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Print version ISSN 0103-2100
Acta paul. enferm. vol.25 no.4 São Paulo 2012
Violence against women and its implications for maternal and child health*
Violencia contra la mujer y sus implicaciones en la salud materno-infantil
Angelina LettiereI; Ana Márcia Spanó NakanoII; Daniela Borges BittarIII
Student (Doctoral), School of Nursing in Ribeirão Preto, University of
São Paulo - USP- Ribeirão Preto (SP), Brazil
IIDoctor of Nursing. Full Professor of the Maternal-Infant and Public Health Department, School of Nursing in Ribeirão Preto, University of São Paulo - EERP/USP - Ribeirão Preto (SP), Brazil
IIIPost-Graduate Student (Doctoral), School of Nursing in Ribeirão Preto, University of São Paulo - USP- Ribeirão Preto (SP), Brazil
To understand how postpartum women perceive the phenomenon of violence and what
relationship they establish with their state of health and that of their child,
the process of pregnancy, birth and puerperium.
METHODS: A qualitative study, with data collected through semi-structured interviews with 43 postpartum women in a maternity hospital in Ribeirão Preto (SP), Brazil.
RESULTS: Through thematic analysis, the mothers characterized violence against women as a social problem caused by gender inequality and/or as a multifactorial occurrence. Facing the situation of violence, they related difficulty in recognizing its effects on their health and that of their children.
CONCLUSION: The results point to the invisibility of these violent events and the naturalization of violence.
Keywords: Violence against women; Women's health; Maternal and child health; Postpartum period
Comprender cómo mujeres puérperas perciben el fenómeno de
la violencia y cuál es la relación que establecen con su estado
de salud y de su hijo, proceso de embarazo, parto y puerperio.
MÉTODOS: Estudio de abordaje cualitativo, cuyos datos fueron recolectados por medio de una entrevista semiestructurada a 43 puérperas atendidas en una maternidad de Ribeirão Preto (SP).
RESULTADOS: Por el análisis temático, las puérperas caracterizaron a la violencia contra la mujer como un problema social, causado por la desigualdad de género y/o de ocurrencia multifactorial. Frente a la situación de violencia, relataron dificultad para reconocer sus efectos sobre su salud y la de sus hijos.
CONCLUSIÓN: Los resultados apuntaron hacia la invisibilidad de esos eventos violentos y hacia la naturalización de la violencia.
Descriptores: Violencia contra la mujer; Salud de la mujer; Salud materno-infantil; Periodo de posparto
Violence is one of the main public health problems in various countries all over the world. The World Health Organization (WHO) defines violence as the intentional use of physical force or power, by means of threat or fact practiced against oneself, another person and against a group or community, which results in, or has great capacity to result in injury, death, psychological damage and harm to development, or privation(1).
Within the complex phenomenon of violence in social space, there is violence against women. This is an expression coined by the feminist social movement, and in general the term refers to traditional suffering and aggressions that are deeply rooted in social life, perceived as normal situations when they are specifically directed against women, due to the fact of being women (2).
The phenomenon is particularly expressed by means of sexual, physical and psychological violence, and is one of the main factors that affect the biopsychosocial integrity of women. In the majority of instances, the acts suffered by women are practiced within the family itself, by persons close to them, particularly in within the domestic sphere. Studies have confirmed that women are at greater risk of violence in relationships with family members and persons close to them than at the hands of strangers, and in the majority of instances the aggressor has been the spouse or partner himself(3).
In this regard, the WHO(4), in researches conducted in various countries in the world, found that the occurrence of physical and/or sexual violence, perpetrated by the partner at some time of her life, is present in 15% and 71% of the women in Japan and Ethiopia, respectively, and in Brazil, 29% of the women in São Paulo and 37% from the Pernambuco Forest zone ("Zona da Mata pernambucana") related physical and/or sexual violence committed by the partner at some time in life.
It is worth considering that violence against women may be present in the different spheres of their lives, with repercussions on their health, and depending on the stage in which it is found, on the health of their offspring. From this perspective, violence is present even in a period of a woman's life in which her wellbeing should be especially assured: gestation.
The consequences of violence during pregnancy is associated with numerous types of damage to the mother's and child's health, including addition health problems during pregnancy, greater probability of pre-term birth, delay in beginning with prenatal care, low birth weight, greater use of health care services and medication in the prenatal (5).
Nevertheless, in view of the numerous types of damage to health, one finds an invisibility of the violent events routinely experienced by the women themselves, which makes them appear to be natural, banal and relative, so that their repercussions are not recognized, as was demonstrated in a research(3) conducted in Porto Alegre-RS with 251 women between the ages of 18 and 49 years. Violence during pregnancy was reported by 17% of the interviewees; however, 69% of them did not recognize the harm it caused to their own health and that of the newborn.
Thus, although present in the majority of societies, violence is frequently unrecognizable, and at times, it is socially accepted as natural; that is, as an expected or customary situation in the female(4). In this context, it is verified that the non identification of the situation of violence experienced by women contributes to perpetuating its cycle, and may interfere in the fight against violence.
It is understood that apart from the statistics on the incidence of violence against women, it is necessary to find out how they think about the phenomenon and recognize the status of awareness of the subject and their needs. Therefore, an understanding of the meanings of violence and the repercussions of violent events on health from the point of view of women, would provide services and professionals with subsidies for improving shelter and assistance, since the theme of violence continues to be a barrier to the promotion of integral health for women(6).
To understand how puerperal women perceive the phenomenon of violence and find out the type of relationship they establish with their state of health, particularly in the process of pregnancy, birth and puerperium, and health conditions of their children.
The aim of this qualitative study was to establish the meanings attributed by women to violence against women. The option to use the qualitative approach was due to the deepening of meanings of in the world, which are not visible in reality, but need to be explained and interpreted by researchers(7).
The study scenario considered in this investigation was a maternity home that cares for the clientele of the Brazilian national health service - SUS ("Sistema Único de Saúde"), included in the mentioned system by the primary health care network to attend to low risk births in Ribeirão Preto(SP). The choice of the mentioned institution as the context of this study, is justified as this is the space in which we work and where we commonly encounter women in a situation of violence that has important repercussions on the health of both mother and infant. It should be pointed out that the health services, especially maternity homes are places where health professions are in a strategic position to diagnose and act on the problem
The empirical universe considered was that of puerperal women cared for in the mentioned maternity home in the period from January to April 2007. The sample consisted of 43 puerperal women who fulfilled the following criteria: Women aged 18 years or older; who accepted participating in the research, by signing the Term of Free and Informed consent, whether or not they had suffered violence. The data were shown to be recurrent after having interviewed about 20 subjects, however, collection was continued in order to seek adequate saturation of the data. Subjects were progressively included, and collection was interrupted when regular presentation of the meanings attributed by the subjects began to appear (7).
The study was conducted in compliance with regulations for research involving human beings, established by the National Health Council Resolution No.196/96. Thus, data collection began after the research project was approved by the Research Ethics Committee, Protocol No. 0688/2006, and the subjects who fulfilled the inclusion criteria were invited to participate in the study. After accepting, the subject was asked to sign the above-mentioned Term. With the purpose of guaranteeing anonymity, identification codes were used in the fragments of interviews.
Data collection was performed on the premises of the institution, in a private room, without the presence of companions. The time chosen was during admission to the rooming facility. To perform data collection, a minimum period of 6 hours after normal birth, and 12 hours after Cesarean delivery was stipulated. These periods were defined in conjunction with the nursing team, based on professional nursing practice with regard to the minimum time interval necessary for the mother to re-establish her need for rest, food and hygiene.
Data were collected in a semi-structured, individual interview, and recorded. In data treatment, the option was to use thematic content analysis, which "consists of discovering the core meanings that compose communication, and whose presence or the frequency in which they appear, may mean something to the chosen analytical objective"(8). Analysis was performed in the following steps: Initial reading, seeking overall understanding of the material; identification of the units of meaning that emerged from the interviewees' statements; discovery of the core, interpretation and discussion of the core meanings found.
The group was composed of 43 puerperal women with the following sociodemographic profile: as regards age, the mean was 25 years, with the minimum being 18 and maximum 44 years. The majority of the women (48.8%) informed they were housewives and (72.01%) said that from two to five persons lived in their home, showing that the family nucleus was composed of various family members. With respect to marital status, 67.4% declared they were single, and as regards the number of children, the minimum was one and maximum five, with a mean of 2 children per person.
The sociodemographic profile has been studied as a factor associated with violence against women, among which the outstanding features are ethnicity, low socioeconomic level, being young, and the low level of social support(9). The study location, which in turn is characterized as a public service that cares for SUS users, among whom the majority of the clientele have a low sociodemographic profile.
Among the 43 women interviewed, 13 reported having suffered some type of physical, sexual and/or psychological violence, of whom six suffered this violence in the gestational period; the other seven declared that it occurred at another stage of their life and in all 13 cases, the aggressor was the spouse. Of the 30 interviewees who said they had not suffered violence, they related having experienced cases of violence in the family or with persons who lived in close contact with them.
From the interviewees' statements, two central thematic categories were defined: comprehension of the phenomenon of violence against women, and the repercussion of violence on health.
In the first thematic category, comprehension of the phenomenon of violence against women, three core meanings were identified.
As regards the first core meaning, problem present in society and varied expressions, as identified in the statements:
My opinion is that unfortunately there is. And a great deal of it". (D10)
"[...] one sees it in various places". (D5)
"Violence is maltreatment, beating, abuse and even when there is no beating, just threatening is a violence". (D6)
"[...] he beat me and said words to humiliate me". (D17)
The interviewees recognized violence as an event that occurred frequently and widely in different societies. In addition, they identified the types of violence, ranging from more concrete expression such as physical violence of the type that attacks the subjectivity of individuals, through to psychological violence.
In the understanding of the phenomenon by the interviewees, the second core meaning was defined, which points towards a look at the surrounding; or, one could say, towards the context in which the expression of violence arises: The family medium as the social space of violence and the factors that precipitate and maintain violence, as identified in the following statements:
"Good heavens, I understand many things because my father used to beat my mother!" (D21)
"He was addicted to drugs and then the fight started". (D15)
"[...] because the husband drinks, or the husband is addicted, one of these hypotheses .. and that causes the fight." (D33)
It was found that violence against women is an occurrence within the sphere of the domestic space, where the conflicts involve actors such as: mother, sister, grandmother and sister-in-law, and the aggressor is the spouse himself. They recognized the existence of factors that predispose to violence, based on the experiences they lived through in their contexts, such as the partner's use of alcohol and drugs.
However, in some of the statements, it was possible to identify that there are other associated factors, apart from alcohol and drug consumption, which motivate violence, such as social maladjustment and poverty. Therefore, it was understood that for the puerperal women in this study, the factors that triggered violence are multifactorial.
"A guy that has no family structure I also think leads to this, who does not have a structure". (D41)
Irrespective of whether or not they had suffered violence at some time in their lives, in their reports the interviewees showed that violence is a common event in their context, in which the trajectories of life are marked by violence within the family, reiterating the fact that violence is a serious and important problem to be combated in society.
In the second central thematic category, the repercussion of violence on health, two core meanings, were identified.
In the first core meaning, the repercussion on the woman's health, as presented in the statements:
It left me weaker, I lost weight. I think I went into deep depression, it affected me". (D 1)
"When I reached the point of trying to kill myself, I was hospitalized, underwent treatment with a psychologist". (D 12)
The visibility of the phenomenon of violence in health was perceived by the interviewees only when it was presented by means of visible symptoms, and the problems frequently mentioned by them were: physical lesions and depression.
However, being of a chronic nature, aggression against women goes beyond the visible traumas and injuries, and is associated with other health problems. The broader perception of the repercussion of violence on health was not recognized by the puerperal women in this study; that is, in terms of the indirect reflections and throughout their lives.
In cases in which violence occurred during the gestational period, perception of the damage to health becomes a little broader, once they establish connections between the violence suffered and the conditions of health in the gestational process. Thus, the problems identified by the interviewees were: depression, feeling unwell, gestational intercurrences and abortion.
"I just suffered, I was an unhappy person, I was fat, ugly, you know! No one knew what I went through and that I even had an abortion because of him [...] he kicked me in the bottom part of my stomach and I was 2 months pregnant with a child, I fell and lost the baby". (D 24)
With reference to the second core meaning, the harm to the children's health, in which the most mentioned consequences were those of a psychological nature, generated because of the children witnessing the aggressions.
"The way I see it my children became very resentful". (D 15)
"Perhaps the psychological aspect". (D 27)
The visibility of the effect of the phenomenon of violence on health was perceived by the interviewees in a manner restricted to the acute conditions of suffering. They believed that the situation of violence experienced by them could affect the development of the child, particularly in questions of a psychological and behavioral order. The weakening of social and psychological structures resulting from violence in the family context manifested a certain sense of guilt and failure in the women because of exposing their children to this situation, which could produce negative effects on their upbringing.
In the studied group, it was found that 30.2% of the women reported having suffered some type of physical, sexual and/or psychological violence over the course of life, and 13.9% suffered it during gestation. In all cases the aggressor was the spouse. A descriptive study(10) of the cross-sectional type developed at the same service in which the present research was conducted, verified that of the 547 puerperal women interviewed, 58.5% suffered some time of violence during the course of their lives, perpetrated by the partner, and 19.6% of them suffered it during gestation. This result shows the high magnitude of the event in the scenario of the study
It is believed that violence is a relational problem of humanity and that it has always formed part of human experience. Nevertheless, a growing increase in this violence is observed in our society, particularly in the large metropolitan regions, where it tends to be persistent(11). The data of this study demonstrate that the puerperal women understood that violence against women is an important and present problem in society.
For the women in this study, the concept of violence coincides with that established by the United Nations General Assembly(12) which defines violence against women as:
[...] any act of gender-based violence that results in, or has the probability of resulting in physical, sexual of psychological damage or suffering to women, including the threat of practicing such acts, coercion or arbitrary privation of liberty, occurring both in public and private life (12).
Studies conducted in different countries have revealed that violence against adult women, in the majority of cases, occurs in the domestic environment. Therefore, the family medium, primarily imagined as being a space of comfort and protection, is transformed into a dangerous environment, being the social space for the expression of diverse types of violence, considering that it is in this environment that 60% of the victims of the female sex are attacked(13). In the present study, it was verified that violence against women is an occurrence within the sphere of the domestic space, where the conflicts involve actors such as family members and spouses.
There is no single factor that explains why some persons behave themselves in a violent manner in relation to others. Violence is the result of a complex interaction of individual factors of social, cultural and environmental relationships(1).
As regards the factors tht trigger and maintain violence, the puerperal women interviewed related the main cause as being the partner's use of alcohol and drugs . One study(14) verified that 70% of the aggressors ingested alcohol before the aggressions and that 11% used drugs, this being a risk factor for the occurrence of violence. It is believed that the use of alcohol and drugs may facilitate the occurrence of this process, as both enormously increase stress and diminish censure. However, there are other associated factors, apart from alcohol and drug consumption, which motivate violence such as social maladjustment and poverty that are responsible for the increase in this violence over the last few years(15).
The specialized literature has demonstrated the association of risk with the experience of violence and the development of damage of a physical and mental order, which have a repercussion on the reduction in "healthy years of life" of women(16). Damage to health occurs immediately after the aggression, and other types of damage take longer to manifest themselves.
Due to its chronic nature, aggression against women goes beyond visible injury and traumas, and is associated with gastrointestinal problems, gynecological complaints, alcohol and drug abuse, vague complaints, depression, insomnia and suicide, mental suffering, lesions and chronic problems, such as dietary disturbances, abdominal pains and headaches, and even arthritis, hypertension and cardiac diseases(17).
With regard to the violent injuries during gestation, a study(18) conducted with the aim of evaluating the association between physical violence, during a period of 12 months before the birth; maternal complications and the results of birth found that physical violence was associated with adverse maternal conditions. There was greater probability of cesarean section and hospitalization before the birth due to complications such as infection, going into premature labor, and trauma due to falling or a blow on the abdomen.
Nevertheless, the visibility of the effect of phenomenon of violence on health is perceived by the interviewees only when it presents visible symptoms. Therefore, what one verifies as regards the damage to health, is that women seek the health services for treatment of the symptoms, such as depression, anxiety and post-traumatic stress disorder. These depressive feelings of low self-esteem and apathy generated by violence are some of the factors that make it difficult to seek solutions to this suffering (14).
It is important to point out that subjective suffering may be more easily accepted as mental illness, but the patient ends up being stigmatized in her role as a socially underprivileged person. Therefore, it is only possible for the effects on health resulting from violence to receive attention when they fit into the category of diseases, and even so, it has been shown that in many institutions, they are very far from receiving the desirable intervention(2).
Therefore, intervention in violence against women is only justified when its consequences are perceived as a disease, otherwise, the complaint is not considered part of health care actions, and is referred to another sector of a social and/or psychological order, disqualifying it for an intervention. With regard to clinical practice, in a study(19) developed at the same service in which the present study was conducted, it was observed that professionals have little knowledge with respect to conduct in these cases, and in the development of professional practice, there is a tendency for biological and fragmented reductionism in attention to women's health.
With reference to the events of violence against women and harm to their children's health, it is believed that the effects result from experiencing the episodes that occur between the parents, or because the children themselves are targets of the violence. The view of the women in this study coincides with that in the literature, which demonstrates that children that witness conjugal violence face higher risks of presenting anxiety, depression, low school performance, low self-esteem, nightmares, aggressive behavior and greater probability of suffering physical, sexual or emotional abuse(20).
A demographic study of the maternal role developed by women who live with violence in the family context, found in the statements of interviewees that the family affective context is an important component, in which the mother's conflictive relationship with her partner could negatively affect her children(21).
Violence against women has been revealed as an important social and health question, both from the point of view of its repercussion on morbidity and mortality and in relation to quality of life.
In the studied group, the data demonstrated that puerperal women characterized violence against women as an important problem present in society, with the main cause being alcohol and drug use. They contextualized violence in the domestic sphere and perpetrated by the companion. However, there is an invisibility of the violent events experienced by the women themselves which leads to violence being accepted as natural, banal and relative. The recognized the effects on their health only when there were concrete physical and psychological debilities, and that they were partly responsible for the negative effects on the health of their children.
In the health service, the clinical space for attendance to women must be considered as o time to make it possible for women to be sheltered from their situation of violence, so that they can recover their health as well as their condition of life an the lives of their dependents, the children. We believe that women need to be made aware of their rights, about questions of reproductive health, in addition to strengthening empowerment strategies, in order to break the cycle of violence.
The authors thank the women who participated in this study and the National Council for Scientific and Technological Development-CNPq.
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Corresponding Author: Received
article 12/02/2010 *
The study was conducted in the Rooming-in care of the Reference Center for Women's
Health (" Alojamento Conjunto do Centro de Referência em Saúde da
Mulher" - CRSM - MATER) - Ribeirão Preto(SP), Brazil.
Ana Márcia Spanó Nakano
Avenida Bandeirantes, 3900.
Cep:14040-902 - Ribeirão Preto, SP - Brasil.
* The study was conducted in the Rooming-in care of the Reference Center for Women's Health (" Alojamento Conjunto do Centro de Referência em Saúde da Mulher" - CRSM - MATER) - Ribeirão Preto(SP), Brazil.