Women's strategies for managing domestic violence during pregnancy: a qualitative study in Iran

Background Domestic violence during pregnancy is a severe public health problem. Abused pregnant women are confronted with the threats posed by domestic violence. Pregnancy and protection of the unborn child could affect maternal strategies for managing violence. The purpose of this study was to explore Iranian women's strategies for managing domestic violence during pregnancy. Methods This qualitative study was conducted in October 2019 to June 2021 in Mashhad, Iran. Data were collected through individual semi structured interviews with 13 women who experienced perinatal domestic violence, two relatives and 24 related specialists as well as two focus group discussions with attendance of 20 abused mothers until the data saturation was achieved. Data were analyzed by the conventional content analysis approach of Graneheim and Lundman. Results The main themes "escape strategies" and "situation improvement strategies" were emerged as the result of data analysis. Escape strategies was comprised of three categories including concealment, passive dysfunctional behaviors and neutral behaviors to control maternal emotional distress. Situation improvement strategies was comprised of three categories including active self-regulation, protecting family privacy and help seeking to control violence. Conclusion Understanding the experience of managing domestic violence among pregnant women is essential to design evidence based violence prevention programs, which enable supportive healthcare and social systems to encourage abused mothers to use more effective strategies and seeking help to overcome domestic violence.


Introduction
Domestic violence is a public health concern and human rights violation affecting more than one third of all women in global [1]. Domestic violence and intimate partner violence are frequently used interchangeably in the literature [2]. It is estimated that one in three women disclose domestic violence during or after pregnancy, but prevalence differs depending on the location [3]. The prevalence has been estimated from 3 to 30 percent [4] reaching 15% to 71% in low to middle-income countries [5]. In relation to the literature the prevalence of domestic violence may increase during pregnancy, remains unchanged or decreases [6]. Despite the prominence of the dignity of the woman in the Islamic, there are different types of violence against women [7]. The results of a review study conducted in Iran (2014) with an assessment of 38 articles showed that the prevalence of domestic violence in Iranian pregnant women varies from 19.3% to 94.5% [8].
Domestic violence during pregnancy threatens maternal and fetal health and is a dangerous but preventable factor for many perinatal morbidity and mortality [9]. These complications included isolation, reduce maternal social networks, inadequate pregnancy care, inadequate pregnancy related weight gain, vaginal bleeding, spontaneous abortion, preeclampsia, sexually transmitted infections, stress, reduced quality of life, dissatisfaction of pregnancy, and drug and alcohol abuse. Other complications included stillbirth, premature birth, low birth weight, newborn complications, avoidance of breastfeeding, delayed mother infant bonding, maternal abusive behaviors toward their infants, and children personality complications [10][11][12][13][14][15][16].
Women who experience domestic violence often use a variety of mental and behavioral strategies to inhibit or stop the violence [17,18]. Actually, in the face of increasing violence, mothers often revealed increased activity in protecting themselves and their children. Abused pregnant women confront significant difficulties in keeping themselves and the unborn baby safe [19]. Pregnancy can create a common sense of isolation that may be enhanced by experiences of domestic violence and reduce maternal social networks [13]. Social support provides the chance to discuss stressful experiences, receive support and reduced risk of suffering from domestic violence during pregnancy [20][21][22].
Coping is an essential strategy for managing domestic violence that includes efforts to manage a problem through the continuous change of intellectual and behavioral efforts [23][24][25]. In domestic violence situations, coping relates to resilience strategies that victims accomplish to minimize harms and handle the situation [26]. The two main forms of coping strategies are problem focused and emotion focused coping [25,27]. The process of coping with domestic violence can be understood in relation to the social and cultural background, capacity and access to supportive resources, and the severity of the violence [24].
The capability to inhibit and cope with violence is different for pregnant women compared to non-pregnant population [28,29] and coping strategies are affected by adolescence and pregnancy [30]. Abused pregnant women may use resilience through problem focused coping, adjusting their motherhood, expand levels of their social support, and seeking help [31]. In spite of the increased risks of domestic violence during pregnancy, many women use their experiences effectively such as resilience [32]. As domestic violence during pregnancy and coping with it has a close association with the social, regional and cultural context, it is essential to collect the associated information in various social and geographical contexts [33], therefore conducting the research in a certain local context can be the most important factor in better clarification and move toward resolving the problem of domestic violence.
Iranian Islamic society is a patriarchal society that highlights men's authority over women in the family [34][35][36]. Wife's obedience to the husband, tolerate husband's violence and keeping the family are women's duties and considered honorable [34]. Islam has highlighted the mothers were interviewed in Mashhad in the north east of Iran. The results showed abused mothers used escape strategies and situation improvement strategies for managing domestic violence. Mostly abused mothers used emotion oriented strategies such as escape strategies for managing violence. These strategies included of concealment, passive dysfunctional behaviors and neutral behaviors. Some mothers with regard to individual decision-making and individual abilities tried to improve their situation by active self-regulation, protecting family privacy and help seeking. The results of these various strategies vary from reducing domestic violence to not changing the intensity of the violence or intensifying the perinatal domestic violence. In conclusion: inappropriate strategies against domestic violence could be threatening for fetal and maternal safety and appropriate strategies should be considered in perinatal education. Understanding the experience of managing domestic violence among abused pregnant women is essential to design evidence based domestic violence prevention strategies and programs.
issue of family integrity and deems divorce is a lawful but undesirable and discouraged act [36]. Women are defined by their roles as mothers or wives which expect them to sacrifice and put their husband's and children's needs ahead of their own to keep their family from breaking up [35]. In such circumstances, abused pregnant women attempt to adopt various strategies to strengthen their marital relationship and prevent family breakup. In order to achieve a deeper understanding about the strategies for managing domestic violence during pregnancy, it is necessary to develop a qualitative study that reflects maternal behaviors and needs. Different qualitative studies on pregnant women's experiences with domestic violence were conducted in the world [19,30,[37][38][39], but no evidence exist to explain the experiences of Iranian pregnant women with domestic violence and their strategies for managing domestic violence during pregnancy. Understanding the experience of domestic violence among these women is essential to design evidence based domestic violence prevention strategies and programs. To the best of our knowledge, this study would be the first one to explore Iranian women's strategies for managing domestic violence during pregnancy.

Design
The conventional content analysis approach was used to design this qualitative study to get deeper insight into pregnant women's experiences of managing domestic violence [40]. Qualitative content analysis is a proper method to study cultural related contextual issue [41] in health science study [42].

Setting
The current study was carried out from October 2019 to June 2021 in Mashhad, the capital of Khorasan Razavi Province, one of the most populous city in the north east of Iran. At first obstetrics and gynecology departments of teaching hospitals were used to select the participants. The reason for this selection were high referral of pregnant women and effective management of these departments. Purposive sampling led to the selection of comprehensive health center, prenatal clinic, midwifery counseling center, provincial welfare center, forensic medicine center, social emergency, consultant voice center, and other related organization as study setting.

Data collection
Purposive sampling with a maximum variation such as age, occupational status, education, number of marriages, gestational age, wanted or unwanted pregnancy and domestic violence screening score was used to select the participants. Data were collected through individual semi structured in-depth interviews with 13 women who experienced perinatal domestic violence, one husband and one daughter and 24 key informants comprising of health care professionals as well as the specialists in reproductive health, social working, forensic medicine, psychology, law, sociology and media. Two focus group discussions with attendance of 20 abused mothers were conducted because of their resistance to be interviewed individually. The participants' profile is shown in Tables 1  and 2.
Inclusion criteria were maternal agreement for participation in the study, their ability to communicate with the researcher, endorsing perinatal domestic violence and ability to share their related experiences. Exclusion criterion was maternal physical and mental disease that prevent their participation in the study.
Interviews were conducted by the first author with good experience of qualitative research and 23 years working experience in the field of reproductive health and midwifery. The interviews were accomplished at a time and place that was appropriate to participants and were audio recorded. The interviews continued until the data saturation. Data saturation was obtained following 37 interviews and 2 focus group discussions. However, to confirm data saturation, two further interviews were carried out which revealed no new data in the field of different maternal strategies in managing domestic violence. An interview guide with open ended questions was used to explore participants' experiences as follows "Please describe your experience of violence during pregnancy or postpartum?" Other questions followed the main question were "How do you react when you are abused?", "How does pregnancy influence the managing skills you used?", "What are some of the ways you keep yourself and unborn baby safe?", and "what is your advice for other pregnant abused women and service providers?".
The interviews lasted between 30 and 120 min (mean: 65 min) and each focus group took approximately 90 min.

Data analysis
Conventional content analysis was used to explain the research question. The data were analyzed concurrently with data collection, based on the Graneheim and Lundman method by MAXQDA software (version 10, VERBI Software, Berlin, Germany) [42]. After each interview, the first author listened to it several times to get an overall perception of the content, and then transcribed the interview verbatim and read it several times to obtain a general understanding of the data. The text of each interview was divided into meaning units as words, sentences, and paragraphs. The meaning units were condensed and condensed meaning units were summarized and coded. Codes were compared based on the similarities and

Trustworthiness
To confirm the rigor and the trustworthiness of the data, Guba and Lincoln's criteria, including credibility, confirmability, dependability and transferability, were applied [43].
To maintain the credibility of the results, the data analysis were reviewed and approved by the participants and three expert qualitative researchers. To increase the credibility purposive sampling with maximum variation and appropriate size was used. For dependability the correctness of data analysis was approved by three external skilled researchers in qualitative research. In order to maintain confirmability some of the transcripts, along with the codes and categories were provided to the main supervisor as well as three other faculty members outside the field of study (all experienced in qualitative research) and the process of analysis was confirmed. To make transferability possible, the research characteristics, including the participants and the context of the study were described in detail, therefore other researchers could be able to evaluate the transferability of the results.

Results
The abused mothers' age were ranged between 19 and 41 years. Maternal educational levels ranged from illiterate to Doctor of Philosophy degrees. Domestic violence screening score ranged from 11 to 20. In present study 1568 codes, 20 subcategories, 6 categories and two main themes emerged from the data analysis. Through the data analysis "escape strategies" and "situation improvement strategies" were emerged as the main themes. Escape strategies was comprised of three categories including concealment, passive dysfunctional behaviors and neutral passive behaviors. Situation improvement strategies was comprised of three categories including positively active self-regulation, protecting family privacy and help seeking ( Table 2). A more precise presentation of the results is given below. Quotations from the participants are included to better clarified women's strategies for managing domestic violence during pregnancy (Table 3).

Escape strategies
Abused mothers were constantly confronted with the harms and threats posed by violence and had to deal with these harms in different ways. At first, they tried to reduce the psychological stress of violence in various ways, such as concealment, passive dysfunctional behaviors and neutral behaviors without directly paying attention to husband's violence reduction.

Concealment
The special socio-cultural conditions of Iran and various contextual factors caused abused mothers to conceal violence.

Concealment of violence
Abused mothers were initially at a crossroads in choosing to disclose domestic violence or conceal violence. Mostly abused Iranian mothers concealed perinatal domestic violence despite the routine screening for domestic violence during prenatal care. They hided violence from family, friends, the health care system, and the legal community and in this manner they manage perinatal violence in their ways. One participant stated: "In my opinion, all pregnant mothers are abused in some way, but they do not disclose it, they don't tell this situation to anyone. They hide violence." (Participant 10-36 years old-1 year postpartum)

Passive dysfunctional behaviors
Abused mothers knew they were being harmed by violence, but remained in a relationship due to maternal commitment and lack of support. Usually they used passive dysfunctional behaviors to decrease psychological complication.

Emotional release
Abused mothers initially react to their husbands' violence by crying, getting angry, and even laughing. This quote reflects it: Under the psychological stress of perinatal domestic violence a few mothers hit the fetus, harassed and beat their children, and even left them. One participant declared:

Helplessness and confusion
Pregnancy and postpartum create a sense of isolation for mother that magnified by experiences of domestic violence. Inefficient self-talk, leave spirituality, inattention to herself, self-worthlessness, self-forgetfulness and wish for death were maternal strategy for dealing with the emotional effect of perinatal domestic violence. One participant explained:

Recourse to divorce
A few abused mothers decided to divorce as the final solution to get rid of their abusive husband when they could not find another way to reduce the violence. One mother said:

Neutral behaviors
The result of the present study indicated that neutral passive behavior such as placating strategies and diverting attention were of the common strategies used by abused mothers to minimize the recurrence and intensifying violence in their marital relationships.

Placating strategies
Placating and conscious acceptance of violence were recommended by most of participants as one of the best ways of minimizing the recurrence of perinatal domestic violence. Placating such as silence, tolerance, patience, obedience, indifference, waiver and violence normalization were of the best ways of keeping peace in the house. The following quote reflects it:

Applying situation improvement strategies
Some mothers, while believing in the necessity of covering up violence with regard to individual decisionmaking and individual abilities, and in the shadow of high self-esteem and self-confidence or disclosing violence and seeking support tried to improve their situation by active self-regulation, protecting family privacy and help seeking.

Active self-regulation
Maternal urge to protect the unborn baby and protect marital life were of the most important impetus to reduce domestic violence by self-actualization, comprehensive self-care skills, promoting positive self-concepts, resilience and strengthening spirituality.

Self-actualization
Some abused mothers used the maternal active strategies for dealing with domestic violence in order to be able to protect the privacy of the marital life without causing psychological harm. These strategies included creating a good mood, self-relaxation, return attention through enjoyable activities, positive mental imagery and maintain authority, skills and empowerment. These quote reflects it:

Comprehensive self-care skills
The abused mothers acquired comprehensive self-care skills through physical self-care, emotional psychological self-care, social self-care and spiritual self-care. The following statement approve this:

Promoting positive self-concepts
Maintaining and promoting self-confidence, self-esteem and self-control were the strategies that the abused mothers used to promote positive self-concepts. The following statement confirm this: "Some pregnant women lost their self-confidence during pregnancy. They think that their husbands are no longer interested in them, because their appearance has become ugly and they have become fat so their situation is getting worse day by day.

Resilience
Despite the increased risk of domestic violence during pregnancy, many women effectively navigate their experiences and come to display adaptive outcomes, such as resilience. Resilience included promote individual growth, being purposeful, internal control, flexibility, realistic look and thinking positive. One participant stated:

Strengthening spirituality
Abused mothers endorsed strengthen spirituality as a form of adaptive coping strategy in dealing with perinatal domestic violence. Relying on God, appealing to the Imams and submitting to the divine destinies were the strategies which resulted in maintaining maternal peace and reducing her vulnerability and ultimately increasing maternal ability to protect the privacy of the marital life. This quote reflects it:

Protecting family privacy
The result of the present study showed that protecting family privacy by a purposeful effort to correct spouse behavior, supportive efforts and maintain maternal commitment were the active maternal problem solving strategy for dealing with domestic violence.

Constructive purposeful efforts
In the initial exposure to violence, some mothers tried to control violence by a purposeful effort to correct husband's behavior such as turn disputes into positive negotiation, building trust, create intimacy, promote his information, maintain his authority, meet his sexual needs, encourage him for psychological counseling and trying to change his destructive behavior. The following statements indicate it:

Supportive efforts
Some mothers supported their husbands in economic and emotional status. Although supportive efforts did not reduce the husband's violence, it could improve the mother's psychological states and it affected the mother's sense of satisfaction with her ability and empowerment. One educated mother stated: "I was teaching at university before I got pregnant, I had some savings. I paid for my prenatal care and screening tests because I felt my husband was resisting paying for them. I was so happy to be able to pay for my prenatal care." (Participant 10-36 years old-1 year postpartum)

Maintaining maternal commitment
Maternal commitment such as efforts to maintain fetal health, trying to keep the children calm and priority the comfort of the fetus and children to maternal liberation from violence made mother to stay in an abusive relationship and didn't think about separation. In fact, mothers sacrificed themselves and put their children's needs ahead of their own to keep their family from breaking up. One mother explained: "When you become a mother, the feeling of motherhood makes you look at life differently, you are responsible for maintaining the health of your child, and the most important thing is to be patient and tolerant." (Participant 1-37 years old-36 weeks of gestation)

Preserving marriage
Some abused mothers tried to save their marital life despite their husbands' violence because of their interest in cohabitation and their husband's satisfactory commitment. One participant stated:

Avoiding social judgments
Avoiding social isolation and preventing the stigma of divorce, the stigma of remarriage, preventing the lack of financial support after divorce and the lack of a supportive family prompted the abused mother to try to protect the privacy of the marital life. One participant described: "I was born and raised in a small town. If a woman divorces, society and her family look at her with pity and her life will destroy. These are the things that make a mother stay under violent circumstances and try to save her common life." (Focus group discussion-28 years old-35 weeks of gestation)

Help seeking
The result of the study revealed that some abused mothers finally tried to generate solutions by disclosure violence and gain formal and informal support.

Disclosure of violence
Some abused mothers finally disclosed domestic violence following the failure of previous strategies and the intensification of violence. Maternal empowerment and familiarity with individual rights, the ability of the health care system to identify violence, the presence of supportive families and support systems and the intensification of violence have been factors that facilitated the disclosure of violence. The following statements confirm this:

Looking for network support
Domestic violence reduced maternal social network and the result of the present study demonstrated the importance of formal and informal support and seek help from these support systems in facilitating dealing with domestic violence. Formal support was included health system, psychological counseling, use of welfare services, forensic medical center, social worker, relief committee, the police and Justice. Informal support was included friends and family. Abused mothers formed a friendly alliance and asked help from formal and informal support systems. The following statements confirm this: "Abused mothers should be informed about support systems. What services can they receive from the health centers? Where can they go for psychological counseling?" (Participant 27-37 years old-key informant).

Discussion
This is the first qualitative study in Iran which identified maternal strategies for managing perinatal domestic violence. According to the results, maternal strategies used for managing perinatal domestic violence included escape strategies and situation improvement strategies. In the shadow of maternal commitment to preserve marriage and child health, mostly abused pregnant women in the early stage of confronting with violence used emotion oriented strategies such as escape strategies for managing violence, gradually the recurrence and intensifying of violence caused applying situation improvement strategies. These results are similar to Lazarus and Folkman conceptualization in which emotion focused coping was used to reduce distress associated with problems such as violence and problem focused coping was used to manage the problems [44].
Despite the routine screening for domestic violence during prenatal care, the majority of abused Iranian mothers concealed perinatal domestic violence. They hided violence from family, friends, the health care system and the legal system. Several factors were important in concealing violence, such as inadequate information on violence, maintaining social reputation, protecting the unborn child, facing multiple fears, social judgments, lack of family support and poor performance of health care and judicial systems. This result is consistent with Damra et al. [45] study. Similar to a study by Kaye et al. [30], findings from this study showed abused young mothers adopted retaliation and fighting back as an emotion oriented strategy which usually had no effect on reducing violence but sometimes intensified husband's violence. Similarly, few abused mothers harmed themselves to cope with the psychological stress and presented additional health concerns which is aligned with previous study conducted by Bhandari et al. [19]. Similar to a research by Zakar et al. [46], findings from this study revealed that some abused mothers did not submit demands of their husband, ignored them and used husband abusive behavior such as sexual disobedience to get rid of their psychological distress. These strategies had no effect on reducing violence and sometimes cause more violent behavior of husbands. Domestic violence usually causes maternal social and physical withdrawal to decrease their emotional distress. This result is aligned with the previous study [30].
Consistent with a study conducted by Bhandari et al. [47], findings from the present study indicated that some abused mothers used placating strategies and diverting attention to minimizing the recurrence of perinatal domestic violence and keeping peace in the their house. Some abused mothers used active self-regulation such as self-actualization, comprehensive self-care skills, resilience, and strengthening spirituality. They could control their distress by these effective strategies. These results indicate the importance of educating mothers about the cycle of domestic violence, the warning signs to look for in marriage and how to develop safety after termination of a violent marital life that is consistent with another study [48]. Self-care is recognized mindful activities and taken by women, families and societies to promote the health status [49].
Some abused pregnant women displayed resilience and actively responding to their husband's harassment behavior for dealing with domestic violence. Resilience cause maternal wellbeing after violence. The result is similar to the study conducted by Levesque et al. [31] that victimized pregnant women may display resilience.
Consistent with the study conducted by Zakar et al. [46], participants in the current study used strengthening spirituality as a form of emotion oriented strategies. These strategies made abused mother calm in dealing with domestic violence.
Some mothers used family protection strategies and stayed in a marital abusive relationship. Maternal commitment and protection of the fetus were the important motivation for dealing with perinatal domestic violence. This result is in contrast to Bhandari et al. [47] study. Abused mothers in the face of intensifying violence increased activity in protecting themselves and their children, which is similar to the result of previous study conducted by Gillum et al. [18].
Pregnant and postpartum women used safety planning, resisting, placating, and formal and informal support networks to deal with violence in their lives. This result is align with Bhandari et al. [47] study.
Social support was associated with reduced risk of perinatal domestic violence since this kind of formal support could provide the opportunity for abused mothers to discuss about their vulnerable experiences and receive support in the context of perinatal domestic violence. This result is consistent with the previous studies [20][21][22].
Family support could help abused mothers to reduce violence and promoting maternal and fetal health. Similarly, family support could help mothers decide to leave the abused marital relationship which is consistent with previous studies [25,50].
Women who received psychosocial counselling showed a reduction in the frequency and severity of domestic violence, and this included both physical and emotional abuse. Psychology counseling could be an effective approach to reduce the recurrence of violence in pregnant women exposed to domestic violence. The basics of counseling was empowerment and increasing self-condense. Through this way abused mothers found that they are able to find appropriate solutions to solve domestic violence through their empowerment and positive negotiations with their husbands. The results were similar to the previous studies [51,52]. The result of the present study recommended that life skills training classes should be considered for abused pregnant women in health centers to reduce the prevalence of prenatal domestic violence which was similar to the study conducted by Taghizadeh et al. [53].
In line with the study conducted by Zakar et al. [46], Bhandari et al. [47] and Kaye et al. [30] some abused mothers used problem solving strategies such as gaining formal and informal network support and asked help from these support systems which could facilitate dealing with violence.
The results of this study increase understanding of Iranian pregnant women's strategies for managing perinatal domestic violence which could enable support systems to encourage abused mothers to use more effective strategies and seeking help to reduce domestic violence. These include strengthening formal and informal support systems and facilitating access for abused pregnant and postpartum women to formal and informal services, particularly the effective health care system.
According to the different cultural values of Iranian society further research is needed to explore facilitators and barriers of disclosing domestic violence during pregnancy. Similarly, further research is also needed to design effective interventions for women who report domestic violence during and after pregnancy.

Strength and limitation
This is the first study performed in Iran to explore Iranian women's strategies for managing domestic violence during pregnancy. Similarly, Data collection through interviewing with specialists from various disciplines, diversity of participants and multiple perspectives of domestic violence during pregnancy and postpartum were the strengths of this study. Patriarchal cultural context of Iran and the difficulty to obtain responses from the abused mothers considering the taboo of violence were important limitations of this study. Information regarding domestic violence during pregnancy is considered an individual family issue and should not be discussed with strangers even though they are health care providers that may, in turn, lead to under reporting of domestic violence during pregnancy by the participants.

Practical implications
Despite the methodological limitations of the study, our findings will be useful to health care providers, program managers, and policy makers in addition to women and human rights activists. They can be used in the development of specialized training and materials for building providers capacities to deal more effectively with cases of domestic violence during pregnancy and postpartum and it is also fundamental to collaborate with other professionals in order to develop shared health-care pathways.

Conclusion
The high prevalence and the negative consequences of domestic violence against pregnant women provide a golden opportunity for performing interventions. Pregnancy and protection of unborn child could affect maternal strategies for dealing with domestic violence. The results of the various strategies that the mother used to reduce perinatal domestic violence vary from reducing domestic violence to not changing the intensity of the violence or intensifying the perinatal domestic violence. It is noteworthy that adopting inappropriate strategies against domestic violence could be threatening for fetal and maternal life and appropriate strategies should be considered and emphasized in maternal education. Understanding the experience of domestic violence among these women is essential to design evidence based domestic violence prevention strategies and programs.