The European Journal of Public Health Advance Access originally published online on March 25, 2007
The European Journal of Public Health 2007 17(6):605-606; doi:10.1093/eurpub/ckm009
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Injuries, Violence, Disasters |
Screening for domestic violence during pregnancy in an antenatal clinic in Lebanon
Nadwa Hammoury1 and Marwan Khawaja1,2
1 Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
2 Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
Correspondence: Dr M. Khawaja, tel: +961 1 350000, fax: +961 1 744470, e-mail: mk36{at}aub.edu.lb
Received October 10, 2006, accepted January 18, 2007
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Abstract |
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The purpose of this brief article is to examine the prevalence of domestic violence during pregnancy using data from 349 women attending an antenatal clinic serving refugees in Saidon, Lebanon. The Abuse Assessment Screen was used to identify cases of abuse among the women attending the clinic during the months of June and July, 2005. A total of 240 (68.8%) women experienced one form of physical, emotional, and sexual abuse in their marital life, and 40 (11.4%) women experienced physical violence during their current pregnancy. Violence during pregnancy was strongly associated with previous experiences of physical, emotional and sexual violence.
Keywords: domestic violence, screening, AAS, pregnancy, refugees, Lebanon
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Introduction |
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Domestic violence against women during pregnancy is an important public health problem worldwide, and is associated with adverse health consequences for both the mother and fetus.1 Routine screening for domestic violence by health care professionals, especially during pregnancy, has been recommended as an intervention strategy to improve maternal and fetal outcomes.2 However, health care providers rarely incorporate universal screening into their practice,3 especially in contexts characterized by persistent patriarchy and gender inequities. In such context, domestic violence is often viewed as a private matter, and not a public health issue,4 and thus physicians and nurses have been often reluctant to raise this seemingly embarrassing issue with their clients.
Studies conducted in the Arab countries show that about one out of three women is beaten by her husband.5 A recent study in Jordan's refugee camps documents a higher prevalence of wife-beating (44.7%) during a woman's lifetime.4 This brief report provides preliminary findings from a screening study of domestic violence in pregnant women attending an antenatal clinic for Palestinian refugees in Lebanon. It documents the overall, as well as form-specific, prevalence of abuse, and the associations between violence during pregnancy and previous experiences of physical violence, emotional abuse and sexual coercion.
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Methods |
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The Abuse Assessment Screen (AAS),6 a well-validated screening instrument, was used to identify cases of abuse among all women attending the primary health care clinic of the United Nation Relief Work Agency (UNRWA) in Sidon, Lebanon, and who were not accompanied by their husbands, during the months of June and July, 2005. This is one of 25 primary health care clinics operated by UNRWA in Lebanon to serve Palestinian refugees.
UNRWA has been the main provider of services for Palestinian refugees in Lebanon since the 1948 Arab–Israeli war. The AAS tool is a five-item screening instrument with ‘Yes’ or ‘No’ answers to questions about physical, emotional and sexual violence. Women were first asked if they had experienced any physical violence during their marital life, during last year and current pregnancy. In addition, they were asked whether or not they fear their husband or someone else in the household (emotional violence), and if they were forced by their husbands to have sexual intercourse. A positive answer to any of the five domestic violence questions was considered a case. The AAS instrument was translated into spoken Arabic, pretested and modified before administering to the women participating in the study. The final instrument was completed by face to face interviews by the first author who is a trained midwife specialist. Women were interviewed in private and informed consent was verbally obtained from them before interviewing.
The sample consisted of all women (n = 351) visiting the clinic in Sidon during their first, or a follow-up, prenatal check-up. A total of 349 pregnant women were interviewed with a response rate of 99.4%. Prevalence point estimates were calculated to reflect the overall extent of domestic violence, and each of the five dimensions of physical, emotional and sexual abuse. Descriptive statistics and 
2 tests of association among the various forms of abuse were performed using the program SPSS 13.0 for windows.
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Results |
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The women who participated in this study were relatively young, with an average age of 28 years, and 75% of them were married for longer than a year. They had relatively low education, completing an average of 9.3 years of schooling. Women were rarely employed (10%), although the vast majority of husbands were at the time of survey.
Over half (52.1%) of the pregnant were multipara and 41.3% were pregnant in their second trimester. Only 12.5% live in extended households. Most of the women (71%) resided outside the refugee camp, largely around the area where the polyclinic is located.
Overall, 240 (68.8%) women experienced one form of abuse, answering yes to at least one of the five domestic violence questions. Of these, 207 (59%) women had ever experienced physical violence, 67 (19.1%) experienced physical violence last year, 92 (26.2%) were subjected to sexual coercion during the past year, 56 (16.0%) experienced emotional violence (fear of husband) and 40 (11.4%) experienced physical violence during their current pregnancy (Table 1). As judged by 2 tests, violence during pregnancy was strongly associated with other forms of abuse: 40 (19.3%) women who were subjected to life-time physical violence were also abused during pregnancy (P < 0.000); 31 (46.3%) who experienced, physical violence during last year were abused during pregnancy as compared with 9 (3%) who were not physically abused last year (P < 0.000); 16 (17.4%) women who experienced, sexual coercion last year were abused during pregnancy as compared with 24 (9.3%) who did not experience sexual coercion (P < 0.037); and 13 (23.2%) who feared their husbands experienced violence during pregnancy as compared with 27 (9.2%) women who did not report fear of their husbands (P < 0.003).
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Discussion |
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This study confirmed previous conclusions that the vast majority of women do not object to screening for domestic violence by health professionals.7 Domestic violence against pregnant women, in its various forms, was rather common in this vulnerable refugee population. Our study revealed that the majority of refugee women (59%) experienced physical violence, and more than one out of every four women experienced forced intercourse during the past year. The reported prevalence of physical abuse during a woman's lifetime and last year are higher than those found previously in the Arab region,5 or among refugees.4,8 However, physical violence was less common during pregnancy compared to marital lifetime or last year. This finding is consistent with previous studies in developing countries,9,10 contradicting the common notion that pregnancy increases the risk of abuse. Although our estimate of violence during pregnancy is within the range of 4–29% reported in previous studies from developing countries,9 it is lower than the 23% reported recently from a study in Pakistan.10 Interestingly, physical abuse during pregnancy was strongly related to previous experiences, and forms, of domestic violence, suggesting that screening for lifetime physical abuse before the onset of pregnancy can be a good predictor of, and a useful tool for prevention programmes concerning abuse during pregnancy.
Our study has several methodological limitations, including its cross-sectional design, possible response bias and under-reporting given the sensitivity of the topic, the use of non-validated screening instrument in Arabic, and the inclusion of women from only one antenatal clinic, and the findings may therefore not be generalizable to other refugee women in Lebanon or elsewhere. Despite these limitations, the study findings should be useful to health professionals and planners underscoring the importance of screening for domestic violence before and during pregnancy if we are to reduce and prevent the burden of abuse faced by both mothers and fetuses. However, the usefulness of the AAS instrument should be tested in other settings before recommending it for wider applications. Although this instrument has been used here because of its simplicity and length, other instruments have been developed to assess for the presence of domestic violence. Further research is needed to better understand the best approach to screen for domestic violence during pregnancy.10 Screening for violence in primary health care settings may help detect and reduce violence against pregnant women, but intervention programmes are also needed to provide support and medical services to women in abusive relationships.
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Acknowledgement |
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The authors would like to thank the ‘United Nation Relief and Work Agency’ for facilitating access to the women in the clinic. Thanks are also due to the pregnant women for their cooperation with the investigators during the course of this study.
Conflict of interest: None declared.
Key points
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References |
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1 Espinosa L, Osborne K. Domestic violence during pregnancy: implications for practice. J Midwifery Women Health (2002) 47:305–17.[CrossRef]
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8 Khawaja M, Tewtel-Salem M. Agreement between husband and wife reports of domestic violence: evidence from poor refugee communities in Lebanon. Int J Epidemiol (2004) 33:526–33.
9 Nasir K, Hyder AA. Violence against pregnant women in developing countries. Review of evidence. Euro J Pub Health (2003) 13:105–7.[CrossRef]
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