July 3, 2022

Cool Rabbits

Healthcare Enthusiast

Women survivors of intimate partner violence talk about using e-health during pregnancy: a focus group study | BMC Women’s Health

As a result of the thematic analysis, three main themes and six sub-themes were identified: (1) Needs and concerns of pregnant women in an IPVAW situation, (2) Video counseling intervention: key aspects and (3) Contributions for safety planning apps.

Needs and concerns of pregnant women in an IPVAW situation

In this first section, a general discussion was raised about the situation of pregnant women that experience IPVAW. Participants were asked about key aspects that might influence a victim during that period.

Support

Participants in the focus group found it particularly relevant to address the support that victims of IPVAW get and what can be done to improve it.

One of the main themes that came up in discussions about support was the role that health care professionals can play. Women pointed out that midwives and gynecologists are visited repeatedly throughout pregnancy, which is why they considered that such professionals have a great opportunity to discover the abuse. They considered that administering a questionnaire or simply asking the woman “if she is happy with her situation, or if she is experiencing it well“, as Woman 2 pointed out, could be a good start.

Woman 5 recalled how her own midwife was the one who realized that something was wrong in her relationship, and emphasized how these professionals can help a lot to detect these kinds of situations in pregnant women.

Woman 5: “my midwife, who was the only person who probably realized and, although I am somebody who doesn’t talk, I don’t talk much, she started to ask me questions I didn’t understand. And I never managed to figure how she realized some situations, as I don’t talk. But it’s true that she inquired and gradually started to ask more. She didn’t find out everything, obviously, but these people can help a lot.”

Regarding this topic, another proposal made by the women was to establish a code that a woman can use to tell her midwife or physician that she is in a violent relationship. In Spain, due to the COVID-19 situation, a strategy has been implemented in pharmacies that consists of a code (“mask-19”), which a woman in a situation of abuse can request and triggers the activation of the necessary resources to help her.

Woman 1: “perhaps now with the COVID situation, if you are abused, isn’t there a code you can use when you go to the pharmacy? I think there is something like that with the family doctor.”

The fact of involving health care professionals is also related to the proposal of one of the women, who mentioned how important it was for the person who found out about the violence to be someone outside her social network, since she was worried about the safety of her loved ones and it was difficult for her to envisage involving her friends or family in her problem:

Woman 2: “Because of this, the help of somebody who is not from your family or a friend is perhaps more positive, more real or better than somebody who is emotionally close to you and may worry (…) I thought, “I’m going to tell my brother because this has to end” but never told him, ever, for fear of the possible consequences. I thought… imagine that I end up harming the people that I love.”

Psychological support seems to be one of the main needs of a pregnant woman who is in a situation of IPVAW. Some women agreed that psychological help was crucial during their process of ending the relationship. For example, Woman 2 doubted that a counselor could help her at first, but eventually concluded that it was a good decision:

Woman 2: “For me, for example, the counselor (..) was the solution to my head. I mean, it was the best thing I could do, it’s clearly the best help I’ve had during the 3 years of this situation. It was the best, I never thought it would do me so much good or that it was going to put me in such a position… In fact, when I went at first I thought, “This is not going to help me at all; I’m sure of what…” That’s why I think psychological help is super important.”

Unlike her, Woman 6 said that she was sure that this type of help was the one she needed from the beginning:

Woman 6: “I knew the first thing I needed was a counselor; the lawyer would come afterwards. But the counselor was first. Because I needed it.”

Concerns

Different concerns that pregnant women might have when experiencing IPVAW and trying to end the relationship were widely discussed in the focus group. The women were worried about the situation other women might face when thinking about the children and the consequences of ending the relationship.

Both the unborn baby and children are of great concern to pregnant women who experience IPVAW. The women explained how they became aware that their feeling of vulnerability, helplessness and danger affected not only them but also the children.

Woman 1: “when you are pregnant you are more vulnerable, you are more afraid of… not only for you but for the baby you are carrying. (…) Well, the first thing that happens is that you feel twice as frightened or you feel very vulnerable because you are carrying a baby and I think on top of it they know it and take advantage of that.”

The perceptions they may have about the aggressive behaviors of their partners and the actions they can take to increase their safety become more relevant when a baby is on the way. Both the wellbeing of their children and the need to be well in order to continue looking after their children becomes more latent.

Woman 2: “I left to protect my daughters, not only to protect [my children] but to protect them from losing me. I mean, in principle he was not going to hurt them because they are his daughters.”

Some women explained that the fact of being pregnant made it harder and more complicated to abandon the life project that they were building together with their partners. As Woman 6 said, “the problem of motherhood, motherhood as a problem.”

Woman 2 explained it in greater detail: ending the relationship at that time meant abandoning her entire life project:

Woman 2: “I think another idea we would all share is that, when you are building a life project with somebody, breaking up at that time is not only breaking up with your partner; you break your structure, your project, your idea. And I think that is psychologically the hardest.”

In fact, Woman 2 explained how sometimes the partner is aware that pregnancy can make it difficult for the woman to end the relationship and may use this to increase his control over her:

Woman 2: “I also think, I wonder if you agree, in my experience, when the abuser wants to have a child it’s a way to keep you there (…). And afterwards, in retrospect, it’s clear that it is also a way of always keeping you there.”

All the women agreed that ending the relationship or seeking help from their social network becomes even more complicated when certain feelings such as shame and guilt come into play. Blaming themselves along with the fear of how other people will react was considered a major barrier for ending an abusive situation. In some cases, participants reported how they decided not to tell anybody for this reason, even though they were aware of their situation:

Woman 1: “Well, in my case, I was very embarrassed also when I started to realize it, I didn’t tell, I didn’t tell anybody.”

Woman 2: “Because it’s like talking badly about yourself.”

Blame was also mentioned as a means of control by the partner, so that everything negative that happens is the woman’s fault. This further complicates the search for help, reduces the real perception of the abusive situation and affects the wellbeing and autonomy of women:

Woman 3: “Oh yes, because everything is always your fault, at least for my husband. I was to blame for everything: for the rain, for him losing his job, for everything.”

Another aspect women reported as being of great concern was the lack of economic independence, which becomes even more relevant when there are children to be considered. This makes any possible action to end the relationship very difficult.

Woman 4: “The economic issue is key (general agreement). If you don’t have a job, you don’t have any money, you see yourself like …”

Woman 2: “And it’s no longer just you, it’s also the children.”

Video counseling intervention: key aspects

Specifically, regarding the possibility of conducting psychological video counseling sessions with pregnant women in an IPVAW situation, the women were asked what content they considered essential to address, and what came up when thinking about these sessions. This last question caused debate about the feasibility, safety and barriers of this type of counseling.

Contents

When asked about what contents a video counseling session should include, four categories were identified as being of particular relevance: the lack of awareness of IPVAW, self-esteem and fears, and legal advice.

Awareness of the IPVAW situation is an aspect that all women defined as very complicated but also as necessary both to eliminate the idea that they are responsible for what is happening to them and to consider how to take action against the abuse. All participants agreed about the importance of this aspect and mentioned it repeatedly, considering that it is essential to address it in the sessions.

Woman 1: “I think it is key [for the woman to be aware of her situation]. That’s my opinion. Because you don’t realize most things that are happening.”

Woman 5:  “It’s very important to understand very clearly what is happening, because doubt is what prevents you from acting (general agreement). Thinking that the situation is your fault. It is very important to know that this is real, that it is happening and that you need to take a step forward.”

Participants also highlighted that making these types of resources available can be useful to increase awareness, even among women who are offered video counseling and reject it. They consider that giving visibility to resources directed to women who may be experiencing IPVAW would help increase awareness of their situation.

Woman 2: “I think that, in fact, if these things didn’t exist, it would take you longer to realize (general agreement). So, getting help in the end, I think the end of the story is positive, even if there are so many women who say, “No, I’m not being abused” or “I don’t want to deal with that, I’m afraid” and so on. But the more this becomes normal and the more it is done, the more helpful it will be for these women.”

In relation to this lack of awareness, participants pointed out the importance of how to confront women with reality. According to the participants, telling the woman directly that she is in a situation of abuse and that she should leave is counterproductive and negative. Woman 4 explained the importance of approaching this topic properly, and also described how she experienced the moment when she was told that she should end the relationship:

Woman 4:  “And I think that making you aware, I mean, telling you some things. The first time I was asked “Have you been abused?”, No, I haven’t… no, no, no. Because I didn’t want to admit it and also I didn’t want to see myself as a victim. You need to gradually see it for yourself rather than have somebody tell you directly, you know?”

Woman 4:  “I think it is counterproductive. For example, when people say, “You should leave him” if they say you should leave him directly it’s like … “Boom”.”

Several women reported that they consider it a priority to address self-esteem and fears, a proposal supported by all the participants. This topic led to a dialogue between Woman 1 and Woman 2; they both stated that they had felt similar fears:

Woman 1: “Self-esteem, for example. Removing all fears, because I was afraid of driving…”

Woman 2: “Yes, so was I.”

Woman 1: (…) “Addressing the issue of fears and also self-esteem, I think (general agreement).”

Along with fears, the concern about certain legal processes appeared repeatedly, especially those related to divorce and custody. The legal process, reporting the abuse and the rights of IPVAW victims were topics that women considered to be overlooked. They agreed that there is a need to address the lack of information on these issues and to provide resources and specialized support for this.

Woman 6: “Legal advice (general agreement). Yes, because you find yourself… it doesn’t matter if you are cohabiting, single, or married, because it’s a child that is your child and his child after all, and if you really want to break that relationship, you need to think of how you should do it to become separated, regarding custody issues… Get some information about whether you should report the situation or not, if you are experiencing abuse, in short, you should know what is at your reach, because we hear some things. But I don’t know…”

Video counseling

In addition to the contents that video counseling should include, a discussion was raised about the technical aspects that should be taken into account when offering this kind of eHealth strategy.

Conducting the sessions in video conference format raised certain doubts among the participants. This type of communication has some requirements, as Woman 2 explained: “Wanting to talk, having a safe and quiet place to talk, not running any risks, of course …”.

Given that finding a place to conduct the sessions is one of the most complicated aspects, many of the suggestions focused on conducting them somewhere outside the home, perhaps taking advantage of a visit to the midwife, where a space could be provided for the session with the counselor. Once again, the figure of the midwife as a facilitator emerged.

Woman 2: “I agree with her, with the excuse of something related to the pregnancy, I could go to a certain place that is not my home or anybody’s home and I have a space to talk, something like that…”

Woman 4: “In your sessions with the midwife for the checkup, she can say “should we have a more thorough examination”? And with that excuse you can have half an hour to talk with the counselor (general agreement).”

One of the participants pointed out that concealing the sessions as routine care could serve as a cover-up explanation to give to the partner about where the woman is going:

Woman 6: “It would be easier if it was in the sessions with the midwife, that is, if you went to see the midwife, as you said. It doesn’t matter if it is a video call or physical visit but, even as an excuse (general agreement) to be able to say where you are going… so that you can have some kind of control, but… it’s complicated.”

For the women, privacy is an important factor to take into account, even if the sessions are not held at home, because the woman may not feel free to speak for fear that someone will overhear the conversation.

Woman 2: “But even if he is somewhere else and you don’t want anybody to hear. I mean, it’s not only him; with him you run a huge risk, but it’s also that you don’t want other people to know.”

If the sessions are conducted at home, a factor that can complicate the situation is the presence of children, as reported by Woman 6. Being alone is complicated in this situation, as the woman would also have to find someone to leave her children with during the sessions.

Woman 6: “Yes, and we haven’t talked about that, but perhaps you are pregnant and have two children and if you’re home alone with the two children it’s not easy to find a private space…

Another issue that arose from the previous question was that of safety, that is, the fear that the partner will find out that the woman is attending the sessions. In particular, in the case of one of the survivors, her partner was a computer technician, which would make it more difficult to use technological means for the intended purpose:

Woman 4: “Him finding out. He had control over my mobile phone. He was a computer technician and used to reset my mobile phone when he could from a distance. He reset it, he asked me for my WhatsApp, my Facebook…”

Another concern mentioned by the participants was that, if the sessions were conducted at home, the partner could appear during the course of one. To solve this safety problem, they proposed to agree some type of signal with the counsellor, which would allow women to change the conversation and continue the session as if it was a pregnancy follow-up.

Woman 3: “I think that perhaps if he is informed that now, I don’t know, for various reasons, there’s a new thing and midwives or family doctors do their follow-up that way, perhaps if you’re talking to this person you can continue talking as if you were talking to your midwife or your family doctor, your gynecologist, and the other person, your counselor … would know that, well, the conversation changed a bit, and know what is happening.”

When participants were asked the first thing that came to mind about the possibility of speaking with a counsellor by video conference, certain barriers arose. Woman 2 said she would feel “coldness”: “Yes, because I would be talking to a stranger through a camera and I don’t know if she would give me much help…”.

When asked about which topics would be difficult for them to address in these video-sessions, there was agreement among the participants that the episodes that are most violent or related to sexual intimacy would be the most difficult to share.

Woman 1: “I found it very hard to describe the most aggressive episodes, for example, when he took our 8-month-old baby boy and went missing all day from 8 a.m. to 1 in the morning, with no bottles or anything, that is, in order to hurt me … That was hard for me. And then when Elena (the counselor) asked me questions about intimacy in the couple… that was terrible, it killed me, it was very hard for me to talk, she had to guide me a bit.”

Contributions for the safety planning app

Finally, the group discussed the opinion of women on the use of an application for the development of safety plans, including safety while using it and the contents it could include.

Safety while using the app

When addressing the possible options to ensure safe use of the app, there were proposals to use one or two passwords so that the partner cannot easily access it:

Woman 5: “That is, you access it with a fingerprint password, but inside you must access from another point because imagine if he asks, “open that app and tell me what that is”. And you would have to do it. When you open it, you should find something, I don’t know, something that is completely unrelated…”

The group discussed the appropriateness of the application being masked so as not to attract the partner’s attention. Women proposed to mask the app by taking advantage of the pregnancy situation, making it look like an app with information about the different pregnancy stages.

Woman 6: “A game for babies, for children, something about motherhood, since we are into that.”

Woman 3: “As you said it is camouflaged to look like another app, it could be another app like “First month of pregnancy, you have to do such and such thing, on another month you have to do something else”. And then you have the option of looking at pregnancy instructions or opening the app…”

In addition, women considered it useful to include a “quick leave” button in the app, in case the partner appears while they are using it. They claimed that this would make them feel safer when using it.

Woman 4: “And also if you can do things like… I find it very useful when you are using the laptop and open a screen with landscapes and, if you’re looking at something and he comes, you just click on the button and the screen pops up. That way if you are looking at something else he doesn’t realize. For example, perhaps you are looking at your plan and if he comes close or you see him come close you do that and the motherhood page appears, you know?”

App resources

After showing the participants different features that safety planning apps commonly have, the group discussed how such features could help women who experience IPVAW during pregnancy and how they could be improved.

One of the sections that was proposed to include in the app was Contacts, with relevant phone numbers (e.g., emergencies, specific IPVAW resources, and relatives/friends). All the participants mentioned that they imagined themselves using this section, and one of them added the following:

Woman 1: “It’s great. I wish I’d had that.”

In this section, women were asked whether they thought it would be appropriate or not to include a confirmation button when calling the emergency telephone number. All the participants agreed that it would be better to eliminate it as they considered the speed with which they could call in an emergency situation was more important than the drawback of having to apologize if they called unintentionally.

Another section that was proposed for inclusion was stories of other women who overcame the abuse. In this section, the stories of IPVAW survivors are shared, so that women who use the app can feel that they are not alone and that other women in the same situation were able to overcome it. Participants considered that it was not a good resource. They argued that hearing stories about other in their situation did not help them, referring to the support group they attended:

Woman 2: “That didn’t do me any good. It didn’t because I was focused on my own issues, you know? The intention is great because you are trying to help, but listening just for the sake of listening to stories like yours when you already have your own …”

Instead of peer stories, women suggested including a chat where they can talk to other women, which could be more interesting and positive for them.

Woman 6: “Like a chat between friends, you know? At times, for example, there may be 4 women connected, and it should be anonymous. Four women are connected: “what’s the matter? Well, I’m here, can you give me some advice?”

Woman 2: “That sounds like a good idea to me, because it gives you some anonymous company and it might be good.”

Another proposal was to include a section where women can rate their mood each day, but it generated rejection among all participants. Women argued that the rating would always be negative and this would have a negative effect.

Woman 6: “That’s a bit depressing, isn’t it?”[Laughs]

Woman 1: “The way I see it, with the huge problem you have and the anxiety you have, everything is going to be “negative, negative, negative”.”

Woman 6: “It should be something to raise your spirits, not to realize how bad you’re feeling.”

The proposal to include information on how the abusive relationship can affect the pregnancy and the baby was also generally rejected, and women proposed to focus instead on positive content or advice from professionals. They proposed to introduce contents that can help them manage certain situations: for example, techniques for managing stress and fear. In general, they preferred the inclusion of positive contents.

Woman 1: “As I said, something positive so that when I’m with it [the app] I can look at it and say, “Look, this makes me laugh”.”

Woman 2: “I find it much more interesting to learn relaxation techniques, how to breathe well, to relax. Something that helps you calm down.”

Woman 6: “Some advice, for example: “What to do after a situation of violence”, you know? That is, as counselors, therapists, whatever. If, when you are scared, you can read a paragraph written by a professional providing advice like: “When you are scared after a situation of violence” or “When you are scared for your children”.”

Regarding the development of a safety plan in the app, participants considered that it may be useful, especially the process of creating it, because it clarifies the strategies that women may have when faced with a dangerous situation. They hardly see themselves using the application at the time of a risk scenario, but believe that having previously thought about these strategies can have a positive effect when responding in each context.

Woman 6: “Also, to practice using these resources, you internalize them better and gradually get better at using them … indeed. [You learn] which ones are automatic, which ones are appropriate, which ones are not. For example, screaming helps me. Keeping quiet doesn’t, so you include it in your everyday life. It’s an analysis rather than something you are going to do at a given time. That is, a self-knowledge exercise.”

Woman 4: “It’s a plan, in my opinion, for example, at that moment I would have liked to know: first call the police, then call so and so, then call the lawyer, then call… I don’t know, those steps. Because I was confused and thought: “What should I do? Where should I go first?”.”

Women also considered it positive to have emergency contacts so that they could call quickly as part of the safety plan if necessary.