Experiences of being exposed to intimate partner violence during pregnancy

Abstract

In this study a phenomenological approach was used in order to enter deeply into the experience of living with violence during pregnancy. The aim of the study was to gain a deeper understanding of women's experiences of being exposed to intimate partner violence (IPV) during pregnancy. The data were collected through in-depth interviews with five Norwegian women; two during pregnancy and three after the birth. The women were between the age of 20 and 38 years. All women had received support from a professional research and treatment centre. The essential structure shows that IPV during pregnancy is characterized by difficult existential choices related to ambivalence. Existential choices mean questioning one's existence, the meaning of life as well as one's responsibility for oneself and others. Five constituents further explain the essential structure: Living in unpredictability, the violence is living in the body, losing oneself, feeling lonely and being pregnant leads to change. Future life with the child is experienced as a possibility for existential change. It is important for health professionals to recognize and support pregnant women who are exposed to violence as well as treating their bodies with care and respect.

Violence and pregnancy are two contrasting phenomena, but some women have to deal with them simultaneously. In most cases, pregnant women are exposed to violence from their partner (Ezechi et al., 2004; Johnson, Haider, Ellis, Hay, & Lindow, 2003). Violence inflicted by a partner may be described as intimate partner violence (IPV), defined by the WHO as “any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002).” Violence inflicted by a partner is sometimes called domestic violence or spouse abuse and includes acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviours by a present or former spouse or partner (Heise & Garcia-Moreno, 2002).

There are large variations in relation to the prevalence of IPV against pregnant women in different countries (3–29%) (Bacchus, Mezey, & Bewley, 2004; Dunn & Oths, 2004; Ezechi et al., 2004; Johnson et al., 2003; Krug et al., 2002). In a Norwegian national report on domestic violence, 4% of the women reported that they had experienced threats and violence during pregnancy (Haaland, Clausen, & Schei, 2005). IPV is often associated with feelings of shame, fear, and guilt among women, and it is possible that the prevalence may be underreported (Edin, Dahlgren, Lalos, & Hogberg, 2010; Lutz, 2005; Seng, Sparbel, Low, & Killion, 2002).

Several studies indicated that women exposed to violence during pregnancy have a lower socioeconomic status (Bacchus et al., 2004; Bhandari et al., 2008; Espinosa & Osborne, 2002; Jeanjot, Barlow, & Rozenberg, 2008). However, one study involving different social and ethnic groups showed no association between prevalence, pattern of abuse, and sociodemographic characteristics (Ezechi et al., 2004). A study from Sweden revealed that the risk of being exposed to IPV, from early pregnancy until a year after childbirth, is greater for women who are aged 24 years or younger, unmarried, born outside Europe, with a partner born outside Europe, with a low level of education, and unemployed (Rådestad, Rubertsson, Ebeling, & Hildingsson, 2004). Other risk factors for violence during pregnancy are if the women witnessed or experienced violence as children and if one partner in the couple has a history of substance abuse (Huth-Bocks, Levendosky, & Bogat, 2002; Wilson et al., 1996)

There is increasing evidence that IPV can affect women's health. Being exposed to violence can lead to health-related problems throughout the lifecycle or at worst to death (Espinosa & Osborne, 2002; Martin, Macy, Sullivan, & Magee, 2007). IPV can also cause depression and anxiety (Bacchus et al., 2004; Brown, McDonald, & Krastev, 2008). Women who are exposed to violence report higher rates of smoking and substance abuse than other women (Bacchus et al., 2004; Bhandari et al., 2008; Rosen, Seng, Tolman, & Mallinger, 2007).

Studies of violence in relation to pregnancy and childbirth show that IPV is significantly associated with both miscarriage and induced abortion (Fanslow, Silva, Whitehead, & Robinson, 2008). During pregnancy, the stress of living with IPV may increase the risk of premature birth (Rosen et al., 2007; Yost, Bloom, McIntire, & Leveno, 2005) and lower birth weight (Rosen et al., 2007; Sharps, Laughon, & Giangrande, 2007; Yost et al., 2005). Research also shows that women who are victims of violence breast-feed less than other women (Kendall-Tackett, 2007; Lau & Chan, 2007). A study from Australia shows that women who are afraid of their intimate partner both before and during pregnancy have poorer physical and psychological health in early pregnancy such as anxiety, depression, urinary incontinence, faecal incontinence, and vaginal bleeding (Brown et al., 2008).

Being exposed to violence leads to a complex life situation (Edin et al., 2010; McCosker, Barnard, & Gerber, 2004) with experiences such as loss of self, being controlled and destruction (McCosker et al., 2004), and struggle to recover from deep internal scars (Häggblom & Möller, 2007). According to studies by Edin et al. (2010) and Lutz, Curry, Robrecht, Libbus, and Bullock (2006), women who are exposed to violence during pregnancy have ambiguous and contradictory feelings. Some studies show that the phenomenon is experienced as difficult and a taboo (Edin et al., 2010; Lutz, 2005). Edin et al. (2010) and Bishop (2005) reported that women found it difficult to tell health professionals about their situation.

In summary, IPV is related to a multiplicity of different health problems and complications during pregnancy and birth. Despite this, there are few studies of women's experiences of living with violence during pregnancy. The WHO reports that ending gender discrimination and all forms of violence against women requires an understanding of the prevailing culture in relation to violence (Krug et al., 2002), which implies the need for more studies from different countries. The present study is a part of a larger Norwegian project that explores various possibilities for change in the life situation of women living with IPV during pregnancy. The women who participated were recruited from Alternative to Violence (ATV), a professional research and treatment centre for violent offenders and people who witness or are exposed to violence. In order to understand and provide appropriate assistance and support to women living with IPV, it is important to gain more knowledge about their experiences. The aim of this study was to describe women's experiences of being exposed to IPV during pregnancy.

Methods

In this study, we used phenomenology in order to enter deeply into the experience of living with violence during pregnancy. The purpose of phenomenology is to describe a phenomenon as it is lived and experienced by individuals (Dahlberg, Dahlberg, & Nyström, 2008; Giorgi, 2009). Based on the work by Husserl (1970) and Merleau-Ponty (2002), phenomenological research seeks to identify and understand meanings in humans’ everyday world of experience, i.e., the lifeworld, in all its variety (Dahlberg et al., 2008; Giorgi, 2009). In phenomenology, the focus is on the description of a phenomenon, which is an object as experienced by a subject (Dahlberg et al., 2008). Living with violence during pregnancy is the object in this study, which encompasses women who still live together with their partner and women who do not. From a phenomenological perspective, it is not possible to describe an object, such as violence during pregnancy, without reference to the subjects: i.e., the women who took part in this study. However, it is impossible to search for a definitive meaning, because people always live in relation to time and space. Meaning is never fixed nor static but contextual and historical (Merleau-Ponty, 2002). This means that the results must be related to the historical time during which the studies were performed and the context in which they took place: a Scandinavian country and women who were exposed to violence during pregnancy and supported by a professional treatment centre.

Sample

Five Norwegian speaking women aged 20–38 years participated. Inclusion criteria were women who had experienced IPV during pregnancy, the birth was within the previous 2 years, and the women were Norwegian speaking. Therapists at the ATV informed women who were exposed to violence about the project, both orally and in writing, and asked them to participate. The women were self-referred to the ATV. The ATV provided the researcher with the names of those women who agreed to participate and information about how they wished to be contacted.

Two of the interviews were conducted when the women were pregnant and three after birth. All the women were first-time mothers, but some of their partners had children from earlier relationships. The women who were pregnant when the interviews took place lived together with their partners who subjected them to violence. The other three were separated. One of the separated women had left her partner during pregnancy, the other two after birth. All of the participants were going to start or had completed university education. The interviews began with one open question: “Could you tell me about your experiences of pregnancy and being subjected to violence by your partner?” The women's responses were followed up by further in-depth questions. Each woman was interviewed on one occasion, for approximately 2 h. All of the interviews, which were conducted in places the interviewees considered safe, were audio-taped and transcribed immediately afterwards. Four of the interviews took place in an undisturbed office in a hospital and the fifth in a room at the ATV premises.

Data analysis

The data were analysed in line with Dahlberg et al. (2008). Openness is important for phenomenological research, which means having an open mind in order “to discover anything new, to see the ‘otherness of something’.” This means that the researcher must treat the informant's experiences in an unprejudiced manner as well as with a reflective and, not least, a self-reflective attitude (Dahlberg et al., 2008). The first step was to read the transcripts of the interviews to gain a sense of the whole. Openness means being open and carefully listening to the tapes and reading the transcripts (Dahlberg et al., 2008). The next step involved dividing the text into parts, called “meaning units” by Giorgi (2009), who highlighted the fact that every qualitative procedure requires this step; the differences emerge with respect to how the partializing is done and how the parts are understood. Meaning units should be concrete descriptions of the informant's everyday world that have meaning in relation to the studied phenomenon (Giorgi, 2009). During the analysis, the text was read and parts that had relevance to the studied phenomenon, living with violence during pregnancy, were marked.

Next, the meaning units were organized to identify and understand patterns. Similarities and differences were reflected on and clusters of meaning emerged (Dahlberg et al., 2008). This process was a constant movement between the interviews and the clusters, going from the whole—to the parts—to the whole (Dahlberg et al., 2008). Clusters of meaning were synthesized into a structure that bound them together, and an essence of the phenomenon started to emerge (Dahlberg et al., 2008). The essence is the phenomenon's essential meaning, whereas constituents are meanings that make up the essence (Dahlberg, 2006). This process was a constant movement between the interviews and the essence, going from the whole—to the parts—to the whole.

Ethical considerations

The Regional Ethics Committee of South-Norway (No S-07107a) and the Norwegian Social Science Data Service (No 16460) approved the study. The International Code of Ethics for Midwives (2008) and the Helsinki's declaration were adhered to throughout the study. Together with the invitation to participate, the women received oral and written information that if the researcher became aware that the woman had children at home who were exposed to violence, it would be her duty to report the matter to the Child Welfare Service.

During the whole study process, the guidelines for research on violence against women were followed, in order to protect the participants, the researcher, and the data (Parker & Ulrich, 1990). As pregnant women exposed to violence are vulnerable, conducting interviews with them requires ethical considerations in order to respect their integrity, security, and confidentiality. Liamputtong (2007) emphasises that researchers need to protect their participants, because telling about their lives might force them to live through their painful experiences once more. Sharing experiences about IPV might give the participants an opportunity to work through their trauma, and in this way, the interview can have a positive, therapeutic effect (Liamputtong, 2007). The participants were informed that they could withdraw from the study at any time.

Result

The essential structure of the lived experience of being exposed to violence by one's partner during pregnancy is characterized by difficult existential choices and ambivalence. Existential choices mean questioning one's own existence, the meaning of life, as well as the responsibility for oneself and others. The existential choices are related to the women's whole life both before and during pregnancy. Ambivalence means being uncertain about one's own feelings, self-esteem, and abilities. Ambivalence in relation to others means conflicting feelings for and being confused about how to relate to the other. The future life with the child is experienced as a possibility for existential change in the women themselves and in others. The essential structure can further be explained by its five constituents: living in unpredictability, the violence is living in the body, losing oneself, feeling lonely, and being pregnant leads to change.

Living in unpredictability

Living in unpredictability is described as a complex and contradictory situation. The violence can come without warning or occur in the context of a growing tension in advance of outbreaks. Furthermore, it is described as an explosive and uncontrolled anger, which might be expressed as slamming doors, punching the wall, smashing windows, destroying furniture, and throwing food on the walls. The uncertainty of not knowing what lead to rage makes the situation a dramatic and threatening experience:

It is just as if something inside him explodes … and then he both cries and screams. There is swearing, slamming doors and he usually never swears and calls me you fucking, damn shit!

Unpredictability and little control in relation to the timing of outbreaks of violence are related to fear and the need to live in constant readiness. To handle this situation, the women are trying to trivialize and normalize violence. Eventually, join the individual actions into a pattern where the total amount of violations experienced becomes unsustainable and destructive. The women described bodily experiences of unpredictability: “Must always be three steps ahead of him and what he might do I hunch my shoulders and look around to check if he is near.”

Living with unpredictability creates a need for women to understand what has happened. Women want control over the situation by understanding the context and the meaning. Despite this, it may be difficult to enter into a dialogue with the men. According to the women, the men have a tendency to run away from the situation by leaving the house and saying that everything went black, so that they do not remember what happened:

He says that everything went black and that he did not remember it afterwards.

I do not know if he remembers it, or if it's just something he says to escape the situation.

The women described that the men said that they did not remember what happened when they were violent, which made it difficult for the women to know whether the men were accountable for their actions. At the same time, the men might express that they were never so angry with someone else, which made the women more insecure about their own responsibility for the situation. When the violence was over and the mood had calmed down, the women reported that the men expressed remorse and despair over their actions:

He keeps on and on and then collapses and starts to cry and hug me. ‘I'm so afraid of losing you’ and ‘I would totally panic if something is to happen to us’ and ‘You are everything to me, and I cannot live without you.’ He is incredibly kind to me, in some ways.

Unpredictability also means that the situation might change from despair and violence into one characterized by intense declarations of love. The man provides declarations of care and love that the woman accepts. After all, they have chosen each other, and the woman expresses that the man is basically good. The aggressive side is “not really like him.” If the woman still lives with her partner, she can consider the declaration of love as a sign of hope of forgiveness. Those who left their partners had lost this hope. Women still living with their partner described the need for forgiveness, while those who had separated did not express the same need for reconciliation. Their descriptions of forgiveness were related to the men's children, who were also living in unpredictability. “And then I thought; have I played a part in putting the children of X into this situation? Has the fact that I didn't leave X earlier made things worse for them?”

The violence is living in the body

The women described how the violence was experienced through their bodies by symptoms such as stress, fear, muscle pain, breathing difficulties, and sensory disturbances. According to the women, violence is related to these symptoms and occupies their attention. “I feel I have to go out. I cannot breathe. It's just like having migraines and pain. The only thing you care about is getting rid of it.” The body was experienced to have shrunk at the same time as the woman's self-image changed. The body felt physically exhausted and powerless, which contributed to the women being unable to resist the violence:

I was very stiff and tense in the neck and shoulders. Finally, I was so tense that I could not see clearly, actually, everything around me was a bit foggy, similar to just before you faint. I very often woke up tense. Very tense … with nightmares.

The violence living in the body is also related to the man's body. According to the women, when the man's body is violent and threatens her, it grows and fills the entire room. Her own body crumbles and wants to disappear.

It's a little hard to explain, but his body seems to dominate him when he gets angry. And I become so small. I will not … I cannot stand up against that anger. I only get small and scared, and I have to retreat. So what I experienced afterwards, when I was gone only a few months, and then came back to collect some stuff, was that he followed me into the laundry room and came up close [indicating with her hand close to her face] with his huge body, and when I begged: ‘Please, don't! I get so scared. You need to keep further away from me.’ And he just laughed and it … it's just as if he was mocking my fear and the child's fear. ‘Yes, but he is not angry! He is not angry! He has never been angry!’ And then he changes completely to? ‘I'm a violent man!’ [shouting] and he became hysterical and the change occurred in just a few seconds, from totally quiet to explosive behavior. I was almost hysterical and could not bear it and [such situations] can make me assume the fetal position and just lie there, wanting to go away. I was totally paralyzed for a long time.

Being exposed to violence during pregnancy means that the women's bodies are in a high state of alert, and their focus is on the powerful pain. According to the women, violence is still expressed by their bodies although they separated from their partners some time ago.

But when I was pregnant, I was often very afraid and suffered from a nightmare about him sticking a knife into my stomach, and as a result I had a high pulse rate and woke up with nightmares and felt hysterical. And when I was pregnant I thought a lot about the fact that it must affect the child in some way [cries as she talks] because it was not just in my head, my body reacted to the stress too.

The violence is living in the body is also related to the fact that the foetus is living inside the woman's body. Through their own bodies, the women experienced the bodily movements of the foetus. When the women were exposed to violence, they experienced a change in foetal movements and that the foetus kicked more powerfully: “You can feel the baby's reactions in the stomach. The foetus kicks so hard and you get so hurt. That is … when he has threatened me or been angry. Angry for no reason.”

Losing oneself

Living with violence during pregnancy means that women have to fight against losing themselves. The women said that the relationships began with love. They dreamed of having children and a happy family life, and after a few months, they moved together. According to the women, none of them had experienced violent behaviour on the part of their partners before the relationship was established. The women were humiliated and degraded through neglect, scolding, hurtful remarks about their behaviour and appearance as well as being made a fool of in different ways. Some men checked the mobile phone to monitor who the women had been talking to. It took a while before the women realized the situation they had ended up in. At the beginning, they tried to protest against the violence, but this often led to an increase in the men's anger. Therefore, the women described that they felt it best to avoid confrontation and find alternative ways of reacting, such as withdrawing into themselves, remaining calm, and avoiding provocation. A particularly vulnerable dimension of losing oneself was the women's description of being raped by their partner. They reported that they lost themselves by shrinking, resigning themselves, and becoming paralyzed, eventually leading to exhaustion.

The psychological reactions to his violence became worse and worse and worse every time. Finally, yes, like the last episode, when he would just leave me, and I was down for the count, it took next to nothing.

Moreover, losing oneself involved experiences of difficulties assessing and taking action, making their own decisions and understanding themselves.

I cannot live up to the expectations in society and so many … so many people say ‘But you were not beaten! Why are you so afraid?’ And I can hardly explain it myself, but I can merely say that I am [cries]. I do not think they can imagine what it is like in such a home … trying to avoid the mood swings. And it becomes a prison. And finally, you no longer know who you are.

Women struggled against losing themselves by refusing to describe themselves as victims of violence, although they acknowledged that they had been exposed to it. They believed that victims disregard their own opportunities and power to cope with life, as violence affects self-esteem and makes them incapable of taking action.

Despite exposure to violence and a changed view of themselves, the fight against losing oneself also continued after they had moved away from their partner. The women believed that they still had skills, motivation, and willingness to get on with life. “But now I feel that in the future, I might be better able to see what is good and not good for me.”

Feeling lonely

Being exposed to violence leads to experiences of being isolated and lonely. At the beginning, the women felt flattered when their partners wanted to be with them all the time.

Suddenly it was no longer okay [for me meeting friends]. Sometimes he became angry, which made things very unpleasant, and the anger lasted for a long time, so in order to maintain peace, you break off contact with friends, stop doing social stuff. At the beginning it's nice, because you take it almost like a compliment somehow, that it is more pleasant to be with you.

Eventually, the women experienced increasing feelings of isolation and loneliness, despite the fact that everyone had some contact with other people. Disclosing their experiences to friends was experienced in different ways and made the women ambivalent. If the friends never witnessed the violence and only were aware of the man's good qualities, the women found that they had little understanding. If, however, friends witnessed the violence, they could not understand why the women did not leave. Being exposed to violence can result in a feeling of shame that creates distance to friends. “I'm going to be incredibly lonely after this, I said to X. No one is going to understand why I accept this. And it's very painful. It means that when things are difficult I have nobody.”

The women sometimes found that friends became tired of hearing about their experiences of violence. The women who were still living together with their partners described their desire to share their experiences in order to obtain support but were afraid that this would result in the loss of their friends. They also described a loyalty to their partners and wished for them to become part of their social networks.

Being pregnant leads to change

Pregnancy introduced a hope that the focus would move away from conflicts and violation to a new and exciting change: the couple becoming parents. “I was very, very happy when I discovered I was pregnant, as we wanted children. I would be a strong mum. I've seen my mum just sitting down and crying when things went wrong, I can't do that.” Although the women had positive expectations for the child, other emotions such as anxiety and distance were also present. They were concerned about the child's condition and health as a consequence of the fear and stress to which they were exposed:

I was a little nervous that I would … That it would trigger a premature birth or something. I was really nervous about that. I was especially afraid that my feelings would have a negative effect on the baby. [Laughs a little].

Being exposed to violence during pregnancy was associated with various emotions. The women described the joy and anticipation of becoming a mother, even though they were aware of the responsibility in relation to the life and health of the child. Responsibility for the child led to a sense of inadequacy because the conflicts in the relationship were difficult and demanding.

You do everything to protect your child when you are pregnant, trying to satisfy your partner at the same time, and hope everything will go well. And I found it very tiring, because one thing is at the expense of the other. It was very tough. I had to push myself a lot.

During pregnancy, the women experienced a change in relation to how they thought about their partner as a father and themselves as a couple. Although the needs of the child and the husband compete, the women felt responsible for meeting them and pushed their own needs into the background. Early in the pregnancy, the women hoped that the relationship would continue and that the child would help to move the focus away from the conflicts.

I hope that the negative train of events will end with me. I wish to do better for the family than my ancestors and also be a better mother. I think when the baby comes you automatically take a back seat to some extent, which may be good for us.

The women described how needs changed as their pregnancies progressed. The focus shifted from their partners’ needs to those of the child. Warm feelings for the man were still present, which was underlined by the fact that the child needs two parents and that a stable relationship with several children is the ideal. At the same time, the women stated that the child's need for protection is important, which can force them to make a choice. “At some point I thought I had to choose between him and the child. I still wanted to be with him because of the child and because of … however, things change.”

The decision to leave a man is difficult, because, even if at times he subjects the woman to violence, they are still awaiting a child together. Divorce can bring both relief and sadness. Some women moved to and away from the man several times. Others left their partner during pregnancy or separated shortly after the baby was born.

If something happens, I must be able to go if necessary. I want my child to understand that mum will take care of things and look after him/her. Well, we'll see if I can manage, it's a high goal and not always possible to achieve.

Thoughts and plans for the future were related to whether or not the man was a part of the picture. The desire for change ranged from having a better life together as parents to making custody agreements and avoiding having to deal with the man who exposed her to violence. The ability to protect their children is important in relation to responsibility and making choices as a mother. “I could not risk being shattered time and time again when I have children. I do not want to be destroyed, but I cannot remain in a relationship that makes me unable to take care of my son.” Making choices also means being able to participate, decide, and have control over future changes in their own lives.

Being believed is extremely important as well as having supporters to back you up. And women generally, or at least I, have some questions. If I'm going to place myself in the hands of someone else, I have questions as I really want to have control of the situation.

Discussion

The aim of this study was to explore women's experiences of being exposed to violence from their partner during pregnancy. The results show that the essential structure of the phenomenon is characterized by living with difficult existential choices and ambivalence, both in relations to the women themselves and their relationship with others. Violence during pregnancy means that women's responsibility for their own life becomes visible. These findings can be related to the philosophy of existentialism, as described by Kierkegaard and Sartre. According to Kierkegaard (2000), each human being is important as an individual and he highlights the value of personal choices and commitments. Sartre (1957) emphasized that as human beings we are “condemned to be free,” implying that we cannot avoid making choices.

A result from our study, not found in earlier research, is that violence is living in the body. According to Merleau-Ponty (1994), the body is relational and provides access between people. The human body and consciousness are inseparable and form a whole. Bodily reactions could be an expression of existential anxiety, as well as reflecting personal values, self-image, and complicated choices, manifested in the present study by breathing difficulties, muscle pain, and sensory disturbances. Women experience that their bodies not only react to the ongoing violence but also continue to remember and express it after it has ended. In this way, a person tells his/her story through and not only about the body (Frank, 1995). Other bodily experiences, such as anxiety and depression, may also be stories, which are expressed through the pregnant body. These experiences are initially described as risk factors associated with exposure to violence in pregnancy. Violence living in the body was also exhibited during the interview when women complained of difficulties breathing, waved their arms, and paced back and forth when talking about their experiences.

The women described that exposure to violence, experienced as living in unpredictability, increased their vulnerability and sensitivity, thus their reactions to the violence became stronger over time. Their bodily experiences therefore involve stress and insecurity. The unpredictability of not knowing when or how the violence will take place constitutes a significant part of the burden (Bacchus, Mezey, & Bewley, 2006; Haggerty, Kelly, Hawkins, Pearce, & Kearney, 2001; McCosker et al., 2004).

According to Merleau-Ponty (1994), the human being both is and has a “subjective body.” When the body and personality are linked, language and the body may provide access to the human life-world. In antenatal care, health professionals perform clinical examinations that involve touching women's bodies. This requires sensitivity, as touching the body can remind the women of the violence and arouse feelings of previous bodily experiences. By knowing the different signs of bodily stories related to violence and risk factors, health professional could maybe identify IPV by listening to women's experiences and thereby promote women's health.

Our study shows that, when a woman is exposed to violence during pregnancy, the body expresses her situation, as does the child. During pregnancy, women may pay greater attention to their bodies and to the child's movements (Raphael-Leff, 1991). When the woman begins to feel foetal movements, she might consider her child as an independent individual. How the woman interprets the child's movements indicates her thoughts, feelings, and inner representations of her child (Raphael-Leff, 1991). Along with the development of the foetus and its increasing movement, the women in our study experienced that pregnancy leads to change and that the foetus communicates by means of movement. The women interpreted the hard kicking of the foetus as an expression of alliance, implying that they both react to the violence. At the same time, the women are responsible for the child's health, because they share the same bodily system: they are two bodies in one system (Ravn, 2004). To become a “responsible pregnant” woman could imply taking care of the foetus and protecting it from risk factors caused by lifestyle and the environment (Ravn, 2004). The women in our study expressed worries about whether the stress and violence to which they were exposed could influence the health of the child. In this way, the bodily experiences during pregnancy influenced the thoughts and actions of the women: their responsibilities, choices, and opportunities for change.

According to our findings, existential choices mean that the identities of these women were affected by ambivalence, which can lead to a sense of loneliness and of losing themselves. These emotions have previously been described in relation to living with violence during pregnancy (Edin et al., 2010; McCosker et al., 2004; Renker, 2002; Rose et al., 2010). Women, who have been exposed to violence, experience making choices as a process of ambivalence (Seng et al., 2002). The ambivalence can be understood in different ways and become a challenge in the relationship with other people such as health care professionals. Miller and Rollnick (2002) noted that ambivalence can bind people to problems and may contribute to resistance to treatment, although it can also be a factor that motivates and signals that the client is considering implementing a change. Accordingly, ambivalence can be seen as an opportunity for change, as it is not only a static concept but also involves moving back and forth.

Related to the responsibility of becoming a mother, the women in our study stressed that the child's safety was so important to them that they might consider leaving their partners, i.e., pregnancy leads to change. Pregnancy is a major reason that influences women's actions and choices when they live in a situation where they are exposed to violence (Lutz et al., 2006). Lutz et al. (2006) described the tension between the woman's unborn child and the violent partner as a “double binding,” a conflict in a psychological and social process. One consequence of the double binding is a feeling of living in two separate worlds (Lutz, 2005). Previous research shows that pregnancy can be a stimulus for them to leave a violent partner (Bacchus et al., 2006), although according to Lutz's study (2005), ending a relationship when pregnant is not an option. Women exposed to violence are often ashamed of their situation and fear that people will think negatively about the pregnancy, their decision to become pregnant, and their choice of becoming involved with a violent partner. The founding of a family and plans for the future bind the women to their partners. Leaving one's husband and ending a relationship during pregnancy can therefore be inappropriate (Lutz, 2005; Seng et al., 2002).

Our study reveals that, during pregnancy, the future life of the child is experienced as an opportunity for existential change. For some women, a change consists of hope for a new and better life with their partner and a desire to create a well-functioning family. Another change experienced by women in this study is related to the necessity and responsibility of leaving their partner, due to their wish to protect the child. However, these findings should be related to the fact that the women who participated in this study were supported by a professional organisation. Maybe the change brought about by pregnancy is not as central to women who have no support during this period. The uniqueness of the present study is that women undergoing treatment were interviewed about their experiences. Both the present study, where the women received support from the ATV, and other studies demonstrate that pregnant women want to provide the best possible care for the baby (Lutz et al., 2006), which might indicate a desire for change.

Another important aspect of opportunities for changing the life situation of women living with IVP during pregnancy is the man's experiences, since he is the father of the unborn child. One study (not yet published) in the project, of which the present study forms a part, is about men's experiences in relation to seeking help for violence towards their partners during pregnancy.

The women in this study stated that they looked forward to becoming mothers and that pregnancy leads to change in different ways. One change is that the body becomes more present not only due to physical changes but also in relation to other people. Pregnancy can symbolize a woman's autonomy and independence and gain her more attention from family, friends, and health professionals (Bacchus et al., 2006), which might create possibilities for change through support and help. A caring approach (Dahlberg & Segesten, 2010) in the encounter with pregnant women exposed to violence not only involves physical measurements of biochemical factors but also implies that health care professionals make room for and are willing to focus on the women's context and lifeworld. The relationship should be built on trust and perceived as safe. By means of care based on a woman's own resources and needs, health care professionals can help support pregnant women exposed to IPV, which in turn can better equip such women to relate to and take care of the baby. Health professionals should also have greater awareness of the importance of the woman's context and ask about her social network, thus assisting in identifying and involving people who can become resources.

Methodological considerations

The strength of a qualitative study is the opportunity to enter deeply into a phenomenon, in this study violence during pregnancy. The present study gives an understanding of women's lifeworld, which is the aim of phenomenological research (Dahlberg et al., 2008; Giorgi, 2009). The women's descriptions have not only similarities but also variations. In this way, qualitative methods offer nuanced knowledge of a complex situation. The interview is a meeting between two subjects: the participant and the researcher. Both have their own life-worlds and, during the interview, share the women's experiences and try to gain an understanding, although one cannot fully understand another person. Even though the researcher tries to bridle her own preunderstanding by reflecting and problematizing her natural desire to clarify what is happening in the encounter between the researcher and the world (Dahlberg et al., 2008), the researcher has her own lifeworld and glasses—as a midwife and a mother. This factor might have influenced the results. Being exposed to violence can involve feelings such as guilt and shame, and it is therefore possible that the women held back some aspects of their experiences.

The findings from a qualitative study must be interpreted in relation to context: time and place, a country in Scandinavia, and women who were supported by an organization. The fact that the findings are contextual does not mean that they have no meaning in other contexts but must be interpreted in relation to any new context.

Ethical reflections

The recruitment of the participants for this study was not easy, partly because the study design had to include a system that took care of the participants’ safety and the need for follow up. In this study, the researcher took care of the women by exhibiting an empathic attitude and sensitivity to their needs. If the women showed signs of discomfort and stress, pauses were taken. At the end of the interview, the researcher asked the women about how they experienced the interview situation, their thoughts, and feelings as well as their safety and security in daily life. Several of the women said that they found it positive to share their experiences, both in relation to the fact that someone listened to them and because they gained a new insight into their situation. Several of the women expressed the hope that their experiences would assist other women who are victims of IPV. After the interviews, the women were given an opportunity to participate in follow-up conversations with experts at the ATV.

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.