Objective: The overall aim of this thesis was to investigate whether selfreported
history of violence is associated with increased risk of labour dystocia
in nulliparous women at term and to elucidate midwives’ awareness of domestic
violence during pregnancy in southern Sweden.
Design/Method/Setting/Population: Paper I utilised a population-based
multi-centre cohort study design. A self-administrated questionnaire was administered
at four points in time with start at 37 weeks of gestation, at nine
obstetric departments in Denmark. The total cohort comprised 2652 nulliparous
women, among whom 985 (37.1%) met the protocol criteria for labour
dystocia. In paper II an inductive qualitative design was utilised, based on focus
group interviews. Participants were midwives with experience of working
in antenatal care units connected to two university hospitals in southern Sweden.
Sixteen midwives were recruited by network sampling complemented by
purposive sampling, and were divided into four focus groups of 3 to 5 individuals.
Results: In paper I cohort of the total, 940 (35.4 %) women reported experience
of violence and of these 66 (2.5 %) women reported exposure of violence
during their first pregnancy. Further, 39.5% (n = 26) of those had never been
exposed to violence before. Univariate logistic regression analysis showed no
association between history of violence or experienced violence during pregnancy
and labour dystocia at term, crude OR 0.91, 95% CI (0.77-1.08), OR
0.90, 95% CI (0.54-1.50), respectively. However, violence exposed women
consuming alcoholic beverages during late pregnancy had increased odds of
labour dystocia (crude OR 1.49, CI: 1.07 – 2.07) compared to unexposed to
violence women who were alcohol consumers (crude OR 0.89, 95 % CI: 0.69-
1.14). In paper II five categories emerged: 1) ‘Knowledge about ‘the different
faces’ of violence’, perpetrator and survivor behaviour, and violence-related consequences. 2) ‘Identified and visible vulnerable groups’, ‘at risk’ groups for
exposure to domestic violence during pregnancy, e.g. immigrants and substance
users. 3) ‘Barriers towards asking the right questions’, the midwife herself
as an obstacle, lack of knowledge among midwives as to how to handle
disclosure of violence, and presence of the father-to-be at visits to the midwife.
4) ‘Handling the delicate situation’, e.g. the potential conflict between the
midwife’s professional obligation to protect the abused woman and the unborn
baby and the survivor’s wish to avoid interference. 5) ‘The crucial role of
the midwife’, insufficient or non-existent support, lack of guidelines and/or
written plans of action in situations when domestic violence is disclosed. The
above five categories were subsumed under the overarching category ‘Failing
both mother and the unborn baby’ which highlights the vulnerability of the
unborn baby and the need to provide protection for the unborn baby by
means of adequate care to the pregnant woman.
Conclusions: Our findings indicate that nulliparous women who have a history
of violence or experienced violence during pregnancy do not appear to
have a higher risk of labour dystocia at term, according to the definition of labour
dystocia used in this study. Additional research on this topic would be
beneficial, including further evaluation of the criteria for labour dystocia (Paper
I). Avoidance of questions concerning the experience of violence during
pregnancy may be regarded as a failing not only to the pregnant woman but
also to the unprotected and unborn baby. Nevertheless, certain hindrances
must be overcome before the implementation of routine enquiry concerning
pregnant women’s experiences of violence. It is of importance to develop
guidelines and a plan of action for all health care personnel at antenatal clinics
as well as continuous education and professional support for midwives in
southern Sweden (Paper II)
