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Prevalence and Risk Factors of Intimate Partner Violence Among Pregnant Women in Japan a
a
b
Sachiko Kita , Kataoka Yaeko & Sarah E. Porter a
Department of Maternal Infant Nursing and Midwifery, St. Luke's College of Nursing, Tokyo, Japan b
School of Nursing, Oregon Health & Science University, Portland, Oregon, USA Accepted author version posted online: 29 Oct 2013.Published online: 18 Dec 2013.
To cite this article: Sachiko Kita, Kataoka Yaeko & Sarah E. Porter (2014) Prevalence and Risk Factors of Intimate Partner Violence Among Pregnant Women in Japan, Health Care for Women International, 35:4, 442-457, DOI: 10.1080/07399332.2013.857320 To link to this article: http://dx.doi.org/10.1080/07399332.2013.857320
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Health Care for Women International, 35:442–457, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2013.857320
Prevalence and Risk Factors of Intimate Partner Violence Among Pregnant Women in Japan
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SACHIKO KITA and KATAOKA YAEKO Department of Maternal Infant Nursing and Midwifery, St. Luke’s College of Nursing, Tokyo, Japan
SARAH E. PORTER School of Nursing, Oregon Health & Science University, Portland, Oregon, USA
Intimate partner violence (IPV) during pregnancy can result in adverse outcomes for both mothers and their infants. This crosssectional study examined the prevalence and risk factors of IPV associated with abuse during pregnancy via a self-administered questionnaire completed by 302 healthy pregnant women. Demographic information was also collected from medical records to analyze risk factors for abuse. Of the 302 women, 48 (15.9%) were identified as experiencing IPV. The identified risk factors were age over 30, multipara, previous abortion experience, and male partner aged under 30. Intimate partner violence (IPV) against women is a major, global public health problem leading to long-lasting negative outcomes (World Health Organization [WHO], 2012). Both resource-rich and resource-limited countries continue to struggle to provide IPV services for women (WHO, 2012). Although Japan is considered a highly developed nation, its IPV services are relatively new. The authors in the article (WHO, 2012) provide a background to Japan’s process of providing IPV services, and examine the necessity for providing IPV services, with the goal of benefitting other nations. It has been well documented that IPV can result in a number of longterm health problems stemming from chronic central nervous system dysfunction, for example, headaches and back pain (Campbell et al., 2002). Battered women also exhibit more somatic signs, symptoms, and illnesses,
Received 30 January 2012; accepted 15 October 2013. Address correspondence to Sachiko Kita, Department of Maternal Infant Nursing and Midwifery, St. Luke’s College of Nursing, 10-1, Akashi-chou, Chuo-ku, Tokyo 104-0044, Japan. E-mail: [email protected] 442
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such as appetite loss, respiratory illness (Campbell et al., 2002; Leseman, Li, Drossman, & Hu, 1998), and chronic pain (Campbell, 2002). Other dysfunctions found were reproductive and gynecological concerns, such as unwanted pregnancies (Goodwin, Gazmararian, Johnson, Gilbert, & Saltzman, 2000), vaginal infections (Campbell et al., 2002), pain during sex (Letourneau, Holmes, & Chasendunn-Roark, 1999), vaginal bleeding, and pelvic pain (Schei & Bakketeig, 1989). Women who are abused physically, psychologically, or sexually by intimate partners are also at increased risk of psychological and behavioral problems, including child abuse (Rumn, Cummings, Krauss, Bell, & Rivara, 2000), depression, fear, anxiety (United Nations Children’s Fund, 2000), and suicidal behaviors (Thompson, Kaslow, & Kingree, 2002). While pregnancy may be regarding as a protective factor against IPV, it may also be regarded as a risk factor, possibly triggering the onset of IPV or aggravating violent behavior in the partner (WHO, 2012). In an English study, Bacchus, Marzey, and Bewley (2004) found a 3% prevalence of IPV during current pregnancy among 200 pregnant women. Using the Index of Spouse Abuse (ISA), Kataoka, Yaju, Eto, and Horiuchi (2005) found that 5.4% of 279 pregnant women from an urban clinic reported that their partners had assaulted them during their pregnancy. In a later Japanese study, Inami, Kataoka, Eto, and Horiuchi (2010) used the Violence Against Women Screen (VAWS) in an urban maternity clinic and found that 31.4% of the 357 pregnant women surveyed experienced IPV during their pregnancy. In a previous study, researchers noted that a significantly greater number of Japanese women reported IPV when data were gathered through questionnaires, as opposed to through interviews (Kataoka, Yaju, Eto, & Horiuchi, 2010). The prevalence rates of IPV (5.4%–31.4%) among pregnant women in Canada (Campbell & Lewandowski, 1997), England (Bacchus et al., 2004), and Japan appear similar. In studies on IPV, prevalence rates varied according to how the questions were asked, what screening tool was used, and participant demographics. Therefore, comparisons among countries must be cautiously interpreted. Violence during pregnancy threatens the health and progress of pregnancy and childbirth, and can even result in the death of the mother and the unborn child. Adverse health outcomes of IPV during pregnancy include hypertension, preterm birth, low birth weight infant (Silverman, Decker, Reed, & Raj, 2006), nonreassuring fetal status, and fetal death (Dye, Tollivert, Lee, & Kenney, 1995). Japan has only recently passed legislation to protect victims of IPV. The Act on the Prevention of Spousal Violence and the Protection of Victims was promulgated in April 2001 after careful study and recognition of unacceptable IPV prevalence rates and adverse social and health-related outcomes in Japan (Gender Equality Bureau, Cabinet Office, 2008a). This was the first law that explicitly labeled spousal violence as a criminal offence, with the
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perpetrator punishable in accordance with criminal law (Gender Equality Bureau, Cabinet Office, 2008a). By 2007, various amendments had extended the scope of the law to include mental, sexual, and social violence; furthermore, Women’s Consultation Offices and other appropriate facilities were authorized within their jurisdiction to function as spousal violence counseling and support centers (SVCSCs). Additional assistance was provided for those experiencing psychological violence, and municipalities increased the number of shelters, women’s consultation offices, and IPV counseling centers (Gender Equality Bureau, Cabinet Office, 2008a). By 2011, Japan had established more than 300 IPV counseling centers (Gender Equality Bureau, Cabinet Office, 2008a). The need for this program is reflected in the number of complaints that they received, which doubled from 35,943 in 2004 to 77,334 in 2011 (Gender Equality Bureau, Cabinet Office, 2011). Although the support systems offered by health care professionals in clinical settings are still insufficient, there are several important strong positive trends toward the goal of supporting survivors of IPV. First, the law recommends that if IPV is detected and the victim wants assistance, then health care providers should report IPV to the police or to an SVCSC (Gender Equality Bureau, Cabinet Office, 2008a). In addition, Horiuchi, Yaju, Kataoka, Eto, and Matsumoto (2009) developed the Clinical Guidelines for Domestic Violence Victims in Perinatal Clinical Settings—the first evidence-based, women-centered, and culturally relevant IPV guidelines for pregnant women in Japanese maternity clinical settings. These guidelines were based on the premise that, with regard to IPV, the most important task of health care professionals is to identify abused women early and provide them with the necessary information about SVCSCs, while respecting the woman’s intention. In Japan, pregnant women are encouraged to receive maternity checkups at least 10 times throughout their pregnancy. These check-ups are paid for, in large part, by the government. The majority of pregnant women visit maternity clinics or hospitals at least once a month during pregnancy, providing an excellent opportunity for health care professionals to identify and assist abused women (Horiuchi et al., 2009). Identifying women who experience IPV is an essential part of prenatal care; such screening can help to decrease IPV prevalence and prevent its adverse health outcomes in both mothers and babies (Horiuchi et al., 2009). The investigators in a survey by the Gender Equality Bureau, Cabinet Office (2008b) gave an indication of the great need for clinicians skilled in IPV detection: of the women abused by spouses, about a half (53.0%) had never told anyone about the violence, 27.6% told friends, and 27.6% told parents; only 3.2% had told a health professional, 1.1% told a SVCSC, and 2.2% told the police. The low percentage of women who seek assistance from qualified professionals for IPV makes clear the crucial need for sensitive case detection and referral. Early IPV detection protects the life of mother and fetus and
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prevents adverse health outcomes. Maternity clinical settings are the natural places within which to identify IPV and refer women to IPV professionals (Horiuchi et al., 2009). Kataoka and colleagues (2005) found that Japanese health care providers lack understanding of IPV victims and the adverse health outcomes. This gap of understanding indicates the need to identify IPV victims during pregnancy in prenatal settings in order to improve their health outcomes. Identifying risk factors related to Japanese pregnant women abused by their male partners should help health care professionals in understanding the characteristics of IPV victims and improve case detection. Such a policy might also contribute to encouraging professionals in maternity settings in other countries to consider which women might be at risk and how best to screen for abuse during pregnancy. There are few studies, however, regarding IPV among pregnant women in Japan. Therefore, we examined the prevalence of IPV during the perinatal period in a hospital in Japan and identified the demographic risk factors.
Definition of IPV IPV is defined as behavior within an intimate relationship that causes physical, sexual, or psychological harm; it includes acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors (WHO, 2010). This definition covers violence by both current and former spouses and partners. IPV, assault, and abuse against women are used interchangeably in this article.
METHODS Our study employed a cross-sectional survey with purposive sampling. Given the dearth of research on our chosen subject, our study was descriptive in nature.
Setting and Sample We drew our sample from 310 pregnant Japanese and non-Japanese women who visited a maternity check-up clinic at an urban hospital in West Tokyo, Japan. We used patient records to identify the pool of potential participants based on the following inclusion criteria: more than 10 weeks pregnant, not diagnosed with major mental illness, and able to understand and complete a questionnaire in Japanese, English, Chinese, or Tagalog. We identified 302 (97.4%) women as eligible participants, and 100% agreed to participate.
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Research Procedure To ensure a safe, confidential, and respectful recruitment process, we offered an “Essentials of IPV recruitment and data collection” half-day training for the seven nurse midwives from the hospital on our recruitment and data collection team. All pregnant women were informed about IPV and screening through posters and pamphlets available at the maternity center. Women eligible for study participation were taken by a member of the recruitment team to a private room (to ensure privacy and safety) where they were assured confidentiality and invited to participate in the study. After providing written consent, women completed the IPV screening tool (VAWS), a selfreport paper-and-pencil questionnaire. It took just a few minutes to complete all the items on the questionnaire. The questionnaire was collected directly by a member of the team who could immediately identify if the woman was at a high risk for IPV. If a woman was reluctant to accept help at that time, the team member asked whether she wished to seek any support. If the woman wanted help, a team member took additional time to discuss her situation and provide her with information about IPV, the relevant laws, and SVCSCs. The researchers or nurse–midwives also collected demographic data from participants’ medical records after the women consented to participate in this study. The study was conducted from September 2009 to November 2009.
Screening Instrument We used a VAWS to assess participants’ IPV experience (Kataoka, 2005). We based our choice of instrument on Kataoka, Yaju, Eto, Matsumoto, and Horiuchi’s (2004) previous indication that Japanese women disclosed abuse more freely through the VAWS than through an oral interview. The VAWS is a 7-item Japanese-language screening instrument. Items include information about a couple’s relationship and perceived behavior of the partner during the preceding 12 months. The seven items ask about (in the following order): (a) difficultly settling arguments by talking them through, (b) becoming frightened, (c) being yelled at, (d) partner hitting the wall or throwing objects, (e) being forced into sex, (f) being pushed or slapped, and (g) being hit or kicked (Kataoka, 2005). The key characteristic of IPV, coercive control, was measured by the VAWS’s first three questions (Kataoka, 2005). Possible responses to items follow: (1) “never,” (2) “sometimes,” or (3) “always,” giving the questionnaire a score range of 7–21. Participants who checked “always” or “sometimes” (cut-off point: score of 9 or higher) were identified as IPV victims (Kataoka, 2005). The cut-off point had good sensitivity (86.7%) and specificity (80.2%) as compared with the Japanese version of the ISA (Kataoka, 2005). The reliability of the VAWS (Japanese) was acceptable; Cronbach’s alpha was 71% for 278 participants of the present study. Kataoka (2005)
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demonstrated credible concurrent validity with the General Health Questionnaire 30 (GHQ 30; r = .30) and the Self-esteem Scale (r = −.26). The sensitivity of VAWS was 86.7% and specificity was 80.2%, based on the Japanese version of the ISA (Kataoka, 2005). In addition, Kataoka and colleagues (2004) recommended that this screening tool be used with Japanese women because of its acceptable psychometric properties, participant acceptability, and greater sensitivity for this population, as compared with the Abuse Assessment Screen (AAS) and the Partner Violence Screen (PVS). For this the present study, bilingual native speakers for each language translated the VAWS from Japanese into their respective languages: Chinese, English, and Tagalog. These languages were selected by the researcher based on the population of non-Japanese women that were served by the clinic. Both the native speakers and the VAWS developer (personal communication, Y. Kataoka, May 20, 2009) confirmed the accuracy and validity of the translated instruments. The sample size of each linguistic group was too small to compute accurate Cronbach alphas.
Demographics We identified known demographic risk characteristics using results from several studies (Kataoka et al., 2005; WHO, 2010). Participants’ medical records were then screened for the following risk factors: age, marital status, working status, nationality, partner’s age, partner’s nationality, infant’s gestational age, parity, previous abortion experience, and previous miscarriages.
Statistical Analysis Data were analyzed using frequencies and percentages. The IPV victim rate was calculated using the established cut-off point of the VAWS. Chi-square testing was used to explore relationships between demographic variables and IPV. Crude odds ratios (ORs) and a 95% confidence interval (CI) were used to indicate the association between these variables and abuse. In addition, multiple logistic regression analysis was conducted to determine the factors associated with exposure to IPV. This analysis also generated adjusted odds ratios (AORs) and 95% CIs for associations with IPV, controlling for confounding factors. All analyses were conducted using SPSS for Windows, version 15.0 J (SPSS Japan Inc.). All p values were two-sided; p < .05 was considered a statistically significant value.
Ethical Considerations The ethical board of the hospital approved the study. Informed consent and withdrawal without penalty were assured. Precautions were taken to
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protect women’s privacy, and the questionnaire was anonymous, so that no participant could be identified. In addition, we provided resource cards containing information about SVCSCs, including phone numbers. These cards were available in the outpatient restroom, so that women could confidentially review IPV-related information. The chief nurse–midwife was responsible for consultation, and the study participants were given information about how to contact her.
RESULTS Demographic Data A majority of the participants 176 (58.3%) were in their thirties; 116 (38.4%) were in their twenties. Most women were married (90.4%) and Japanese (92.4%). Other nationalities (7.6%) were composed of Chinese (5.9%), Filipina (1.0%), one Thai, and one Saudi Arabian participant. Multiparas made up 38.5% of total participants. The majority of partners were age 30 and over (67.9%), with 31.1% in their twenties (Table 1).
Prevalence of IPV During Pregnancy Two hundred participants (66%) marked “none” for all the VAWS questions, leaving 101 women (34%) who marked either “always” or “sometimes” on one or more questions. In other words, approximately one in three pregnant women experienced at least one form of physical, mental, or sexual violence. Applying the VAWS cut-off point, we identified 48 women (16%) as IPV victims. In addition, 94 participants (31%) had experienced difficulties in their relationship with their partner, or were abused mentally by their partners. Four participants (2.3%) had experienced physical violence, and three women (1.0%) were assaulted sexually during their pregnancy (Table 2).
Risk Factors for Violence During Pregnancy Multiple logistic regression analysis showed risk factors of IPV during pregnancy: age over 30 (OR = 1.17, 95% CI = 0.16–2.23, AOR = 2.70, 95% CI = 1.11–6.57), multipara (OR = 1.93, 95% CI = 1.03–3.60, AOR = 2.99, 95% CI = 1.47–6.07), previous abortion experience (OR = 2.50, 95% CI = 1.11–5.64, AOR = 2.73, 95% CI = 1.10–6.78), male partner aged under 30 (OR = 2.15, 95% CI = 1.12–3.94, AOR = 3.78, 95% CI = 1.53–9.09). These results are presented in Table 3.
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TABLE 1 Demographic Characteristics of Participants (n = 302)
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Characteristic
n%
Age (years) 20–29 30–39 ≥40 Number of children None 1 2 3 4 Marriage status Married Single Nationality Japanese Phillipine Chinese Others Working status Working Nonworking Gestational age >22 22–33 33< Previous abortion experience Yes None Previous miscarrage experience Yes None Partner’s age (years) 20–29 30–39 40–49 49< Partner’s nationality Japanese Phillipine Chinese Others
116 (38.4) 176 (58.3) 10 (3.3) 163 (54.0) 108 (35.8) 23 (7.6) 5 (1.7) 3 (1.0) 273 (90.4) 28 (9.3) 279 (92.4) 3 (1.0) 18 (6.0) 2 (0.7) 166 (55.0) 132 (43.7) 150 (49.7) 103 (34.1) 49 (16.2) 34 (11.3) 267 (88.4) 52 (17.2) 249 (82.7) 94 (31.1) 167 (55.3) 38 (12.6) 2 (0.7) 286 (94.7) 2 (0.7) 9 (3.0) 3 (1.0)
DISCUSSION Demographics Although the percent of non-Japanese women in this study exceeded the general rate of 1% for Japan, the number was still too small for statistical analyses. The authors in a previous study conducted in Japan (Inami et al., 2010) using the VAWS found no statistical differences in IPV among Japanese
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TABLE 2 Frequency of Each Question of VAWS No. 1 2 3 4 5 6
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Question (VAWS) Is it difficult to settle by talking arguments between you and your partner? Do you feel frightened by what he does or says? Has your partner screamed or yelled at you? Has your partner ever hit a wall or thrown objects? Has your partner forced you to have sex? Has your partner pull can your arm, pushed, or slapped you? Has your partner ever hit or kicked you?
1: Always or sometimes (n (%))
2: None (n (%))
53 (17.5)
249 (82.5)
24 13 4 3 3
278 238 273 285 290
(7.9) (4.3) (1.3) (1.0) (1.0)
1 (0.3)
(92.1) (95.7) (98.7) (99.0) (99.0)
301 (99.7)
VAWS is Violence Against Women Screen.
and non-Japanese women from one clinic. The researchers in studies from other countries, however, indicated a strong association between abuse and immigrant or minority status (Muldoon, Himchak, & Lemond, 2011).
Prevalence of IPV Compared with prior research using the same screening tool (Inami et al., 2010) in which 30.1% of both Japanese and non-Japanese pregnant women were assaulted by intimate partners during their pregnancy, the prevalence in this study was almost half that rate. In England, Bacchus and colleagues (2004) identified 23.5% of women as experiencing abuse; the prevalence of IPV in this study was also lower compared with those studies (Bacchus et al., 2004; Inami et al., 2010). We hypothesize that the main reason for the differences in IPV prevalence among the three studies was due to differences in research procedures. In the present study, participants completed the questionnaires about IPV in a private room with the researchers or staff nurses present, so that we could collect the questionnaires directly from the women and ensure their safety. Upon questionnaire completion, we immediately confirmed if participants were at a high risk for IPV. That level of staff involvement might have discouraged disclosure about IPV among women who feared stigmatization or reprisal. All of the women who were abused either physically or sexually reported difficulties in their relationships with their partners. This indicated strong associations between psychological, physical, and sexual abuse. “Relationship difficulties” may be a common theme, however, and could therefore be one of the predictors of IPV for pregnant women across cultures.
Relationships Between IPV and Age, Multiparas, and Abortion There were four common characteristics of abused women in this study: age over 30, multiparas, previous abortion experience, and male partner aged under 30.
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Age 20–29 Over 30 Marriage status Married Single Missing Working status Working Non working Missing Nationality Japanese Other nationalies Missing Partner’s age 20–29 Over 30 Missing Partner’s nationality Japanese Other nationalies Missing Gestational week >22w 22w≤ Missing
Characteristic 17 (35.5) 31 (64.5) 39 (83.0) 8 (17.0) 30 (62.5) 18 (37.5) 45 (93.8) 3 (6.2) 22 (45.8) 26 (54.2) 47 (97.9) 1 (2.1) 27 (56.2) 21 (43.8)
273 28 1
166 132 4
278 23 1
94 206 2
285 14 3
149 152 1
Positive n = 48 n (%)
116 186
Participants n
122 (48.2) 131 (51.8)
238 (94.8) 13 (5.2)
72 (28.6) 180 (71.4)
233 (92.1) 20 (7.9)
136 (54.6) 113 (45.4)
233 (92.1) 20 (7.9)
99 (39.2) 154 (60.8)
Negative n = 254 n (%)
VAWSa
TABLE 3 Risk Factors Related to Violence During Pregnancy
18.1 13.8
16.5 7.1
23.4 12.6
1.62 13.0
18.1 13.7
14.3 28.6
14.6 16.6
IPVc Prevalence %
∗
∗
0.39 (0.50−3.05)
0.72 (0.39−1.35)
.35
0.77 (0.22−2.72)
.43
.22
0.72 (0.38−1.36)
.74
2.15 (1.12−3.94)
0.41 (0.17−1.01)
.12
.003
1.17 (0.16−2.23)
OR (95%CI)
.03
p valueb
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(Continued on next page)
0.72 (0.37−1.41)
0.17 (0.01−2.80)
3.78 (1.53−9.09)
1.96 (0.36−10.54)
5.21 (0.25−1.06)
0.45 (0.17−1.22)
2.70 (1.11−6.57)
AOR (95%CI)f
452 23 (47.9) 25 (52.1) 10 (20.8) 38 (79.2) 9 (18.8) 39 (81.2)
185 116 1 34 266 2 51 249 2
Positive n = 48 n (%)
42 (16.7) 210 (83.3)
24 (9.5) 228 (90.5)
162 (64.0) 91 (36.0)
Negative n = 254 n (%)
bp
Violence Against Women’s Screen. value was caculated by multiple logistic regression analysis. p = .05. cIPV: intimate partner violence. dPrimiparas means women with no experience of childbirth. eMultiparas means women who experienced childbirth once or more previously. fAOR means adjusted odds ratio caculated by multiple logistic regression.
aVAWS:
Parity Primiparasd Multiparase Missing Previous abortion experience Yes No Missing Previous miscarriage experience Yes No Missing
Characteristic
Participants n
VAWSa
TABLE 3 Risk Factors Related to Violence During Pregnancy (Continued)
17.6 15.7
29.4 14.3
12.4 21.6
IPVc Prevalence %
2.50 (1.11−5.64)
0.86 (0.39−1.92)
.002 .03
.99
∗
1.93 (1.03−3.60)
OR (95%CI)
∗
p valueb
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0.99 (0.40−2.47)
2.73 (1.10−6.78)
2.99 (1.47−6.07)
AOR (95%CI)f
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Older women were more likely to be multipara than younger women. We believe that this is why, in the present study, older women were more likely to be abused. In other words, age was a confounding factor. Multipara women were more likely to be abused by their partners as compared with primipara women. Kataoka and colleagues (2005) found that women who had previous experience of childbirth were four times more likely to suffer abuse as compared with those who had never given birth. This result was similar to that of a previous study in Japan (Kataoka et al., 2005). In the present study the prevalence of IPV during pregnancy for women with previous experiences of abortion was approximately 2.7 times higher than for those who never had abortions. The implication is that women who chose to have abortions most likely had an unwanted or unplanned pregnancy. Researchers in the United States (Goodwin et al., 2000) found that women who had unwanted pregnancies had a 2.5 times higher risk of physical abuse as compared with those women whose pregnancies were intended. Therefore, there may be a strong association between unwanted pregnancy and IPV during pregnancy.
Relationships Between Abuse and Male Partners Aged Under 30 Cronholm (2006) cited several studies from the late 1990s, which noted that younger men, ethnic minorities, and those of a lower socioeconomic class had higher rates of IPV. Similarly, other researchers (WHO, 2010) found a higher rate of abuse reported by women who were younger, less educated, and poor. Although abuse cuts across all ages and socioeconomic statuses, rates are clearly higher for some populations, Cronholm (2006) identified antecedents related to men who perpetrate IPV, and found two useful factors to consider: history of childhood abuse and normative patriarchal male social structure.
Necessity of Screening Pregnant Women in Clinical Settings There have been differences of opinion regarding the recommendation to regularly screen pregnant women for IPV. In a systemic review to evaluate whether screening programs met criteria established by the UK health system, Feder and colleagues (2009) concluded there was insufficient evidence to implement a screening program for partner violence against women either in health services generally or in specific clinical settings; further, there were no trials for screening program that measured harm or effectiveness of screening and interventions in clinical settings (Feder et al., 2009). Despite this fact, numerous researchers have recommended routine IPV screening of all pregnant women as a first intervention to minimize the adverse health consequences of abuse on women and infants (Horiuchi et al., 2009; Inami
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et al., 2010). Nelson, Bougatsos, and Blazina (2012), conducting a systematic review of screening programs to update the 2004 U.S. preventive task force recommendations, concluded that, despite limitations of study quality, there was sufficient evidence to assert that screening did have benefits for different populations of women, with minimal harmful effects. The researchers stated that health providers needed to be aware of and willing to address violence and coercion as part of their commitment to promoting women’s sexual and reproductive health. On the basis of these study findings, we believe that further research, including trials of system-level intervention and of psychological and advocacy interventions, is necessary to strengthen the evidence for screening programs.
Study Limitations This study has several limitations. First, the sample size was small, and the sample size for each non-Japanese linguistic group (English, Chinese, and Tagalog) was too small to validate the psychometric properties of the translated VAWS. Second, our study did not investigate the detailed social, financial, and psychological statuses of participants and their partners. These additional factors need to be investigated to identify more specific risk factors for IPV. Last, we conducted this study at an urban prenatal clinic. Further studies are needed to establish the generalization of the results to other areas (i.e., suburban, rural). In order to better understand IPV prevalence and risk factors during pregnancy in Japan, we believe that it would be necessary to conduct research in a variety of settings investigating a greater range of risk factors, including abortion and miscarriage. A study validating the translated screening tools would also be needed to more accurately measure IPV among non-Japanese women in Japan. Given these limitations, our results should be cautiously interpreted.
CONCLUSION Our cross-sectional study investigating prevalence and risk factors of IPV during pregnancy in 302 healthy pregnant women found the following: (a) The VAS identified 15.9% pregnant women as currently experiencing abuse by their partners. (b) Risk factors associated with IPV during pregnancy were as follows: over 30 years old, multipara, previous abortion experience, and male partner under 30 years old. As a result of our study findings, we recommend that all pregnant women be routinely screened for IPV during pregnancy. Multipara women,
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pregnant women with abortion experience, and women whose partners are under 30 may be at more risk; we highly recommend IPV screening to help prevent severe abuse and its adverse obstetrics outcomes.
FUNDING This study was supported by St. Luke’s College of Nursing. The authors are deeply grateful to the participants for their cooperation.
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REFERENCES Bacchus, L., Marzey, G., & Bewley, S. (2004). Domestic violence: Prevalence in pregnant women and associations with physical and psychological health. European Journal of Obstetrics, Gynecology & Reproductive Biology, 113(1), 6–11. Campbell, J. C. (2002). Health consequence of intimate partner violence. Lancet, 359(9314), 1331–1336. Campbell, J. C., Jones, A. S., Dienemann, J., Kub, J., Schollenberger, J., O’Campo, P., . . . Carlson, A. (2002). Intimate partner violence and physical health consequences. Archives of Internal Medicine, 162, 1157–1163. Campbell, J. C., & Lewandowski, L. A. (1997). Mental and physical health effects of intimate partner violence on women and children. Psychiatric Clinic of North America, 20, 353–374. Cronholm, P. F. (2006). Intimate partner violence and men’s health. Primary Care, 33(1), 199–209. Dye, T. D., Tollivert, N. J., Lee, R. V., & Kenney, C. J. (1995). Violence, pregnancy and birth outcome in Appalachia. Paediatric & Perinatal Epidemiology, 9(1), 35–47. Feder, G., Ramsay, J., Dunne, D., Rose, M., Arsene, C., Norman, R., Kuntze, S., . . . Taket, A. (2009). How far does screening women for domestic violence in different health-care settings meet criteria for a screening program? Systematic reviews of nine UK national screening committee criteria. Health Technology Assessment, 13(16), 3–76. Gender Equality Bureau, Cabinet Office. (2008a). Information of assistance in incident of spousal abuse: Stop the violence. Retrieved from http://www. gender.go.jp/e-vaw/book/images/pdf/stoptheviolence.pdf Gender Equality Bureau, Cabinet Office. (2008b). National survey: Survey of abuse from intimate partners. Retrieved from http://www.gender.go.jp/e-vaw/ chousa/images/pdf/chousagaiyou2103.pdf Gender Equality Bureau, Cabinet Office. (2011). National survey: Survey of abuse from intimate partners. Retrieved from http://www.gender.go.jp/e-vaw/ book/images/pdf/stoptheviolence.pdf Goodwin, M. M., Gazmararian, J. A., Johnson, C. H., Gilbert, B. C., & Saltzman, L. E. (2000). Pregnancy intendedness and physical abuse around the time of pregnancy: Findings from pregnancy risk assessment monitoring system, 1996–1997. PRAMS Working Group. Pregnancy Risk Assessment Monitoring System. Maternity Child Health Journal, 4(2), 85–92.
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Horiuchi, S., Yaju, Y., Kataoka, Y., Eto, H., & Matsumoto, N. (2009). Development of an evidence-based domestic violence guideline: Supporting perinatal womencentered care in Japan. Midwifery, 25(1), 72–78. Inami, E., Kataoka, Y., Eto, H., & Horiuchi, S. (2010). Intimate partner violence against Japanese and non-Japanese women in Japan: A cross-sectional study in the perinatal setting. Japan Journal of Nursing Science, 7, 84– 95. Kataoka, Y. (2005). Jyosei ni tisuru bouryoku screening syakudo no kaihatsu [Development of the violence against women screening]. Nihon Kango Kagaku Gakkai Zasshi, 25(3), 51–60. Kataoka, Y., Yaju, Y., Eto, H., & Horiuchi, S. (2005). Ninshinki ni okeru domestic violence [Domestic violence against women during pregnancy]. Nihon Kosyueisei Zasshi, 52, 785–795. Kataoka, Y., Yaju, Y., Eto, H., & Horiuchi, S. (2010). Self-administered questionnaire versus interview as a screening method for intimate partner violence in the prenatal setting in Japan: Randomized controlled trial. BMC Pregnancy Childbirth, 24(10), 84–90. Kataoka, Y., Yaju, Y., Eto, H., Matsumoto, N., & Horiuchi, S. (2004). Screening of domestic violence against women in the perinatal setting: A systematic review. Japan Journal of Nursing Science, 1, 77–86. Leseman, J., Li, Z., Drossman, D. A., & Hu, Y. J. (1998). Selected symptoms associated with sexual and physical abuse among female patients with gastrointestinal disorders: The impact on subsequent health care visits. Psychology Medicine, 28, 417–425. Letourneau, E. J., Holmes, M., & Chasendunn-Roark, J. (1999). Gynecologic health consequence to victims of interpersonal violence. Women Health Issues, 9, 115–120. Muldoon, J., Himchak, M., & Lemond, D. (2011). International problems of intimate partner violence and its impact upon immigrant groups in the United States. Journal of Global Social Work Practice, 4(2). Retrieved from http://www.globalsocialwork.org/vol4no2/Muldoon.html Nelson, H., Bougatsos, C., & Blazina, I. (2012). A systematic review to update the 2004 U.S. preventive services task force recommendation. Retrieved from http:// www.uspreventiveservicestaskforce.org/uspstf12/ipvelder/ipvelderart.htm Rumn, P. D., Cummings, P., Krauss, M. R., Bell, M. A., & Rivara, E. P. (2000). Identified spouse abuse as a risk factor for child abuse. Child Abuse & Neglect, 24, 1375–1381. Schei, B., & Bakketeig, L. S. (1989). Gynecological impact of sexual and physical abuse by spouse: A study of a random sample of Norwegian women. British Journal of Obstetrics & Gynecology, 96, 1379–1383. Silverman, J. G., Decker, M. R., Reed, E., & Raj, A. (2006). Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: Associations with maternal and neonatal health. American Journal of Obstetrics & Gynecology, 195, 140–148. Thompson, M. P., Kaslow, N. J., & Kingree, J. B. (2002). Risk factors for suicide attempts among African women experiencing recent intimate partner violence. Violence Victim, 17, 283–295.
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United Nations Children’s Fund. (2000). Domestic violence against women and girls. Florence, Italy: Author. World Health Organization (WHO). (2010). Preventing intimate partner and sexual violence against women-taking action and generating evidence. Geneva, Switzerland: Author. World Health Organization (WHO). (2012). Prevention of intimate partner violence and sexual violence. Retrieved from http://www.who.int/violence_ injury_prevention/violence/activities/intimate/en/index.html
Health Care for Women International Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcw20
Prevalence and Risk Factors of Intimate Partner Violence Among Pregnant Women in Japan a
a
b
Sachiko Kita , Kataoka Yaeko & Sarah E. Porter a
Department of Maternal Infant Nursing and Midwifery, St. Luke's College of Nursing, Tokyo, Japan b
School of Nursing, Oregon Health & Science University, Portland, Oregon, USA Accepted author version posted online: 29 Oct 2013.Published online: 18 Dec 2013.
To cite this article: Sachiko Kita, Kataoka Yaeko & Sarah E. Porter (2014) Prevalence and Risk Factors of Intimate Partner Violence Among Pregnant Women in Japan, Health Care for Women International, 35:4, 442-457, DOI: 10.1080/07399332.2013.857320 To link to this article: http://dx.doi.org/10.1080/07399332.2013.857320
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Health Care for Women International, 35:442–457, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2013.857320
Prevalence and Risk Factors of Intimate Partner Violence Among Pregnant Women in Japan
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SACHIKO KITA and KATAOKA YAEKO Department of Maternal Infant Nursing and Midwifery, St. Luke’s College of Nursing, Tokyo, Japan
SARAH E. PORTER School of Nursing, Oregon Health & Science University, Portland, Oregon, USA
Intimate partner violence (IPV) during pregnancy can result in adverse outcomes for both mothers and their infants. This crosssectional study examined the prevalence and risk factors of IPV associated with abuse during pregnancy via a self-administered questionnaire completed by 302 healthy pregnant women. Demographic information was also collected from medical records to analyze risk factors for abuse. Of the 302 women, 48 (15.9%) were identified as experiencing IPV. The identified risk factors were age over 30, multipara, previous abortion experience, and male partner aged under 30. Intimate partner violence (IPV) against women is a major, global public health problem leading to long-lasting negative outcomes (World Health Organization [WHO], 2012). Both resource-rich and resource-limited countries continue to struggle to provide IPV services for women (WHO, 2012). Although Japan is considered a highly developed nation, its IPV services are relatively new. The authors in the article (WHO, 2012) provide a background to Japan’s process of providing IPV services, and examine the necessity for providing IPV services, with the goal of benefitting other nations. It has been well documented that IPV can result in a number of longterm health problems stemming from chronic central nervous system dysfunction, for example, headaches and back pain (Campbell et al., 2002). Battered women also exhibit more somatic signs, symptoms, and illnesses,
Received 30 January 2012; accepted 15 October 2013. Address correspondence to Sachiko Kita, Department of Maternal Infant Nursing and Midwifery, St. Luke’s College of Nursing, 10-1, Akashi-chou, Chuo-ku, Tokyo 104-0044, Japan. E-mail: [email protected] 442
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such as appetite loss, respiratory illness (Campbell et al., 2002; Leseman, Li, Drossman, & Hu, 1998), and chronic pain (Campbell, 2002). Other dysfunctions found were reproductive and gynecological concerns, such as unwanted pregnancies (Goodwin, Gazmararian, Johnson, Gilbert, & Saltzman, 2000), vaginal infections (Campbell et al., 2002), pain during sex (Letourneau, Holmes, & Chasendunn-Roark, 1999), vaginal bleeding, and pelvic pain (Schei & Bakketeig, 1989). Women who are abused physically, psychologically, or sexually by intimate partners are also at increased risk of psychological and behavioral problems, including child abuse (Rumn, Cummings, Krauss, Bell, & Rivara, 2000), depression, fear, anxiety (United Nations Children’s Fund, 2000), and suicidal behaviors (Thompson, Kaslow, & Kingree, 2002). While pregnancy may be regarding as a protective factor against IPV, it may also be regarded as a risk factor, possibly triggering the onset of IPV or aggravating violent behavior in the partner (WHO, 2012). In an English study, Bacchus, Marzey, and Bewley (2004) found a 3% prevalence of IPV during current pregnancy among 200 pregnant women. Using the Index of Spouse Abuse (ISA), Kataoka, Yaju, Eto, and Horiuchi (2005) found that 5.4% of 279 pregnant women from an urban clinic reported that their partners had assaulted them during their pregnancy. In a later Japanese study, Inami, Kataoka, Eto, and Horiuchi (2010) used the Violence Against Women Screen (VAWS) in an urban maternity clinic and found that 31.4% of the 357 pregnant women surveyed experienced IPV during their pregnancy. In a previous study, researchers noted that a significantly greater number of Japanese women reported IPV when data were gathered through questionnaires, as opposed to through interviews (Kataoka, Yaju, Eto, & Horiuchi, 2010). The prevalence rates of IPV (5.4%–31.4%) among pregnant women in Canada (Campbell & Lewandowski, 1997), England (Bacchus et al., 2004), and Japan appear similar. In studies on IPV, prevalence rates varied according to how the questions were asked, what screening tool was used, and participant demographics. Therefore, comparisons among countries must be cautiously interpreted. Violence during pregnancy threatens the health and progress of pregnancy and childbirth, and can even result in the death of the mother and the unborn child. Adverse health outcomes of IPV during pregnancy include hypertension, preterm birth, low birth weight infant (Silverman, Decker, Reed, & Raj, 2006), nonreassuring fetal status, and fetal death (Dye, Tollivert, Lee, & Kenney, 1995). Japan has only recently passed legislation to protect victims of IPV. The Act on the Prevention of Spousal Violence and the Protection of Victims was promulgated in April 2001 after careful study and recognition of unacceptable IPV prevalence rates and adverse social and health-related outcomes in Japan (Gender Equality Bureau, Cabinet Office, 2008a). This was the first law that explicitly labeled spousal violence as a criminal offence, with the
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perpetrator punishable in accordance with criminal law (Gender Equality Bureau, Cabinet Office, 2008a). By 2007, various amendments had extended the scope of the law to include mental, sexual, and social violence; furthermore, Women’s Consultation Offices and other appropriate facilities were authorized within their jurisdiction to function as spousal violence counseling and support centers (SVCSCs). Additional assistance was provided for those experiencing psychological violence, and municipalities increased the number of shelters, women’s consultation offices, and IPV counseling centers (Gender Equality Bureau, Cabinet Office, 2008a). By 2011, Japan had established more than 300 IPV counseling centers (Gender Equality Bureau, Cabinet Office, 2008a). The need for this program is reflected in the number of complaints that they received, which doubled from 35,943 in 2004 to 77,334 in 2011 (Gender Equality Bureau, Cabinet Office, 2011). Although the support systems offered by health care professionals in clinical settings are still insufficient, there are several important strong positive trends toward the goal of supporting survivors of IPV. First, the law recommends that if IPV is detected and the victim wants assistance, then health care providers should report IPV to the police or to an SVCSC (Gender Equality Bureau, Cabinet Office, 2008a). In addition, Horiuchi, Yaju, Kataoka, Eto, and Matsumoto (2009) developed the Clinical Guidelines for Domestic Violence Victims in Perinatal Clinical Settings—the first evidence-based, women-centered, and culturally relevant IPV guidelines for pregnant women in Japanese maternity clinical settings. These guidelines were based on the premise that, with regard to IPV, the most important task of health care professionals is to identify abused women early and provide them with the necessary information about SVCSCs, while respecting the woman’s intention. In Japan, pregnant women are encouraged to receive maternity checkups at least 10 times throughout their pregnancy. These check-ups are paid for, in large part, by the government. The majority of pregnant women visit maternity clinics or hospitals at least once a month during pregnancy, providing an excellent opportunity for health care professionals to identify and assist abused women (Horiuchi et al., 2009). Identifying women who experience IPV is an essential part of prenatal care; such screening can help to decrease IPV prevalence and prevent its adverse health outcomes in both mothers and babies (Horiuchi et al., 2009). The investigators in a survey by the Gender Equality Bureau, Cabinet Office (2008b) gave an indication of the great need for clinicians skilled in IPV detection: of the women abused by spouses, about a half (53.0%) had never told anyone about the violence, 27.6% told friends, and 27.6% told parents; only 3.2% had told a health professional, 1.1% told a SVCSC, and 2.2% told the police. The low percentage of women who seek assistance from qualified professionals for IPV makes clear the crucial need for sensitive case detection and referral. Early IPV detection protects the life of mother and fetus and
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prevents adverse health outcomes. Maternity clinical settings are the natural places within which to identify IPV and refer women to IPV professionals (Horiuchi et al., 2009). Kataoka and colleagues (2005) found that Japanese health care providers lack understanding of IPV victims and the adverse health outcomes. This gap of understanding indicates the need to identify IPV victims during pregnancy in prenatal settings in order to improve their health outcomes. Identifying risk factors related to Japanese pregnant women abused by their male partners should help health care professionals in understanding the characteristics of IPV victims and improve case detection. Such a policy might also contribute to encouraging professionals in maternity settings in other countries to consider which women might be at risk and how best to screen for abuse during pregnancy. There are few studies, however, regarding IPV among pregnant women in Japan. Therefore, we examined the prevalence of IPV during the perinatal period in a hospital in Japan and identified the demographic risk factors.
Definition of IPV IPV is defined as behavior within an intimate relationship that causes physical, sexual, or psychological harm; it includes acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors (WHO, 2010). This definition covers violence by both current and former spouses and partners. IPV, assault, and abuse against women are used interchangeably in this article.
METHODS Our study employed a cross-sectional survey with purposive sampling. Given the dearth of research on our chosen subject, our study was descriptive in nature.
Setting and Sample We drew our sample from 310 pregnant Japanese and non-Japanese women who visited a maternity check-up clinic at an urban hospital in West Tokyo, Japan. We used patient records to identify the pool of potential participants based on the following inclusion criteria: more than 10 weeks pregnant, not diagnosed with major mental illness, and able to understand and complete a questionnaire in Japanese, English, Chinese, or Tagalog. We identified 302 (97.4%) women as eligible participants, and 100% agreed to participate.
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Research Procedure To ensure a safe, confidential, and respectful recruitment process, we offered an “Essentials of IPV recruitment and data collection” half-day training for the seven nurse midwives from the hospital on our recruitment and data collection team. All pregnant women were informed about IPV and screening through posters and pamphlets available at the maternity center. Women eligible for study participation were taken by a member of the recruitment team to a private room (to ensure privacy and safety) where they were assured confidentiality and invited to participate in the study. After providing written consent, women completed the IPV screening tool (VAWS), a selfreport paper-and-pencil questionnaire. It took just a few minutes to complete all the items on the questionnaire. The questionnaire was collected directly by a member of the team who could immediately identify if the woman was at a high risk for IPV. If a woman was reluctant to accept help at that time, the team member asked whether she wished to seek any support. If the woman wanted help, a team member took additional time to discuss her situation and provide her with information about IPV, the relevant laws, and SVCSCs. The researchers or nurse–midwives also collected demographic data from participants’ medical records after the women consented to participate in this study. The study was conducted from September 2009 to November 2009.
Screening Instrument We used a VAWS to assess participants’ IPV experience (Kataoka, 2005). We based our choice of instrument on Kataoka, Yaju, Eto, Matsumoto, and Horiuchi’s (2004) previous indication that Japanese women disclosed abuse more freely through the VAWS than through an oral interview. The VAWS is a 7-item Japanese-language screening instrument. Items include information about a couple’s relationship and perceived behavior of the partner during the preceding 12 months. The seven items ask about (in the following order): (a) difficultly settling arguments by talking them through, (b) becoming frightened, (c) being yelled at, (d) partner hitting the wall or throwing objects, (e) being forced into sex, (f) being pushed or slapped, and (g) being hit or kicked (Kataoka, 2005). The key characteristic of IPV, coercive control, was measured by the VAWS’s first three questions (Kataoka, 2005). Possible responses to items follow: (1) “never,” (2) “sometimes,” or (3) “always,” giving the questionnaire a score range of 7–21. Participants who checked “always” or “sometimes” (cut-off point: score of 9 or higher) were identified as IPV victims (Kataoka, 2005). The cut-off point had good sensitivity (86.7%) and specificity (80.2%) as compared with the Japanese version of the ISA (Kataoka, 2005). The reliability of the VAWS (Japanese) was acceptable; Cronbach’s alpha was 71% for 278 participants of the present study. Kataoka (2005)
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demonstrated credible concurrent validity with the General Health Questionnaire 30 (GHQ 30; r = .30) and the Self-esteem Scale (r = −.26). The sensitivity of VAWS was 86.7% and specificity was 80.2%, based on the Japanese version of the ISA (Kataoka, 2005). In addition, Kataoka and colleagues (2004) recommended that this screening tool be used with Japanese women because of its acceptable psychometric properties, participant acceptability, and greater sensitivity for this population, as compared with the Abuse Assessment Screen (AAS) and the Partner Violence Screen (PVS). For this the present study, bilingual native speakers for each language translated the VAWS from Japanese into their respective languages: Chinese, English, and Tagalog. These languages were selected by the researcher based on the population of non-Japanese women that were served by the clinic. Both the native speakers and the VAWS developer (personal communication, Y. Kataoka, May 20, 2009) confirmed the accuracy and validity of the translated instruments. The sample size of each linguistic group was too small to compute accurate Cronbach alphas.
Demographics We identified known demographic risk characteristics using results from several studies (Kataoka et al., 2005; WHO, 2010). Participants’ medical records were then screened for the following risk factors: age, marital status, working status, nationality, partner’s age, partner’s nationality, infant’s gestational age, parity, previous abortion experience, and previous miscarriages.
Statistical Analysis Data were analyzed using frequencies and percentages. The IPV victim rate was calculated using the established cut-off point of the VAWS. Chi-square testing was used to explore relationships between demographic variables and IPV. Crude odds ratios (ORs) and a 95% confidence interval (CI) were used to indicate the association between these variables and abuse. In addition, multiple logistic regression analysis was conducted to determine the factors associated with exposure to IPV. This analysis also generated adjusted odds ratios (AORs) and 95% CIs for associations with IPV, controlling for confounding factors. All analyses were conducted using SPSS for Windows, version 15.0 J (SPSS Japan Inc.). All p values were two-sided; p < .05 was considered a statistically significant value.
Ethical Considerations The ethical board of the hospital approved the study. Informed consent and withdrawal without penalty were assured. Precautions were taken to
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protect women’s privacy, and the questionnaire was anonymous, so that no participant could be identified. In addition, we provided resource cards containing information about SVCSCs, including phone numbers. These cards were available in the outpatient restroom, so that women could confidentially review IPV-related information. The chief nurse–midwife was responsible for consultation, and the study participants were given information about how to contact her.
RESULTS Demographic Data A majority of the participants 176 (58.3%) were in their thirties; 116 (38.4%) were in their twenties. Most women were married (90.4%) and Japanese (92.4%). Other nationalities (7.6%) were composed of Chinese (5.9%), Filipina (1.0%), one Thai, and one Saudi Arabian participant. Multiparas made up 38.5% of total participants. The majority of partners were age 30 and over (67.9%), with 31.1% in their twenties (Table 1).
Prevalence of IPV During Pregnancy Two hundred participants (66%) marked “none” for all the VAWS questions, leaving 101 women (34%) who marked either “always” or “sometimes” on one or more questions. In other words, approximately one in three pregnant women experienced at least one form of physical, mental, or sexual violence. Applying the VAWS cut-off point, we identified 48 women (16%) as IPV victims. In addition, 94 participants (31%) had experienced difficulties in their relationship with their partner, or were abused mentally by their partners. Four participants (2.3%) had experienced physical violence, and three women (1.0%) were assaulted sexually during their pregnancy (Table 2).
Risk Factors for Violence During Pregnancy Multiple logistic regression analysis showed risk factors of IPV during pregnancy: age over 30 (OR = 1.17, 95% CI = 0.16–2.23, AOR = 2.70, 95% CI = 1.11–6.57), multipara (OR = 1.93, 95% CI = 1.03–3.60, AOR = 2.99, 95% CI = 1.47–6.07), previous abortion experience (OR = 2.50, 95% CI = 1.11–5.64, AOR = 2.73, 95% CI = 1.10–6.78), male partner aged under 30 (OR = 2.15, 95% CI = 1.12–3.94, AOR = 3.78, 95% CI = 1.53–9.09). These results are presented in Table 3.
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TABLE 1 Demographic Characteristics of Participants (n = 302)
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Characteristic
n%
Age (years) 20–29 30–39 ≥40 Number of children None 1 2 3 4 Marriage status Married Single Nationality Japanese Phillipine Chinese Others Working status Working Nonworking Gestational age >22 22–33 33< Previous abortion experience Yes None Previous miscarrage experience Yes None Partner’s age (years) 20–29 30–39 40–49 49< Partner’s nationality Japanese Phillipine Chinese Others
116 (38.4) 176 (58.3) 10 (3.3) 163 (54.0) 108 (35.8) 23 (7.6) 5 (1.7) 3 (1.0) 273 (90.4) 28 (9.3) 279 (92.4) 3 (1.0) 18 (6.0) 2 (0.7) 166 (55.0) 132 (43.7) 150 (49.7) 103 (34.1) 49 (16.2) 34 (11.3) 267 (88.4) 52 (17.2) 249 (82.7) 94 (31.1) 167 (55.3) 38 (12.6) 2 (0.7) 286 (94.7) 2 (0.7) 9 (3.0) 3 (1.0)
DISCUSSION Demographics Although the percent of non-Japanese women in this study exceeded the general rate of 1% for Japan, the number was still too small for statistical analyses. The authors in a previous study conducted in Japan (Inami et al., 2010) using the VAWS found no statistical differences in IPV among Japanese
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TABLE 2 Frequency of Each Question of VAWS No. 1 2 3 4 5 6
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7
Question (VAWS) Is it difficult to settle by talking arguments between you and your partner? Do you feel frightened by what he does or says? Has your partner screamed or yelled at you? Has your partner ever hit a wall or thrown objects? Has your partner forced you to have sex? Has your partner pull can your arm, pushed, or slapped you? Has your partner ever hit or kicked you?
1: Always or sometimes (n (%))
2: None (n (%))
53 (17.5)
249 (82.5)
24 13 4 3 3
278 238 273 285 290
(7.9) (4.3) (1.3) (1.0) (1.0)
1 (0.3)
(92.1) (95.7) (98.7) (99.0) (99.0)
301 (99.7)
VAWS is Violence Against Women Screen.
and non-Japanese women from one clinic. The researchers in studies from other countries, however, indicated a strong association between abuse and immigrant or minority status (Muldoon, Himchak, & Lemond, 2011).
Prevalence of IPV Compared with prior research using the same screening tool (Inami et al., 2010) in which 30.1% of both Japanese and non-Japanese pregnant women were assaulted by intimate partners during their pregnancy, the prevalence in this study was almost half that rate. In England, Bacchus and colleagues (2004) identified 23.5% of women as experiencing abuse; the prevalence of IPV in this study was also lower compared with those studies (Bacchus et al., 2004; Inami et al., 2010). We hypothesize that the main reason for the differences in IPV prevalence among the three studies was due to differences in research procedures. In the present study, participants completed the questionnaires about IPV in a private room with the researchers or staff nurses present, so that we could collect the questionnaires directly from the women and ensure their safety. Upon questionnaire completion, we immediately confirmed if participants were at a high risk for IPV. That level of staff involvement might have discouraged disclosure about IPV among women who feared stigmatization or reprisal. All of the women who were abused either physically or sexually reported difficulties in their relationships with their partners. This indicated strong associations between psychological, physical, and sexual abuse. “Relationship difficulties” may be a common theme, however, and could therefore be one of the predictors of IPV for pregnant women across cultures.
Relationships Between IPV and Age, Multiparas, and Abortion There were four common characteristics of abused women in this study: age over 30, multiparas, previous abortion experience, and male partner aged under 30.
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Age 20–29 Over 30 Marriage status Married Single Missing Working status Working Non working Missing Nationality Japanese Other nationalies Missing Partner’s age 20–29 Over 30 Missing Partner’s nationality Japanese Other nationalies Missing Gestational week >22w 22w≤ Missing
Characteristic 17 (35.5) 31 (64.5) 39 (83.0) 8 (17.0) 30 (62.5) 18 (37.5) 45 (93.8) 3 (6.2) 22 (45.8) 26 (54.2) 47 (97.9) 1 (2.1) 27 (56.2) 21 (43.8)
273 28 1
166 132 4
278 23 1
94 206 2
285 14 3
149 152 1
Positive n = 48 n (%)
116 186
Participants n
122 (48.2) 131 (51.8)
238 (94.8) 13 (5.2)
72 (28.6) 180 (71.4)
233 (92.1) 20 (7.9)
136 (54.6) 113 (45.4)
233 (92.1) 20 (7.9)
99 (39.2) 154 (60.8)
Negative n = 254 n (%)
VAWSa
TABLE 3 Risk Factors Related to Violence During Pregnancy
18.1 13.8
16.5 7.1
23.4 12.6
1.62 13.0
18.1 13.7
14.3 28.6
14.6 16.6
IPVc Prevalence %
∗
∗
0.39 (0.50−3.05)
0.72 (0.39−1.35)
.35
0.77 (0.22−2.72)
.43
.22
0.72 (0.38−1.36)
.74
2.15 (1.12−3.94)
0.41 (0.17−1.01)
.12
.003
1.17 (0.16−2.23)
OR (95%CI)
.03
p valueb
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(Continued on next page)
0.72 (0.37−1.41)
0.17 (0.01−2.80)
3.78 (1.53−9.09)
1.96 (0.36−10.54)
5.21 (0.25−1.06)
0.45 (0.17−1.22)
2.70 (1.11−6.57)
AOR (95%CI)f
452 23 (47.9) 25 (52.1) 10 (20.8) 38 (79.2) 9 (18.8) 39 (81.2)
185 116 1 34 266 2 51 249 2
Positive n = 48 n (%)
42 (16.7) 210 (83.3)
24 (9.5) 228 (90.5)
162 (64.0) 91 (36.0)
Negative n = 254 n (%)
bp
Violence Against Women’s Screen. value was caculated by multiple logistic regression analysis. p = .05. cIPV: intimate partner violence. dPrimiparas means women with no experience of childbirth. eMultiparas means women who experienced childbirth once or more previously. fAOR means adjusted odds ratio caculated by multiple logistic regression.
aVAWS:
Parity Primiparasd Multiparase Missing Previous abortion experience Yes No Missing Previous miscarriage experience Yes No Missing
Characteristic
Participants n
VAWSa
TABLE 3 Risk Factors Related to Violence During Pregnancy (Continued)
17.6 15.7
29.4 14.3
12.4 21.6
IPVc Prevalence %
2.50 (1.11−5.64)
0.86 (0.39−1.92)
.002 .03
.99
∗
1.93 (1.03−3.60)
OR (95%CI)
∗
p valueb
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0.99 (0.40−2.47)
2.73 (1.10−6.78)
2.99 (1.47−6.07)
AOR (95%CI)f
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Older women were more likely to be multipara than younger women. We believe that this is why, in the present study, older women were more likely to be abused. In other words, age was a confounding factor. Multipara women were more likely to be abused by their partners as compared with primipara women. Kataoka and colleagues (2005) found that women who had previous experience of childbirth were four times more likely to suffer abuse as compared with those who had never given birth. This result was similar to that of a previous study in Japan (Kataoka et al., 2005). In the present study the prevalence of IPV during pregnancy for women with previous experiences of abortion was approximately 2.7 times higher than for those who never had abortions. The implication is that women who chose to have abortions most likely had an unwanted or unplanned pregnancy. Researchers in the United States (Goodwin et al., 2000) found that women who had unwanted pregnancies had a 2.5 times higher risk of physical abuse as compared with those women whose pregnancies were intended. Therefore, there may be a strong association between unwanted pregnancy and IPV during pregnancy.
Relationships Between Abuse and Male Partners Aged Under 30 Cronholm (2006) cited several studies from the late 1990s, which noted that younger men, ethnic minorities, and those of a lower socioeconomic class had higher rates of IPV. Similarly, other researchers (WHO, 2010) found a higher rate of abuse reported by women who were younger, less educated, and poor. Although abuse cuts across all ages and socioeconomic statuses, rates are clearly higher for some populations, Cronholm (2006) identified antecedents related to men who perpetrate IPV, and found two useful factors to consider: history of childhood abuse and normative patriarchal male social structure.
Necessity of Screening Pregnant Women in Clinical Settings There have been differences of opinion regarding the recommendation to regularly screen pregnant women for IPV. In a systemic review to evaluate whether screening programs met criteria established by the UK health system, Feder and colleagues (2009) concluded there was insufficient evidence to implement a screening program for partner violence against women either in health services generally or in specific clinical settings; further, there were no trials for screening program that measured harm or effectiveness of screening and interventions in clinical settings (Feder et al., 2009). Despite this fact, numerous researchers have recommended routine IPV screening of all pregnant women as a first intervention to minimize the adverse health consequences of abuse on women and infants (Horiuchi et al., 2009; Inami
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et al., 2010). Nelson, Bougatsos, and Blazina (2012), conducting a systematic review of screening programs to update the 2004 U.S. preventive task force recommendations, concluded that, despite limitations of study quality, there was sufficient evidence to assert that screening did have benefits for different populations of women, with minimal harmful effects. The researchers stated that health providers needed to be aware of and willing to address violence and coercion as part of their commitment to promoting women’s sexual and reproductive health. On the basis of these study findings, we believe that further research, including trials of system-level intervention and of psychological and advocacy interventions, is necessary to strengthen the evidence for screening programs.
Study Limitations This study has several limitations. First, the sample size was small, and the sample size for each non-Japanese linguistic group (English, Chinese, and Tagalog) was too small to validate the psychometric properties of the translated VAWS. Second, our study did not investigate the detailed social, financial, and psychological statuses of participants and their partners. These additional factors need to be investigated to identify more specific risk factors for IPV. Last, we conducted this study at an urban prenatal clinic. Further studies are needed to establish the generalization of the results to other areas (i.e., suburban, rural). In order to better understand IPV prevalence and risk factors during pregnancy in Japan, we believe that it would be necessary to conduct research in a variety of settings investigating a greater range of risk factors, including abortion and miscarriage. A study validating the translated screening tools would also be needed to more accurately measure IPV among non-Japanese women in Japan. Given these limitations, our results should be cautiously interpreted.
CONCLUSION Our cross-sectional study investigating prevalence and risk factors of IPV during pregnancy in 302 healthy pregnant women found the following: (a) The VAS identified 15.9% pregnant women as currently experiencing abuse by their partners. (b) Risk factors associated with IPV during pregnancy were as follows: over 30 years old, multipara, previous abortion experience, and male partner under 30 years old. As a result of our study findings, we recommend that all pregnant women be routinely screened for IPV during pregnancy. Multipara women,
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pregnant women with abortion experience, and women whose partners are under 30 may be at more risk; we highly recommend IPV screening to help prevent severe abuse and its adverse obstetrics outcomes.
FUNDING This study was supported by St. Luke’s College of Nursing. The authors are deeply grateful to the participants for their cooperation.
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