Violence against women has been recognized by the World Health Organization (WHO)
as a health problem and a human rights violation with epidemic proportions which requires
an urgent action.[1]
[2] Worldwide it is estimated that ∼1 in 3 women have suffered physical and/or sexual
violence by an intimate partner or non-partner sexual violence in their lifetime.[3] The United Nations considered as violence against women “any act of gender-based
violence that results in, or is likely to result in, physical, sexual, or mental harm
or suffering to women, including threats of such acts, coercion or arbitrary deprivation
of liberty, whether occurring in public or in private life.”[4]
Domestic violence (DV), family violence (FV) and intimate partner violence (IPV) are
terms frequently observed in the literature.[5] Unfortunately, domestic environment it is a place where many women might suffer
violence perpetrated by relatives, former or current partner, showing that particularly
their homes could be unsafe places from many women around the world.
In Brazil, recent statistics from Brazilian Forum of Public Security show that 230
160 women disclosed domestic violence and 1.350 feminicides occurred during 2020.[6] If we observed victims’ sociodemographic characteristics it is appreciated a higher
number of young women of reproductive health age which are particularly vulnerable
to experience diverse forms of violence.
Throughout pregnancy violence episodes could be more frequent and DV might increase
during the pregnancy course as well as in the postpartum period.[7] On the other hand, other authors have shown that women with history of violence
reported an apparently decrease of DV episodes during pregnancy.[3]
[8] This variability suggest that some changes in severity and frequency of violence
may occur during this period and pregnant woman could be experiencing forms less explicit
of violence. However, identify those pregnant women might be suffered current or past
experiences of DV contribute to understand the importance to be awareness of this
issue and the necessity to provide an appropriate approach during routine antenatal
care (ANC). Accordingly, it has been recognized that DV might be more prevalent during
pregnancy compared with other conditions such preeclampsia and gestational diabetes
commonly screening during this period.[9]
There is a consensus regarding history of violence as a risk factor to experiences
futures episodes and several evidence confirm that many forms of violence might be
experienced during pregnancy and postpartum period.[7]
[8]
[10]
[11]
[12] Also, when observed these patterns, it is necessary highlight the importance to
observe domestic violence as a continuum.[7] In this sense, it is important to recognize that violence can be perform as a cycle
and episodes of violence could be recurrent through women’s lifetime.
Regarding the prevalence of physical violence during pregnancy a WHO Multi-Country
Study on Women's Health and Domestic Violence against Women observed a variability
among countries 1% in Japan city to 28% in Peru province.[3] A Brazilian study conducted among pregnant undergoing ANC in basic health care units
of the Brazilian Health System (SUS), revealed that 19.1% (n = 263) reported psychological violence and 6.5% (n = 89) disclosed physical/sexual violence.[11] However, similarly to global estimates, the prevalence of DV among pregnant varied
among studies conducted in Brazil.
Furthermore, a widely body of evidence has been shown serious consequences of DV to
women wellbeing, particularly to sexual and reproductive health such as neonatal low-birth
weight, unintended pregnancies, sexually transmitted infections, and preterm birth.[13] Also, mental health problems such as depression, anxiety, post-traumatic stress
disorder and adverse consequences in mother-child bond[14] are described as some consequences of DV experiences during pregnancy.
DV it is a complex phenomenon, and it is needed develop profounder analysis about
their dynamics. In this sense, we highlight the importance to improve understanding
about DV dynamic based on ecological perspective recognizing that individual, relationship,
community and society factors are necessary to achieve a comprehensive approach and
consequently implementing strategies to response and prevent violence in all their
forms.[3]
[15]
Underreporting DV is common and most of survival have fears, feel worried about safety
and face barriers and difficulties to disclose DV experiences.[1]
[16] However, health system has been recognized as a key sector and those women who experienced
DV might show clinical conditions associated with past and/or current DV experiences.
Health services are often the first contact for survivors of violence and some clinical
conditions associated with IPV experiences could be identified during obstetrics consultations
such as unexplained reproductive symptoms, including pelvic pain, sexual dysfunction,
repeated vaginal bleeding and sexually transmitted infections, unexplained genitourinary
symptoms and chronic pain among others.[17]
Health sector response including strategies focused on primary, secondary and tertiary
prevention undoubtedly requires a multidisciplinary approach. In the last years WHO
have been developed strategies to strengthen the role of the health system including
a multisectoral response to address interpersonal violence, especially against women
and girls.[2] Women survivors of violence may have a safety, financial, psychosocial, legal protection
and health needs[1] and for this reason it is important to recognize the role to addressing DV through
implementing public policies, legal services, preventive health care services and
psychosocial support.
Several international organizations, including the World Health Organization and International
Federation of Gynecology and Obstetrics (FIGO), have developed statements, ethical
guidance and recommendations regarding DV and IPV in healthcare settings. The 2013
WHO guideline included a series of minimum conditions to address violence in this
context such as a protocol, training for providers, private setting, confidentiality
and a system for referral.[17] In addition, particularly during pregnancy has been recognized that IPV it is a
relevant issue to be address considering that implementing an appropriate enquiry
during antenatal care contribute to a positive experience during this period.[18] In addition, professional organizations such as American Medical Association (AMA),
American Academy of Family Physicians (AAFP), Emergency Nurses Association (ENA) and
American Academy of Pediatricians (AAP) among others recognized the importance to
screening for violence experiences. For instance, American College of Obstetricians
and Gynecologists (ACOG) agreed that during pregnancy it is necessary to implementing
a screening systematically. In this sense, they recommend routine enquiry during prenatal
care and extended to postpartum period.[19] Similarly, FIGO has issued a publication entitled Ethical guidance on healthcare professionals' responses to violence against women reinforcing the consequences of DV experiences and the role of gynecologists and
obstetricians to address this issue.[20]
Gynecologists and obstetricians should play an important role in identification, provide
quality information, support, and referral survivals of DV. In this sense, routine
enquiry during ANC has been recognized as an opportunity to offer supporting and quality
information, helping access resources and validating women’s history.[17]
[20] The systematic contact between physicians and pregnant women should be considered
as a possibility to create a confidential and trustiness bond.
However, implementing a routine enquiry about DV during ANC it is not an easy task
and requires several conditions and ethical principles that must be guarantee. Studies
revealed that lack of time and knowledge about this topic were some barriers among
health professionals to address DV.[21] Despite barriers and challenges evidences showed a positive attitude among women
when questioned about DV experiences during ANC consultations.[22] For this reason, it is important implementing gender sensitive training among healthcare
providers particularly obstetricians, gynecologists and residents, integrating DV
education into medical school curricula and creating an institutional culture favorable
to listen and offer an appropriate care to DV survivors. Technical preparation about
how to ask and response is an essential knowledge, but DV is a sensitive topic that
requires respectful of women's autonomy choices, non-judgmental, empathic, and confidential
attitudes.
Additionally, it is observed an especial interest on examine effectiveness interventions
to address DV during pregnancy. Thus, systematic reviews were conducted with this
aimed showing a diversity of strategies including brief individualized consultation,
referral to other professional and multiple therapy sessions.[5]
[23] Although the effectiveness of interventions still a literature gap due to lack of
data and consistency in the outcomes[5] evidences suggest that not harmful effects were found due to interventions.[23] Furthermore, interventions for reducing and/or controlling DV among pregnant women
conducted in low- and middle income countries were based in similar criteria such
as women empowerment and contributing to identify resources and supporting women decisions
to rise solutions according their particularly situation.[5] Hence, it is recommended that women centered-care response must to be the principal
focus of interventions programs in healthcare settings.
Emergency and humanitarians' crises may present the risk of additional forms of violence
and exacerbated conditions widely known as factors that increase women vulnerabilities.[15]
[24] Considering ANC as an essential service during Covid-19 pandemic context it is relevant
to reinforce the importance of gynecologists and obstetricians to be aware to DV patterns
and opportunities to offered first-line support to survivals.
Challenges such as strengthen and build capacities to implementing strategies to prevent
DV in healthcare settings and especially during ANC, training healthcare providers
and stakeholders, strengthen the representation of health sector as safety places
for women and their children, change cultural norms which maintenance different forms
of violence against women as an acceptable behavior are some critical points to strengthen
and encouragement gynecologist and obstetricians to implementing routine screening
about DV during pregnancy.
