Comprehensive examination, analysis and evaluation of the issue of intimate

Comprehensive examination, analysis and evaluation of the issue of intimate partner violence during pregnancy as discussed in the article. (Summarize the article and give your impressions of the content. Has your thinking regarding IPV changed since reading the article? Explain) “Keeping Up a Front”: Narratives About Intimate Partner Violence, Pregnancy, and Antenatal Care 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 diffi- culties (Ellsberg, Heise, Pena, Agurto, & Winkvist, 2001). Violence during pregnancy may put both the mother and the unborn baby simultaneously at risk and, apart from 1UmeaÌŠ University, Sweden Corresponding Author: Kerstin E. Edin, Epidemiology and Global Health, Public Health and Clinical Medicine, UmeaÌŠ University, SE-90185 UmeaÌŠ, Sweden Email: k..n@epiph.umu.se 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 vio- lence (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 develop- ment 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 preg- nant 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 sub- jected 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 meet- ing 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 rela- tionship 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 profes- sional 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 Board of Health and Welfare has not provided any national regulations or recommenda- tions 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 tran- scripts. 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 nar- ratives (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 varia- tions, 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 consider- ations of safety, confidentiality, and support (Watts, Heise, Ellsberg, & Moreno, 2001). The study was approved by the local Ethics Committee at the Faculty of Medicine, UmeaÌŠ University. 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 rela- tionship 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 tod- dler. 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 illus- trating 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. 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 prop- erly, 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 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 impor- tant 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. 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-to- day 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 done 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. Edin et al. 195 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 Violence Against Women 16(2) 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 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 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 selec- tion 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). TheTwo-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 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 mean- ing 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 behav- ior 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 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

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