339-350.. Having children from other relationships can trigger disagreements as it generates insecurity and concerns of involvement with the ex-partner. The findings of a study with a group of men undergoing criminal prosecution for domestic violence revealed that some did not accept the cohabitation of children from previous relationships¹⁰10 Lírio JG S, Pereira A, Gomes NP, Paixão GPN, Couto TM, Ferreira AS. Elements which precipitate conjugal violence: the discourse of men in criminal prosecution. Rev Esc Enferm USP 2019; 53:e03428..

After adjusting for possible confounding factors, the association between the variables having a jealous and controlling partner and violence during pregnancy was not maintained. However, studies show a strong association between IPV and controlling behavior⁹9 Leite FMC, Luis MA, Amorim MHC, Maciel ELN, Gigante DP. Violência contra a mulher e sua associação com o perfil do parceiro íntimo: estudo com usuárias da atenção primária. Rev Bras Epidemiol 2019; 22:e190056.^,3131 Lencha B, Ameya G, Baresa G, Minda Z, Ganfure G. Intimate partner violence and its associated factors among pregnant women in Bale Zone, Southeast Ethiopia: a cross-sectional study. PLoS One 2019; 14(5):e0214962.. A study in Ethiopia showed that pregnant women with a partner who had aggressive behavior were 2.8 times more likely to experience IPV during pregnancy (95%CI = 1.7-4.6)³¹31 Lencha B, Ameya G, Baresa G, Minda Z, Ganfure G. Intimate partner violence and its associated factors among pregnant women in Bale Zone, Southeast Ethiopia: a cross-sectional study. PLoS One 2019; 14(5):e0214962., while a study in Vitória reported that the prevalence of violence was 1.96 times higher in women with a controlling partner (95%CI = 1.50-2.62)⁹9 Leite FMC, Luis MA, Amorim MHC, Maciel ELN, Gigante DP. Violência contra a mulher e sua associação com o perfil do parceiro íntimo: estudo com usuárias da atenção primária. Rev Bras Epidemiol 2019; 22:e190056.. It is important to note that women often have difficulty in realizing that they are victims of IPV and may confuse controlling behavior and jealously with love and care³²32 Netto LA, Moura MAV, Queiroz ABA, Leite FMC, Silva GF. Isolamento de mulheres em situação de violência pelo parceiro íntimo: uma condição em redes sociais. Esc Anna Nery Rev Enfer 2017; 21(1):e20170007.^,3333 Almeida T, Rodrigues KRB, Silva AA. O ciúme romântico e os relacionamentos amorosos heterossexuais contemporâneos. Estud Psicol 2008; 13(1):83-90..

Controlling behavior is characterized by constant domination and monitoring, inhibiting forms of expression, ways of relating and dressing in clothes considered inappropriate by the partner⁸8 Silva AF, Gomes NP, Pereira A, Magalhães JRF, Estrela FM, Sousa AR, Carneiro JB. Atributos sociais da masculinidade que suscitam a violência por parceiro íntimo. Rev Bras Enferm 2020; 73(6):e20190470.. Regardless of the type of behavior, controlling behavior distances the victim from their family and friends and other people who could potentially help them³²32 Netto LA, Moura MAV, Queiroz ABA, Leite FMC, Silva GF. Isolamento de mulheres em situação de violência pelo parceiro íntimo: uma condição em redes sociais. Esc Anna Nery Rev Enfer 2017; 21(1):e20170007.. Although naturalized, controlling behaviors constitute a violation of women’s rights to come and go and to dignity, harming their well-being and quality of life⁸8 Silva AF, Gomes NP, Pereira A, Magalhães JRF, Estrela FM, Sousa AR, Carneiro JB. Atributos sociais da masculinidade que suscitam a violência por parceiro íntimo. Rev Bras Enferm 2020; 73(6):e20190470..

Another element that can trigger violence in jealously. Be it motivated by the partner’s social life and family or suspicion of infidelity, jealously involves gender issues that perpetuate possessiveness³⁴34 Silva ACLG, Coelho EBS, Njaine K. Violência conjugal: as controvérsias no relato dos parceiros íntimos em inquéritos policiais. Cienc Saude Colet 2014; 19(4):1255-1262.. Jealously can be understood as a form of understanding traditional masculinity, as it legitimizes violence when pre-established gender attributes are not observed²⁵25 Novaes RCP, Freitas GAP, Beiras A. A produção científica brasileira sobre homens autores de violência - reflexões a partir de uma revisão crítica de literatura. Barbarói 2018; 1(51):154-176..

This study has some limitations. First, the data were collected in the postpartum period, which is a time when women feel especially vulnerable, possibly resulting in the underestimation of the prevalence of violence. Second, the fact that answers to the questions on partner characteristics were responded by the postpartum women means that the answers, particularly those about behavioral characteristics, may be subject to participant bias. Finally, the fact that the study population was made up of women admitted to a public maternity facility means that the results should be interpreted with caution and should not be generalized to the overall population of postpartum women.

Conclusion

Our findings show an association between IPV during pregnancy and intimate partner socioeconomic and behavioral characteristics.

In view of the above, it is worth bearing in mind that the factors that determine the occurrence and permanence of IPV constitute a complex social dynamic in which social services must engage. The findings demonstrate the need to promote the utilization of health services by men in order to address social and behavioral risk factors for violence during pregnancy. With regard to pregnancy and the postpartum period, it is worth highlighting that the involvement partners from the beginning of antenatal care is essential, as it is an opportune time to approach men about health care and offer treatment.

With regard to aggressive partners, there is an urgent need to discuss how to approach this issue in health services and develop effective multi-sectorial actions that promote changes in behavior within family and social relations. In this respect, improving understanding among health professionals about IPV during pregnancy can help enable the adoption of individual and collective violence prevention and coping strategies. Finally, actions to change individual attitudes and behavior need to be developed in networks in order to safeguard rights and ensure the provision of adequate care.

Acknowledgements

Fundação de Amparo à Pesquisa e Inovação do Espírito Santo - FAPES (call for proposals FAPES/CNPq 04/2017. Code 80641393/2017).

References

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