Violence Against Women - CiteSeerX

Violence Against Women http://vaw.sagepub.com

"Keeping Up a Front": Narratives About Intimate Partner Violence, Pregnancy, and Antenatal Care Kerstin E. Edin, Lars Dahlgren, Ann Lalos and Ulf Högberg VIOLENCE AGAINST WOMEN 2010; 16; 189 DOI: 10.1177/1077801209355703 The online version of this article can be found at: http://vaw.sagepub.com/cgi/content/abstract/16/2/189

Published by: http://www.sagepublications.com

Additional services and information for Violence Against Women can be found at: Email Alerts: http://vaw.sagepub.com/cgi/alerts Subscriptions: http://vaw.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations http://vaw.sagepub.com/cgi/content/refs/16/2/189

Downloaded from http://vaw.sagepub.com at Umea University Library on January 17, 2010

Article

“Keeping Up a Front”: Narratives About Intimate Partner Violence, Pregnancy, and Antenatal Care

Violence Against Women 16(2) 189–206 © The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801209355703 http://vaw.sagepub.com

Kerstin E. Edin,1 Lars Dahlgren,1 Ann Lalos,1 and Ulf Högberg1

Abstract Nine women who had been subjected to severe intimate partner violence during pregnancy narrated their ambiguous and contradictory feelings and the various balancing strategies they used to overcome their complex and difficult situations. Because allowing anyone to come close posed a threat, the women mostly denied the situation and kept up a front to hide the violence from others. Three women disclosed ongoing violence to the midwives, but only one said such disclosure was helpful. This article highlights the complexity of being pregnant when living with an abusive partner and challenges antenatal care policies from the perspective of pregnant women.

Keywords pregnancy, prenatal care, spouse abuse Pregnancy is no protection against intimate partner violence (IPV), and violence during pregnancy is highly predictive of further violence (Shadigian & Bauer, 2004). Even if IPV can start during pregnancy, it is mostly a continuation of earlier violence (World Health Organization [WHO], 2005). The reported prevalence of IPV during pregnancy usually ranges from 1% to 20% (Jasinski, 2004), but they are even higher in some countries (WHO, 2005). These variations can be partly explained by sociocultural differences and varying study designs, as the issue is sensitive and often entails methodological and ethical difficulties (Ellsberg, Heise, Pena, Agurto, & Winkvist, 2001). Violence during pregnancy may put both the mother and the unborn baby simultaneously at risk and, apart from 1

Umeå University, Sweden

Corresponding Author: Kerstin E. Edin, Epidemiology and Global Health, Public Health and Clinical Medicine, Umeå University, SE-90185 Umeå, Sweden Email: [email protected]


190

Violence Against Women 16(2)

psychosocial consequences, they are in danger of suffering various physical and medical complications (Jasinski, 2004). Abused women often choose to remain in their situations, rather than face the hurdles involved in seeking help (Petersen, Moracco, Goldstein, & Clark, 2004). Earlier studies have shown that pregnancy might be both a motivation (Petersen, Saltzman, Goodwin, & Spitz, 1998) and a brake in deciding to make a change in a violent relationship (Helton & Snodgrass, 1987; Rosen & Bird, 1996). Studies indicate that abused women are in favor of the idea of being asked about violence (Chang et al., 2005; Plichta, 2007). This includes pregnant women enrolled in antenatal care (ANC; Stenson, Saarinen, Heimer, & Sidenvall, 2001). However, in general, few abused women are identified in health care, and the reason might lie in the staff’s reluctance to ask direct questions (Edin & Högberg, 2002; Waalen, Goodwin, Spitz, Petersen, & Saltzman, 2000) and women’s hesitation in talking spontaneously about the violence (Petersen et al., 2004; Plichta, 2007). Given that women do not often directly disclose IPV, the ANC visits have been considered a gateway, opening the way for the issue of violence to be brought up, as the repeated visits during pregnancy allow for the development of trust and confidence on the part of the pregnant women (Ellsberg, 2006). Yet, this does not happen without certain incentives, and our previous research regarding ANC clinics with no routine assessments characterized the midwives’ position as beating about the bush (Edin & Högberg, 2002). This article adds to that picture by including the pregnant women’s position as keeping up a front. In this article, we will underline the complexity as well as the special circumstances involved in being pregnant while living in a violent relationship. We will also present indications of the reasons why only one out of nine abused pregnant women found ANC a helpful resource and what we can learn from this when deciding on ANC policies. The aim of this article was to understand and give voice to women who had been subjected to IPV during pregnancy, focusing on the pregnant women’s strategies and motives for managing and continuing their partner relationships as well as their experience of meeting the midwife at the ANC.

Method Subjects, Interviews, and Analyses Coordinators at three women’s crisis centers, at different locations in Sweden, received detailed information about the study and the inclusion criteria (exposure to IPV in a relationship when they became pregnant). All the women had at some stage received support from the crisis centers, and their narratives were almost certainly influenced by professional discourses (Hall, 2001). The interviews were carried out by the first author, three in 2001 and six in 2003. The interviews took place in undisturbed settings, carefully chosen to make the women feel safe. All the women interviewed had been enrolled during their pregnancy in Swedish ANC clinics, where women typically visit a midwife for about 10 routine checkups and where there were no policies in place requiring routine questions to be asked about IPV. The background to this is that the Swedish National


191

Edin et al.

Board of Health and Welfare has not provided any national regulations or recommendations regarding abuse assessment and intervention, and it was, and still is, left to the county or the health district authority, or even each clinic or individual midwife, to either include or exclude the topic. The author’s actual position as a registered nurse midwife and a mother of children appeared to facilitate trust, understanding, and openness about sensitive issues (Davies & Harré, 2001; Kvale, 1996) and hence allowed the women to tell stories that they had not found it possible to tell anyone before. The stories about the violent acts during pregnancy were generally very detailed, vivid, and dramatic. However, repressive mechanisms were used by some women when they touched on certain particularly taxing details. They found it difficult—or were even reluctant—to remember and provided only fragmentary memories. Nevertheless, the women’s attempts to reconstruct their lives and understand what they had experienced were obvious, and they all seemed to find it very valuable to tell their stories. The writer completed memoranda and preliminary analyses for each interview. Further analyses were made in discussions with senior researchers who had access to all the transcripts. The text was coded into categories in order to find structures and plots and also identify essential themes and main categories in order to provide frameworks for the narratives (Dahlgren, Emmelin, & Winkvist, 2004). The women told their own personal stories, which did not have one common general feature, and in order to point out the variations, they are either presented as individual stories or as a variety of voices intertwined into more or less coherent narratives (Kvale, 1996).

Qualitative Methods The qualitative research interviews were viewed as dialogues and as joint constructions of meaning between the interviewer and interviewees (Kvale, 1996; Riessman, 1993). As the interviews emerged as connected, extensive, and significant stories, the intention was to not overly transform them or to build theoretical models. Our ambition was to provide a place for the women’s voices and a focus for their own reflections and appraisals. For this reason, the narrative method was chosen for the analysis, and the main emphasis was put on the meanings of lived experiences (i.e., what the women said) rather than on how the stories were told (Crossley, 2000). This is not to imply that the narratives were viewed as true mirrors of reality. Instead, they were regarded as narrated experiences that might have been constructed and reconstructed many times before the choice was made to tell this particular story in the actual interview situation (Crossley, 2000; Riessman, 1993).

Ethics The research process followed the WHO recommendations concerning ethical considerations of safety, confidentiality, and support (Watts, Heise, Ellsberg, & Moreno, 2001). The study was approved by the local Ethics Committee at the Faculty of Medicine, Umeå University.


192


Findings All nine women interviewed had experienced severe physical and/or sexual violence and/ or threats of brutal violence during at least one pregnancy. At the time of the interviews, for seven of the nine women the last pregnancy (when subjected to violence) had taken place less than 7 years ago (range 1.5-20). They were all in regular employment (although one was on sick leave because of back pain) with an average educational background (from vocational education to a university degree). The women were Swedish born, except for one who was an immigrant, and all but one were married or in a cohabiting intimate relationship when the violence started. Apart from two separations during pregnancy, the women broke up with their violent partners when their youngest child was a baby or a toddler. Although the women had made attempts to resume their relationships, at the time of the interview all seemed to have left their partners for good. The overall core category for the results of this article is keeping up a front, and this is substructured by main categories analogous to the subheadings in italics (see below). The quotations are used to exemplify or underline certain utterances seen as important in illustrating the narratives. The presentation is divided into two sections corresponding to the two narrative themes: managing IPV during pregnancy and the role of the ANC.

Managing IPV During Pregnancy I lived in such a terrible nightmare. What runs through all the women’s stories is that the violence had completely permeated their relationships and life situations when they were expecting a baby. None of the women described pregnancy as a protective factor against IPV, but it was recognized as the starting or restarting point for violence in 5 out of 14 pregnancies. In the other nine cases, the pregnancy was just one period in the ongoing violence that either remained about the same or became worse. Then he pulled me into the bedroom and there I got the head butt, he pressed his body against me, he spat on me and he dragged me. “You devil, I will bloody well teach you to shut up,” like a devil. The descriptions of physical violence included all kinds of brutality, and three women had even been kicked in their pregnant abdomen or had it jumped on. However, emotional violence appeared to have been the worst part (apart from the sexual aspects of the violence) and was largely what the relationships consisted of. Certain types of verbal intimidation were severe, such as threats to shoot the woman, to kill her, or to kidnap the baby. In addition, their partners’ behavior commonly changed for the worse during pregnancy. With few exceptions, they stopped showing positive feelings, neglected both the woman and the pregnancy, and became more uncommunicative and irritated or else worried and tense regarding the pregnancy, which then manifested itself as more violence.


193

Edin et al.

Finding no support or sympathy from their partner during pregnancy, the women felt lonely, isolated, unhappy, sad, tired, and powerless. Their partners controlled and oppressed the women as if they owned both them and their pregnancies. Six of the women could compare earlier violence-free pregnancies with those with ongoing IPV and spoke about the differences and difficulties of not having an involved or caring partner. Compared to previous pregnancies, the women mentioned extreme weariness, being unable to eat properly, not being fully able to take in the growth of the stomach or the fetal movements, and generally having problems enjoying the pregnancy and the expected baby. The women often felt extremely stressed and frightened during pregnancy and gave examples of how the partner could fly into a rage without thinking about the risks to the unborn child: But he absolutely never thought of the child when he got that angry, when it changed, and you could never know. It is not good for someone who is pregnant to land on the floor, backwards, or have his weight on you. And you see, I was dead scared. You have no self-confidence; you are nothing, squashed flat. The narratives described how the partner changed, becoming more and more possessive, and the woman had to comply with what he wanted in strange ways that were hard to understand. It might concern quite trivial matters; this is what happened to one woman in the sixth month of her pregnancy: I did not do the dishes, when he thought I should do them or such, it was not such big things but very small matters, then he kicked, eh, he kicked me in the stomach. The women’s self-confidence was affected very negatively. It also hurt a lot to be told that one had a “nonexistent IQ” or was a “bloody cunt” and also to hear that their partners either regretted or questioned the paternity of the child or else hearing the pregnancy and the baby denigrated: He has said to me so many times during the pregnancy, “I have bloody fucked myself into having a brat with you,” and it hurt so badly, very badly, to say that, you see. The most heartbreaking thing, however, was probably to be criticized as a mother, to feel unappreciated and unworthy: I can say that I have felt like the bearer of his child. I have not felt that I was important to him at all. He has never allowed me to feel as if I was a nice mom, that I was important to him, never, he has never, he has pushed that away all the time. One woman was humiliated and lost her status once she said she was pregnant and was suddenly seen as a bad woman, and her partner threatened her with serious consequences if she did not have an abortion. One man repeatedly told the woman how disgusting she was when pregnant and that she was a fat, ugly fiend; he felt ashamed and did not want to be seen with her.


194


Although we had the same working hours and did not work so far from each other, we still went in separate cars, “he did not want a fat toad in the car;” I had to go to work in my own car then. To parry every step. For all the women, there was a constant feeling of insecurity like living on a “dreadful emotional roller coaster,” never knowing what was going to happen next or when it would happen, like waiting for something to explode anytime, and striking a balance was like “walking on a very, very narrow tightrope.” To avoid the violence, that was even felt to be life threatening both for the pregnant woman and the unborn baby, the women learned to get out of the way, to adapt, to behave in a certain way and not to give free rein to their own personalities but to obey their partner unquestioningly. But he could have killed me as well; in fact, he could have kicked the child to death. I did nothing. The women seemed to successively accustom themselves to the situation and also revealed their use of repressive mechanisms to shut out the pain, calm down, and avoid transferring their stress to the baby in tense situations. To endure this strange day-today life, one woman said that she turned into a zombie, living in her and her baby’s own little world. Another way was to think of the abnormal relationship as temporary and thus to visualize an end to it. Yet, another passive strategy was to offer the partner no resistance when he wanted sex, using this as a means to prevent a beating or as a move to calm him down or to postpone his rage. The women said, however, that it was impossible to get used to using sex in this unfeeling way. It was more like choosing the lesser of two evils and left them feeling empty and disgusted. To cope but refusing to give in. Even if a great deal of the women’s everyday lives was about coping with the situation, they did not just hold back all the time and gave many examples of their resistance. Even if they were sometimes scared to death, they said no to sex, were critical and obstinate, made their own decisions, showed anger, and argued back. During and after the acts of violence, the women sometimes questioned their partner’s behavior, issued ultimatums, did not back down, and even fought back and screamed to get attention or help from neighbors. One woman, who had once been kicked in the stomach during pregnancy, was so scared afterwards that she would do anything just to avoid repetition of the violence. Yes, he did that a lot of times, but he didn’t kick me in the stomach, but then I was always afraid of that, and it became so much that I said, that you . . . don’t touch me, because then I’ll leave you or . . . yes or yes . . . and I’ll report you . . . and then it also seemed wrong, for everything is gone . . . you can’t live with someone that you don’t . . . no . . . With one single exception, all the women, despite ambiguity, described how they increasingly questioned their relationships. This certainly seemed to be emphasized more during pregnancy, and they became very well aware that it was not normal but all wrong.


195

Edin et al.

This is all cockeyed, here I have conceived a child with a person who beats me . . . he beats me when I am pregnant. Seeing the violence as dangerous or even potentially fatal, the women found ways to interrupt the violent acts and, in trying to avert the violence, some sharply reminded their partners to be mindful of the pregnancy and the baby. Thump, so he pressed down his head and rubbed himself against me like this. “Oh, mind the baby, mind the baby. I don’t care a damn in hell about that bugger.” Tackling contradictions. Life seems to have been complicated and difficult, like living in a “nightmare” while the wishful “rosy dream” about the relationship became increasingly blurred. However, the overall picture was a search for ways in which to overcome the problem rather than ways in which to leave. “You hope against hope all the time,” and in general the women certainly expressed the hope that there would be a change for the better. It seemed to be very much about defending the relationships and not breaking up the family, to stay, struggle, continue and hope for the best. None of the women had been forced into the relationship; instead, everything started well with shared feelings of deep passion and love. Despite the violence, some women gave examples of how love did not just cease, and two said they were able to maintain positive and reciprocal sex that nourished the relationship and contrasted sharply with its usual course. Some described relationships that had lasted a long time, and some viewed their relationship as their destiny. This seems to have nurtured hope and purpose, for some of them, until the very last. You know there was a rosy dream surrounding this, we were meant to live together, I kept it up . . . it was what I saw. And probably that’s where most of the heartache lies afterwards, that it did not come true . . . this dream did not turn out as I thought it would. The women used various strategies to enable them to endure quite conflicting feelings and, on one hand, believe that the violence was their own fault as well as, on the other hand, see it as totally wrong. They simultaneously adapted to the man’s behavior and stood up to him. The narratives even included hope that the partner would improve. If I just love him more, then everything will be all right. On one hand, the pregnancy gave the women certain strengths, but on the other, they were unable to stand up to their partner as they would have done otherwise; instead, they were more afraid and in a weaker position that he could exploit. Generally, it appeared that circumstances during pregnancy made it hard for the women to leave. One planned to leave at the end of pregnancy, but she ultimately did not dare to go; she was too insecure and frightened about what might happen to her, her previous child, and the unborn baby. Two left because they were subjected to serious life-threatening violence and intimidation.


196


One had already left her violent partner when she discovered she was pregnant, but then her mother made her feel ashamed and persuaded her to take him back. And then she says with contempt in her voice and like . . . “Oh, I see, you are going to be one of those single mothers” and that settled the matter then. “And he does not drink and really he isn’t so violent; you may have to restrain yourself a little bit.” I became an expert at lying. The impression the women gave of their intimate relationships was ambiguous and included contradictions, but they typically behaved strategically in order to save face as a way of surviving their ongoing but faltering reality. Overall, the situation was multifaceted and difficult and, because letting anyone come close was a threat, the women carried a lot of secrets and mostly kept up a front to hide the IPV from others, and they told nobody, or at most a selected few, about the violence. And I can really, see, in general that I believe it is very hard for someone outside to enter into something, it is the same as when I did not tell my parents, since I did not want to, because if someone else enters, then it is more threatening, if you keep up a front you may be able to get through it. The reasons for this silence and for covering most things up in front of others appeared to be complex. The women did not dare, or found it difficult, to verbalize the violence, and telling someone about it was the same as revealing oneself as foolish for having allowed something that was so wrong. Those times when I said, “now I will really call the police,” “Right then, do it, call then,” he said. And then kind of, no, then it’s the protective thing and it’s kind of embarrassing to call because you are subjected to something “shameful like this,” then . . . The woman hovered between actually recognizing his behavior as abnormal and, in her lack of self-confidence, accusing herself of being part of the problem because she was unable to manage the relationship. I was scared stiff that it would come out that he did this and that I let it happen . . . do you understand . . . it feels as if you have agreed to it, and it feels like it was my fault.

The Role of ANC According to the narratives, the women had not been asked any direct questions about violence at the ANC. The clinical appointments during pregnancy were generally described in terms of lacking importance, diffuse events that were even hard to remember, bland routine medical checks, or else they were described as menacing events where they had to cover up, lie, and even avoid appointments. Only two women mentioned the men’s


197

Edin et al.

involvement in the ANC appointments and gave examples of the two extremes. One man would under no circumstances accompany his partner to the midwife. The other never left his partner’s side at the ANC; he talked a lot and was courteous and nice. In only 3 of the 14 narrated pregnancies did the midwife know about the violence, but this was viewed as helpful by only one woman. They just measured. The women interviewed largely identified midwives as being mainly responsible for the somatic side of pregnancy rather than as a potential resource to help them with difficulties they might be facing. At the antenatal clinic, they just measured my stomach and weight; I don’t know if she was a midwife. Another reason for the women not to disclose the ongoing violence during pregnancy was lack of confidence in the midwife; they did not see her as someone with whom they could have a person-to-person dialogue, and hence their expectations regarding psychosocial support seemed to be quite low. One woman felt belittled by her midwife, and she interpreted this as being due to the fact that she was a single mother, she always came alone, and the baby’s father was not Swedish. She and another woman had both revealed their situations to the midwife, but they did not see it as being helpful or as making any difference; the midwives just made referrals leading to quite worthless contacts where the women did not get the support they expected and needed. If one is keeping up a front. The motives for hiding the violence and not saying anything to the midwives probably need to be understood in terms of the interrelationships rather than simply, as from the women’s perspective, that the ANC appointments were more or less fleeting and cursory contacts. The women for their part often seemed uncomfortable about the contacts with the midwife during pregnancy and thus felt it necessary to keep their distance. They covered up or lied about bruises and skipped appointments. Furthermore, it also seemed to be too demanding to just let someone else into their situation when all their energy was absorbed in putting up with their life in general. But I believe I did not have the energy, you know, I believe I could not cope with any questions, I simply could not have someone looking at me. The midwives were described by some women as being authorities, and disclosing violence to them was threatening, as it revealed the shame of agreeing to remain in a situation considered to be so bad. It was a pleasure to go to her. One narrative differed from the others and interestingly described a process of change in attitude toward the midwife from the one to the other of two pregnancies with ongoing IPV. The reason for this may possibly rest with both the midwife and the woman. During the interview, the woman found it hard at first to remember her appointments with the midwife during her first pregnancy. The memories were blurred and there was a negative touch of authority, which was regarded as threatening. In addition, at the time of the first pregnancy with the violent partner, the


198


relationship was new and fragile, and it was hard to put her feelings and experiences into words. By the time of the next pregnancy with ongoing violence, some years had passed and the woman seemed to be willing and in a position to tell the midwife what was going on. The woman described the midwife in positive terms as being a very caring and sympathetic person who was open to dialogue and tears. Well, I explained why and . . . she just listened and that was kind of enough, see. The contact seemed to have played a crucial role in the situation of continuing violence. The woman was convinced that the midwife was capable of giving good advice had she wanted it, but what she really wanted just then was a willing listener—and that was what she got.

Discussion Running through all the narratives in this article are descriptions of how the women, during the period of pregnancy and while they were being subjected to severe violence, managed to maintain various and complex balancing strategies in order to continue the relationship backstage while keeping up a front. Consequently, the real situation was not usually revealed to people around them, including the staff in ANC. Before discussing the findings, some methodological considerations need to be addressed.

Methodological Considerations Final selection of interviewees was intentionally handed over to the coordinators at the crisis centers in the belief that their experience would enable them to find eligible women while remaining aware of individual and ethical issues, for the sake of the women and their safety (Ellsberg & Heise, 2002). However, this gives rise to an uncertainty about the selection because whether any additional sampling criteria were used apart from the sampling instructions from the investigator was never investigated. Without judging the recollected traumatic memories, the narratives in this study were viewed as constructed, malleable stories about personal experience regarding IPV (Laney & Loftus, 2005). The length of time that had elapsed since the violent events probably could have made a crucial difference, although it was not believed to be so as research has found such traumatic memories to remain rather constant even after long periods of time (McNally, 2005; Williams, 1995).

The Two-Sided Barrier The women in this study had been enrolled during pregnancy at ANC clinics where the practice of asking about violence was not implemented, and this most likely meant a high probability of malfunction in dealing with the complex issue of IPV (cf. Allen, Lehner, Marrison, Miles, & Russel, 2007). Our previous research from such clinics characterized


199

Edin et al.

the midwives’ side of the communication as beating about the bush (cf. Edin & Högberg, 2002), and the narratives in this study characterized the abused pregnant women’s side as keeping up a front, that is, a meeting foredoomed to failure in interaction. Although there was no routine inquiry about violence, three women still disclosed the violence to which they were subjected. One of these recognized the disclosure as being very important because the midwife really listened and showed compassion. From an outsider’s perspective, however, this could be judged as a case of omission because the midwife did not take any specific action besides listening, although her listening had a significant meaning for the woman (cf. Chang et al., 2003). For the other two, it seemed that the midwives were efficient and did the right thing in taking action and referring the pregnant women to other professionals, but this action had no relevance from the women’s perspective. The referrals might be interpreted as the midwives’ way of avoiding coming to grips with the women’s actual needs during pregnancy. Probably the midwives felt they could not offer satisfactory advocacy as they had no formal training or supervision (cf. Ramsay, Rivas, & Feder, 2005) and did not know exactly what to do or did not dare to believe in their own capacity. Consequently, they handed the case over to other professionals who were neither prepared nor had enough knowledge about this subject area either. Moreover, one of the midwives was regarded as being disdainful in her contacts, and the woman felt put down and belittled. This is in line with research that has pointed out that the provider’s own behavior often determines whether the actions regarding IPV have a positive influence on the woman (Chang et al., 2003; Feder, Hutson, Ramsay, & Taket, 2006; Liebschutz, Battaglia, Finley, & Averbuch, 2008; Thackeray, Stelzner, Downs, & Miller, 2007). Recognizing the existence of the two-sided barrier makes it more understandable (but still quite incomprehensible) that six of the nine women, despite very severe violence and extremely stressful life situations, could visit the ANC clinic during pregnancy without it being recognized that they were in serious trouble. The women described feelings of shame, lack of confidence in the midwives, seeing them as authorities, and viewing ANC appointments as threatening events. This may explain why the women generally kept up a front, hiding their situations from the ANC. The women kept their distance, the midwives did not manage to get close, and so the interaction failed. However, the reasons for keeping up a front also need to be understood as a part of a multifaceted interaction between individual, contextual, and sociocultural factors (Heise, 1998), where male dominance and power are major determinants (Babcock, Waltz, Jacobson, & Gottman, 1993; Firestone, Harris, & Vega, 2003). Some possible aspects of this complexity will be discussed below.

Gendered Adaptability Might Accelerate During Pregnancy Some of the gendered adjustments described by the women in this current study might even be compared with those employed in other relationships without violence, where women reinterpret subordination as love and caring for his needs, waving aside problems with the excuse that men are men and thus saving face for both (Kalman, 2002). This way of doing gender becomes a way of coping but maintains and reconstructs constraints and


200


asymmetry in the distribution of power between men and women (West & Zimmerman, 2002). The violent relationships can be seen as the extreme of prevailing gender positions regarding interaction, agreements, and intimacy between men and women in general, and the limits might sometimes be very fluid when so-called normal gendered behavior gradually accelerates (Goldner, Penn, Sheinberg, & Walker, 1990). The women in the present study told how they endured and adapted to an even greater degree during the period of pregnancy compared to other times. They would do almost anything to reduce stressful situations or to avoid violence so as to protect and care for the expected baby. The pregnancy thus placed them in a weaker position that the partner could then exploit. This does not mean that the women capitulated or accepted the situation but rather the opposite, in that they realized how abnormal the relationship was as he could even abuse her when she was pregnant. It seemed to be a question of timing and, despite the women’s doubts and resistance, the complex situation of pregnancy mostly gave them every reason to keep calm while awaiting a more optimal time to act and make a change.

Ambiguity and Striving for Normality as Expectant Mothers All separations involve stress. Leaving a violent relationship entails additional pressure (Walker, Logan, Jordan, & Campbell, 2004), and the pregnancy brings a third stress factor into play (Lutz, 2005a). Despite ongoing violence, many women choose to stay in their situation because they fear what will follow after they have sought help (Petersen et al., 2004). From the narratives in this study, the women could not really make up their minds regarding how or when to make a change, so instead they were using “keeping up a front” as a strategy to shut others out while they were struggling backstage. The women were hovering between diverse, incongruous and contradictory negative and positive feelings, and the situation became even more complicated during pregnancy. These paradoxes between love and violence as strong bonds of attachment, and also resistance, have been described in other research and have been understood as part of the gendered premises that keep the couples together in a violent relationship (Rosen & Bird, 1996). However, the women were simultaneously making plans to leave and so playing both sides. Such ambivalence makes it difficult to make a factual change (Goldner et al., 1990; Helton & Snodgrass, 1987) but can still be an important part of a leaving process (Anderson & Saunders, 2003). It has also been shown in other research that pregnancy may bring with it additional hopes and dreams, such as the idealized image of being happily expecting and the value of having a father for the child as opposed to the uncertainties of becoming a single parent (Lutz, 2005b). Moreover, gendered positions (such as motherhood) are so profoundly rooted in family relations that even with conflicting reasons and contradictions, the woman continues her gendered ideas about the relationship and family (Goldner et al., 1990). This was exemplified in this study and can be understood as striving for normality. The women talked about the “rosy dream;” about not breaking up the family; how they tried to believe in the relationship, his love, and longstanding friendship; and that he might change his behavior. One woman who had left was persuaded to return to her violent partner when she found out she was pregnant to avoid being a single mother. Another woman said that if she


201

Edin et al.

could just love him some more it would probably change or stop the violence. This is described in research as being a way of doing gender in volatile relationships. Although the man uses violence to stay a man (i.e., not being feminine), the woman’s gender identity (i.e., being feminine) is as one who has the ability to keep things together, to feel compassion, to give loving care to others; hence, staying is what her gendered self-esteem demands (Goldner et al., 1990; West & Zimmerman, 2002). However, if this destructive gendered alliance becomes unbalanced, as might happen when the woman and the relationship change during pregnancy when, for example, she makes demands and does not have the strength to care for him as usual, it might constitute a threat to him as a man and may trigger violence (cf. Campbell, Oliver, & Bullock, 1993; Edin, Högberg, Dahlgren, & Lalos, 2009). Pregnancy and caring for the baby, however, have also been shown to highly motivate some women to make a move and break up the relationship (Petersen et al., 1998). Two of the nine women in the current study left during their pregnancies because the situation became life threatening, whereas one woman was at the point of leaving but was too insecure and frightened about what might then happen, not only to her but also to the unborn baby and her older child. Her fears were probably justified because research shows that separation greatly increases the risk of violence (Rodriguez, Quiroga, & Bauer, 1996) and also constitutes a significant risk of lethal violence (Campbell et al., 2003).

Conclusion and Implications for Practice In conclusion, the two-sided barrier at the ANC is explained and clarified more than adequately by understanding the failed interaction with, on one hand, the midwives’ lack of policies and, on the other hand, the pregnant women’s very complex balancing strategies with the need to keep up a front to hold off the threat of IPV disclosure. The challenge then is not only to overcome the two-sided barrier and thereby increase disclosure but also to make sure that the interventions really reduce violence and support the women. If a certain action plan is followed in stages, as for other types of medical screening (Glass, Dearwater, & Campbell, 2001; Waalen et al., 2000), it most certainly increases both the questioning and the identification rates (Garcia-Moreno, 2002; Plichta, 2007) and improves knowledge about IPV among health personnel (Garcia-Moreno, 2002). However, the term IPV screening is confusing and problematic because it can be criticized for not following the medical prerequisites for screening in general (Spangaro, 2007). Moreover, screening might not work for pregnant women who are ambivalent and not yet ready for a change; it may instead have a negative effect (Zink, Elder, Jacobson, & Klostermann, 2004). As an alternative, it is probably a better idea to include a routine inquiry when taking the health history and then see the empathetic asking as an achievement and a first helpful step in itself, regardless of subsequent disclosure or decisions about change (Gutmanis, Beynon, Tutty, Wathen, & MacMillan, 2007; Liebschutz et al., 2008). Moreover, it has been debated whether disclosures do in fact reduce violence and improve the women’s life situations at all (Ramsay, Richardson, Carter, Davidson, & Feder, 2002; U.S. Preventative Services Task Force, 2004; Wathen & MacMillan, 2003). However, some recent studies provide evidence of positive effects, such as reduced


202


violence and a better health status (McCloskey et al., 2006). It seems very likely that the outcome is largely dependent on the communication in the encounter, that is, how the needs of the women are met (Liebschutz et al., 2008). In encouraging the willingness to routinely ask about IPV in the ANC, the most important factor is preparedness through the provision of guidelines, professional networks, and education (Allen et al., 2007; Gutmanis et al., 2007). When caregivers at the ANC are educated and dare to routinely ask sensitive questions about IPV, apart from disclosure the overall relationships and conversations with the care providers are likely to deepen (Jones & Bonner, 2002). However, some pregnant women might not want support from authorities or do not believe in the ANC as a reliable or desirable source of help (as most of the women in the current study said). One study from Australia shows that about 75% of the pregnant women who had disclosed violence at the ANC did not want any further support when it was offered by the midwives (Jones & Bonner, 2002). The caregivers’ attitudes and behavior, though, seem crucial (Chang et al., 2003). Those in authority, such as the midwives, need to show empathy and not act as if there were only one correct solution to the problem (Peled, Eisikovits, Enosh, & Winstok, 2000). They need to include the women in the decision making (Feder et al., 2006). It is also important to be nonjudgmental, as external criticism of the relationship may make the couple hide and bind them even more tightly to one another by creating a shared sense of togetherness (Goldner et al., 1990). Instead, when confidence is established, it may help to openly shed light on the gendered ties in the commonly absurd mix of positive and negative sides in the complex interplay of the violent relationship because that could help loosen the bonds that make the woman carry on despite the destructive situation (Goldner et al., 1990). Empowerment and appropriate psychosocial support are essential to further prepare a woman to act and change her situation or to prepare her for leaving (Anderson & Saunders, 2003). However, in the process of breaking up, most women seem to go through different stages of decision making; the process is not linear (Chang et al., 2006). Instead, they go through many phases of leaving, emotionally and in their imaginations, before making a real physical move. It is important to recognize and accept ambivalence as an essential part of the process of change and leaving (Anderson & Saunders, 2003). The complexity, especially when pregnant, also needs to be acknowledged in an uncritical way that empowers the women to feel they have the freedom to choose and move on in the process of making decisions instead of being forced to take one or another definitive stance (Peled et al., 2000; Walker et al., 2004). To sum up, to encourage pregnant women to share their personal experiences of IPV and of living in complex and ambivalent relationships, it is vitally important that those regarded as authorities in the ANC should be nonjudgmental, open-minded, compassionate, lenient, and caring with regard to what the woman thinks and what kind of support she really wants and needs.

Acknowledgments With all our hearts we express our gratitude to the nine women who were willing to share their personal stories.


203

Edin et al. Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research and/or authorship of this article: This study was made possible through the financial support of the Swedish Research Council (K2002-27X14290-01A).

References Allen, N. E., Lehner, A., Marrison, E., Miles, T., & Russel, A. (2007). Promoting systems change in the health care response to domestic violence. Journal of Community Psychology, 35, 103-120. Anderson, D. K., & Saunders, D. G. (2003). Leaving an abusive partner: An empirical review of predictors, the process of leaving, and psychological well-being. Trauma, Violence & Abuse, 4, 163-191. Babcock, J. C., Waltz, J., Jacobson, N. S., & Gottman, J. M. (1993). Power and violence: The relation between communication patterns, power discrepancies, and domestic violence. Journal of Consulting and Clinical Psychology, 61, 40-50. Campbell, J. C., Oliver, C., & Bullock, L. (1993). Why battering during pregnancy? AWHONNS Clinical Issues in Perinatal Women’s Health Nursing, 4, 343-349. Campbell, J. C., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., & Curry, M., et al. (2003). Risk factors for femicide in abusive relationships: Results from a multi-site case control study. American Journal of Public Health, 93, 1089-1097. Chang, J. C., Dado, D., Ashton, S., Hawker, L., Cluss, P. A., Buranosky, R., et al. (2006). Understanding behavior change for women experiencing intimate partner violence: Mapping the ups and downs using the stages of change. Patient Education and Counseling, 62, 330-339. Chang, J. C., Decker, M., Moracco, K. E., Martin, S. L., Petersen, R., & Frasier, P. Y. (2003). What happens when health care providers ask about intimate partner violence? A description of consequences from the perspectives of female survivors. Journal of the American Medical Women’s Association, 58, 76-81. Chang, J. C., Decker, M. R., Moracco, K. E., Martin S. L., Petersen, R., & Frasier P. Y. (2005). Asking about intimate partner violence: Advice from female survivors to health care providers. Patient Education and Counseling, 59, 141-147. Crossley, M. L. (2000). Introducing narrative psychology, self, trauma and the construction of meaning. Buckingham, UK: Open University Press. Dahlgren, L., Emmelin, M., & Winkvist, A. (2004). Qualitative methodology for international public health. Umeå, Sweden: Print and Media. Davies, B., & Harré, R. (2001). Positioning: The discursive production of self. In M. Wheterell, S. Taylor, & S. J. Yates (Eds.), Discourse theory and practice: A reader (pp. 261-271). London: Sage.


204


Edin, K. E., & Högberg, U. (2002). Violence against pregnant women will remain hidden as long as no direct questions are asked. Midwifery, 18, 268-278. Edin, K. E., Högberg, U., Dahlgren, L., & Lalos, A. (2009). “The pregnancy put the screws on”: Discourses of professionals working with men inclined to violence. Men and Masculinities, 11, 307-324. Ellsberg, M. (2006). Violence against women and the Millennium Development Goals: Facilitating women’s access to support. International Journal of Gynecology and Obstetrics, 94, 325-332. Ellsberg, M., & Heise, L. (2002). Bearing witness: Ethics in domestic violence research. Lancet, 359, 1599-1604. Ellsberg, M., Heise, L., Pena, R., Agurto, S., & Winkvist, A. (2001). Researching domestic violence against women: Methodological and ethical considerations. Studies in Family Planning, 32, 1-16. Feder, G. S., Hutson, M., Ramsay, J., & Taket, A. R. (2006).Women exposed to intimate partner violence: Expectations and experiences when they encounter health care professionals: A meta-analysis of qualitative studies. Archives of Internal Medicine, 166, 22-37. Firestone, J. M., Harris, R. J., & Vega, W. A. (2003). The impact of gender role ideology, male expectancies, and acculturation on wife abuse. International Journal of Law and Psychiatry, 26, 549-564. Garcia-Moreno, C. (2002). Dilemmas and opportunities for an appropriate health-service response to violence against women. Lancet, 359, 1509-1514. Glass, N., Dearwater, S., & Campbell, J. (2001). Intimate partner violence screening and intervention: Data from eleven Pennsylvania and California community hospital emergency departments. Journal of Emergency Nursing, 27, 141-149. Goldner, V., Penn, P., Sheinberg, M., & Walker, G. (1990). Love and violence: Gender paradoxes in volatile attachments. Family Process, 29, 343-364. Gutmanis, I., Beynon, C., Tutty, L., Wathen, C. N., & MacMillan, H. L. (2007). Factors influencing identification of and response to intimate partner violence: A survey of physicians and nurses. BMC Public Health, 24, 7-12. Hall, S. (2001). Focault: Power knowledge and discourse. In M. Wetherell, S. Taylor, & S. J. Yates (Eds.), Discourse theory and practice: A reader (pp. 72-81). London: Sage. Heise, L. L. (1998). Violence against women: An integrated, ecological framework. Violence Against Women, 4, 262-290. Helton, A. S., & Snodgrass, F. G. (1987). Battering during pregnancy: Intervention strategies. Birth, 14, 142-147. Jasinski, J. L. (2004). Pregnancy and domestic violence: A review of the literature. Trauma, Violence & Abuse, 5, 47-64. Jones, C., & Bonner, M. (2002). Screening for domestic violence in an antenatal care clinic. Australian College of Midwives Incorporated, 15, 14-20. Kalman, H. (2002). Gender oppression and human dignity. In F. Birulés & M. I. P. Aguado (Eds.), A passion for freedom: Action, passion and politics: Feminist controversies (pp. 330-333). Barcelona, Spain: University of Barcelona. Kvale, S. (1996). Interviews: An introduction to qualitative research interviewing. Thousand Oaks, CA: Sage.


205

Edin et al.

Laney, C., & Loftus, E. F. (2005). Traumatic memories are not necessarily accurate memories. Canadian Journal of Psychiatry, 50, 823-828. Liebschutz, J., Battaglia, T., Finley, E., & Averbuch T. (2008). Disclosing intimate violence to health care clinicians: What a difference the setting makes: A qualitative study. BMC Public Health, 8, 229-236. Lutz, K. F. (2005a). Abused pregnant women’s interactions with healthcare providers during the childbearing years. Journal of Obstetrics, Gynecology, and Neonatal Nursing, 34, 151-162. Lutz, K. F. (2005b). Abuse experiences, perceptions, and associated decisions during the childbearing cycle. Western Journal of Nursing Research, 27, 802-824. McCloskey, L. A., Lichter, E., Williams, C., Gerber, M., Wittenberg, E., & Ganz, M. (2006). Assessing intimate partner violence in health care settings leads to women’s receipt of interventions and improved health. Public Health Reports, 4, 435-444. McNally, R. J. (2005). Debunking myths about trauma and memory. Canadian Journal of Psychiatry, 50, 817-822. Peled, E., Eisikovits Z., Enosh, G., & Winstok, Z. (2000). Choice and empowerment for battered women who stay: Toward a constructivist model. Social Work, 45, 9-25. Petersen, R., Moracco, K. E., Goldstein, K. M., & Clark, K. A. (2004). Moving beyond disclosure: Women’s perspectives on barriers and motivators to seeking assistance for intimate partner violence. Women’s Health, 40, 63-76. Petersen, R., Saltzman, L. E., Goodwin, M., & Spitz, A. (1998). Key scientific issues for research on violence occurring around the time of pregnancy. Atlanta, GA: Centers for Disease Control and Prevention. Plichta, S. B. (2007). Interactions between victims of intimate partner violence against women and the health care system: Policy and practice implications. Trauma, Violence, & Abuse, 8, 226-239. Ramsay, J., Richardson J., Carter Y. H., Davidson L. L., & Feder, G. (2002). Should health professionals screen women for domestic violence? Systematic review. British Medical Journal, 325, 314-318. Ramsay, J., Rivas, C., & Feder, G. (2005). Interventions to reduce violence and promote the physical and psychosocial well-being of women who experience partner violence: A systematic review of controlled evaluations. London: Queen Mary’s School of Medicine and Dentistry. Riessman, C. K. (1993). Narrative analysis. Newbury Park, CA: Sage. Rodriguez, M. A., Quiroga, S. S., & Bauer, H. M. (1996). Breaking the silence: Battered women’s perspectives on medical care. Archives of Family Medicine, 5, 153-158. Rosen, K. H., & Bird, K. (1996). A case of woman abuse, gender ideologies, power paradoxes and unresolved conflicts. Violence Against Women, 2, 302-321. Shadigian, E. M., & Bauer, S. T. (2004). Screening for partner violence during pregnancy. International Journal of Gynaecology and Obstetrics, 84, 273-280. Spangaro, J. M. (2007). The NSW Health routine screening for domestic violence program. NSW Public Health Bulletin, 18, 86-89. Stenson, K., Saarinen, H., Heimer, G., & Sidenvall, B. (2001). Women’s attitudes to being asked about exposure to violence. Midwifery, 17, 2-10.


206


Thackeray, J., Stelzner, S., Downs, S. M., & Miller, C. (2007). Screening for intimate partner violence: The impact of screener and screening environment on victim comfort. Journal of Interpersonal Violence, 22, 659-670. U.S. Preventive Services Task Force. (2004). Screening for family and intimate partner violence: Recommendation statement. Annals of Family Medicine, 2, 156-160. Waalen, J., Goodwin, M. M., Spitz A. M., Petersen R., & Saltzman L. E. (2000). Screening for intimate partner violence by health care providers: Barriers and interventions. American Journal of Preventive Medicine, 19, 230-237. Walker, R., Logan, T. K., Jordan, C. E., & Campbell, J. C. (2004). An integrative review of separation in the context of victimization: Consequences and implications for women. Trauma, Violence, & Abuse, 5, 143-193. Wathen, C. N., & MacMillan, H. L. (2003). Interventions for violence against women: Scientific review. Journal of the American Medical Association, 289, 589-600. Watts, C., Heise, L., Ellsberg, M., & Moreno, C. G. M. (2001). Putting women first: Ethical and safety recommendations for research on domestic violence against women. Geneva, Switzerland: World Health Organization. West, C., & Zimmerman, D. H. (2002). Doing gender. In S. Fenstermaker & C. West (Eds.), Doing gender, doing difference (pp. 3-23). New York: Routledge. Williams, L. M. (1995). Recovered memories of abuse in women with documented child sexual victimization histories. Journal of Traumatic Stress, 8, 649-673. World Health Organization. (2005). WHO multi-country study on women’s health and domestic violence against women. Geneva, Switzerland: Author. Zink, T., Elder, N., Jacobson, J., & Klostermann, B. (2004). Medical management of intimate partner violence considering the stages of change: Precontemplation and contemplation. Annals of Family Medicine, 2, 231-239.

Bios Kerstin E. Edin, RN midwife, MPH, PhD, is a research fellow in the Unit for Epidemiology and Global Health, Department of Public Health and Clinical Medicine, and also is affiliated to Umeå Centre of Gender Studies, Umeå University. Her research interest is in intimate partner violence, with a special focus on gender, sexuality, and pregnancy. Lars Dahlgren, PhD, is a professor in medical sociology in the Department of Sociology at Umeå University. His research interest is in the sociology of emotions and attempts to apply qualitative methods. He is currently involved in domestic violence research in Nicaragua and Sweden. Ann Lalos, PhD, is a professor in public health in the unit for Obstetrics and Gynecology, Department of Clinical Sciences, Umeå University. Her research interests are in reproductive health with psychosocial and gender perspectives, with special interest in induced abortion, infertility, gynecological cancer, STIs, and domestic violence. Ulf Högberg, MD, PhD, is a professor in the unit for Epidemiology and Global Health, Department of Public Health and Clinical Medicine, also affiliated to the unit for Obstetrics and Gynecology, Umeå University. His research interest is in reproductive health and epidemiology. He is currently engaged in domestic violence research in Nicaragua, Ethiopia, and Sweden. Downloaded from http://vaw.sagepub.com at Umea University Library on January 17, 2010