Negotiating Peril: The Lived Experience of Rural, Low-Income Women Exposed to IPV During Pregnancy and Postpartum

Abstract

This qualitative study of 10 rural women examines their lived experience of intimate partner violence during pregnancy and the first 2 postpartum years. In-depth interviews occurred during pregnancy and 4 times postpartum. A Heideggerian approach revealed “negotiating peril” as the overarching theme; sub-themes were unstable environment, adaptive calibration, primacy of motherhood, and numb acceptance. Some incremental shifts in severity of abusive situations were observed. Results elucidate the ambivalence with which these women view institutions that are designed to help them. Findings highlight factors that may explain why interventions designed to help often do not appear efficacious in facilitating complete termination of an abusive situation.

Introduction

Intimate partner violence (IPV) is a serious public health threat that affects between 25 and 44% of women in the United States in their adult lifetime (Breiding, Black, & Ryan, 2008; Thompson et al., 2006). A study by Martin, Mackie, Kupper, Buescher, and Moracco (2001), using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) of North Carolina (N = 2,648) revealed perinatal IPV prevalence of 6.9% in the 12 months prior to pregnancy, 6.3% during pregnancy, and 3.2% at 3 months postpartum. However, in 2007, a large nationally representative sample from 20 large cities found an increase to 19.8% for IPV during pregnancy and 51.7% for the postpartum period (Charles & Perreira, 2007). Only a few studies have focused on examining the prevalence of IPV in women living in rural areas of the United States.

A study by Bailey and Daugherty (2007) in a rural Appalachian population showed the rate of IPV during pregnancy at 80.8%, highlighting the dramatic scope of the problem in this unique group. It has been reported that social isolation and sheltering the family unit from community involvement, a common practice in rural families, contributes to this increase in domestic violence (Gallup-Black & Weitzman, 2004). Other common contributing stressors noted in rural populations involve increased poverty, especially in families with children, as well as higher rates of drug and alcohol abuse, suicide, mental illness, domestic violence, and infant/maternal mortality (Letvak, 2002).

Although the prevalence of IPV during pregnancy is concerning on a national level, the frequency among the rural population is even more alarming. The definition of rural varies depending on the source; however, the concept has some common characteristics. Generally, rural refers to areas that are at a significant distance from an urban resource, with a small, spread out population (Letvak, 2002). The U.S. Census Bureau definition defines rural as areas outside of an urban area or cluster, and having less than 2,500 residents (Letvak, 2002). Stressors in rural populations that increase the risk for abuse according to Websdale (1995) are attributable to decreased available resources, such as limited employment opportunities, child care, social support, available housing, and public transportation.

IPV During Pregnancy

The safety risks and health consequences of abuse are severe enough for a woman at any time in her life; however, it becomes heightened during pregnancy and the postpartum period as the harm is done to not just one person, but two or more. Violence during pregnancy has also been shown to be more severe than other times in a woman's life, due to an increased risk for homicide (Silverman, Decker, Reed, & Raj, 2006). Some of the major health risks associated with IPV during pregnancy involve preterm labor and premature rupture of membranes (with associated morbidity/mortality to infant), vaginal bleeding, hypertension, extreme nausea and vomiting, diabetes, and kidney and bladder infections (Sharps, Laughon, & Giangrande, 2007; Silverman et al., 2006). Consequences of IPV during pregnancy include low–birth weight infants, which occur in 10% of pregnancies exposed to abuse, adjusting for other factors that contribute to low birth weight (Silverman et al., 2006; Stampfel, Chapman, & Alvarez, 2010). In addition to the physical complications to the pregnancy, many psychological effects of IPV affect pregnancy outcomes, such as depression and posttraumatic stress disorder (PTSD), which are both frequently seen in women experiencing IPV, and negatively affect fetal development (Silverman et al., 2006; Stampfel et al., 2010). Factors associated with PTSD in pregnant women are increased risk for ectopic pregnancy, severe nausea, vomiting, spontaneous abortion, preterm labor, and excessive fetal growth (Stampfel et al., 2010). When confounded by the specific social dynamics of living in a rural community, the risks to mothers, infants, and children are significantly exacerbated.

Rural Considerations

Rural communities have unique characteristics such as isolation, limited diversity, disdain for government, social control and collectivist thinking, valuing religion, distrust for outsiders, and emphasis on traditional patriarchal gender roles (Websdale, 1995). A study by Beard, Tomaska, Earnest, Summerhayes, and Morgan (2009) identified various factors at the individual and neighborhood levels that interact to influence health in rural communities. Although socioeconomic disadvantage was identified as one of the biggest influences on health, high levels of social cohesion and collective efficacy often found in rural communities were also seen as important contributors to health (Beard et al., 2009). Another way of maintaining health in rural communities is through resilience. According to Leipert and Reutter (2005), hardiness, defined as women's increased confidence and perseverance, develops in rural communities as a result of their geographical challenges.

Facets of relationship patterns and stressors that affect rural, low-income women play a significant role in their responses to IPV and its effects on their lives. A historical study examining isolation by Fink (1992) cites how isolation of farm women in the 1800s left them even more vulnerable when dealing with an abusive partner. Networks of family and friends can either be a support or a stressor, depending on the relationship and interdependence of those relationships. Rural communities tend to have very close family ties and often prefer to handle issues internally rather than seek outside help (Letvak, 2002). Keeping problems in the family discourages the use of available community resources such as medical, social services, violence shelter, or mental health care.

Social support for rural residents is found in relationships with family and friends, local community or religious affiliated services, and fee for service agencies. Rural inhabitants generally prefer the former two types of support more so than the latter (Letvak, 2002). Family and friend support with this population is typified by close and frequent contact, emotional devotion among participants, and frequent help with daily issues (Kohler, Anderson, Oravecz, & Braun, 2004). As a result of close rural support networks, resilience can emerge and play an important role in women's health and well-being (Harvey, 2007). Even with all the apparent support systems available, there are other factors that influence how support is administered and recognized.

Despite what may appear to be a reasonable network of support for women experiencing IPV, there are obstacles inherent in such a network. According to Letvak (2002), the best predictor of whether or not support is effective or beneficial is not the amount available but the woman's belief of support based on the actions of others, that is, her feeling of being supported. Other obstacles include confidentiality issues and the patriarchal nature of rural existence. Although it can be helpful to have a close network, many women may be hesitant to disclose problems to others for fear that their problems will be discussed with others within the community. With disclosure comes fear of the abuse being reported to child protective services, resulting in the child(ren) being removed from the abusive home. As a result, the network of family, friends, and resources that a woman relies on may actually be less supportive and place blame on the woman for her situation (Bosch & Bergen, 2006). Hence, it is not surprising that Taillieu and Brownridge (2010) found that women experiencing IPV during pregnancy are often less likely to receive support from social networks than non-abused pregnant women.

Theory

A phenomenological approach was used to understand the lived experience of low-income, pregnant, or newly postpartum women exposed to IPV in rural settings. Heidegger's (1999) phenomenology seeks to make connections with experiences rather than picking apart lived experiences and describing the components of them (Beistegui, 2003). Bridging the gap between the empirical or scientific realm and the less tangible human experience of the world allows for the explanation of phenomenon (that which appears or presents itself to a person), as it is experienced by individuals within their unique position in the world (Hammond, Howarth, & Keat, 1991). It examines how individuals are engaged in the world and how actions only have meaning within the context of a person's involvements with others (Polt, 2005). There were two guiding principles for this analysis. First, a Heideggerian (1999) approach toward qualitative data, which acknowledges a person's unique place in the world, not only in society and physical location, but temporally as well. And also four facets of “phenomenological reflection: temporality (lived time), spatiality (lived space), corporeality (lived body), and relationality or communality (lived human relation)” (Morse & Richards, 2002, p. 49).

Standpoint theoretical perspective (McClish & Bacon, 2002) considers that a person's experience and epistemology is dependent on their social position and power relationships. Therefore, the group that a person belongs to, their experiences, and the social and political power they exert greatly affect their perception of the events around them, making their lived experience unique to their standpoint. The basis of standpoint theory is that one cannot be completely objective or neutral when interpreting events or experiences, whether as a scientist studying a phenomenon, or a person experiencing life events (Adler & Jermier, 2005). This perspective also helped to inform the interpretation and analysis of the lived experiences of the women in this study by considering their unique location as a group of rural, low-income women experiencing IPV. Considering the position and power structure these low-income, abused women in a rural setting occupied was critical to fully comprehending how they met and responded to the challenges of their situation. Attention to both the intersection of multiple factors that influence these women's lives and the aforementioned aspects of phenomenological analysis revealed a multifaceted understanding of the true lived experience of abused women in a rural, low-income situation.

Method

The parent study for this qualitative analysis was the Domestic Violence Home Visitation (DOVE) Study; a large, multi-state, mixed-methods randomized controlled trial (RCT; R01 NR009093) that evaluated the effectiveness of home visit interventions with rural, low-income women who were victims of IPV during pregnancy and postpartum. Only low-income women receiving publicly funded prenatal care were eligible to participate in the perinatal home-visiting program from which these women were recruited.

Of the 239 women who participated in the original RCT, 147 were from the Midwest. Both quantitative and qualitative data were gathered at baseline, then at 3, 6, 12, and 24 months postpartum (quantitative data were also collected at 18 months). The qualitative data collected from 52 Midwestern women used a semi-structured interview guide. A subsample of the most geographically rural women who had completed all six interviews was purposively selected for this analysis. This sample included 10 women (age range = 16-32 years); seven had their GED (General Educational Development) or high school diploma, and half the women had at least some college education. Three were married at the time of data collection, although one was separated from her spouse, and the rest were single or divorced. Two thirds of the sample were Caucasian, a third were African American or Hispanic. At baseline, two thirds of the women were pregnant for the first time; the remainder had one to three children. Most of these women were unemployed, although two were working part time. Their baseline Edinburgh Postpartum Depression Scale (EPDS) scores ranged from 4-25. Seven of the 10 women scored 13 or higher, the level that indicates risk for depression (Schaper, Rooney, Kay, & Silva, 1994).

Analysis

Thematic analyses were done through an iterative process that involved reading and rereading the multiple interview transcripts from baseline during pregnancy through 24 months postpartum for the 10 participants while identifying emergent and re-emerging themes. Codes and themes were developed starting with data reduction that includes deciding which data to focus on and place into segments for coding (Miles & Huberman, 1994). Analysis of coded data produced meaning and conclusions (Cobb & Hagemaster, 1987) through convergence (those things that fit together) and subsuming these ideas into descriptive categories (Patton, 2002) that further evolved into themes.

The thematic analysis was done by four members of the research team who initially listened to the interview audiotapes to develop familiarity with the data and then coded the transcripts. A word document template was developed and used to consistently code and organize the data at each data point and later revised to also include emerging themes over time. The broader codes of environment, abuse, parenting, and integrity, each contained sets of related sub-codes, were selected based on their prominent appearance in the preliminary review of two sets of interviews across all time points. During the analysis process, multiple checks and rechecks for consistency of coded data were performed. Discussions took place regarding emergent themes that resulted in the identification of preliminary themes. These emerging themes were compared within and between each other to establish trustworthiness and ensure saturation leading to the crystallization of the themes. This process generated the overarching theme of negotiating peril from which the sub-themes of unstable environment, purposive calibration, primacy of motherhood, and numb acceptance evolved.

Results

The overarching theme of “negotiating peril” is indicative of the peril stemming from instability in the internal and external environment of the women as they face struggles with personal autonomy, substance use and mental health within the context of tenuous family relationships, and job, housing, and food insecurity, all amid pervasive and structural violence. These women use purposive calibration, one of the four emergent sub-themes that reflect frequent decision making to ensure the safety and survival of themselves and their children, while ultimately inhibiting complete escape from abusive environments. Their maternal role sustains them, becoming a primary source of intimacy, self-empowerment and validation of their self-worth, and providing motivation to continually negotiate the peril in their lives. Throughout, the women exhibit numb acceptance of the peril that becomes apparent as a powerlessness to change their circumstances.

Negotiating Peril

The peril that these women negotiate in their lives is multi-layered. These women are often simultaneously negotiating true peril in the reality of their day-to-day lives while trying to navigate their quest for an ideal life. It is the duality of the internal and external states of constant peril that appear to have shaped these women's responses to the presence of violence in their lives. From early childhood exposure to violence and their current abusive situation, their problem-solving strategies and responses to abusive behavior suggest that the state or atmosphere in which they live is not only perilous but also requires continual negotiation to survive. In their day-to-day existence, these women experience danger and difficulty as they navigate abusive situations and relationships.

This peril translates into an emotional experience that involves inner conflict and tensions for these women. One of the most evident tensions is between their stance on fear and being afraid. The women present themselves as tough and appear to have an unrealistic interpretation of the danger around them, as being less threatening than it would appear to an outsider. One young woman tells the interviewer that she has never been physically abused but goes on to describe her boyfriend stabbing her with a pencil:

And I got mad and I picked a chair up and tried to hit him with a chair. And it turned in, it turned into from him stabbing me, me pushing him into, you know, an object, and then him trying, we're trying to hit each other with chairs.

Later, she lists warning signs other women should know might lead to abuse: “red flags was the verbal, the shoving, pushing, kicking, biting, just the little things, name calling, starts off” the violence. This disconnection between reality and their perception of danger also permeates their lives. Simply, these women are living in a state of fear and accept this as an ordinary way of being in the world. This was captured by a participant who states, “I'm not trying to make it better, I'm just trying to figure out a way to keep it under control.”

Still, there were some women who were aware that they were living in situations that could become life-threatening at a moment's notice and therefore found various ways to navigate through the unpredictability of such a tenuous situation. In one case, a woman living with her abusive truck-driving partner in his truck describes having to escape from him at a truck stop:

I saw a rest area coming up and I said ok, now's the time to get out and I said that I needed to go to the bathroom . . . so I got out, he got out and I ran into the bathroom and locked myself in one of the stalls and he kept calling on the cell phone and I wouldn't pick up and I finally picked up and said I'm done, I can't do this anymore.

Over time, the women have come to accept the unpredictability and lack of control of the situation. As they describe how their relationship could become life-threatening, the women paradoxically grasp for ideals within the relationship that contradict the stark reality of their circumstances. A teen mom spoke of her hopes that when she finishes school, she, the baby, and her baby's father would become a family, and then things would be better. A year later, the same teen conveyed the following:

I was afraid he'd leave me and I was in love with him . . . and I knew there was something there from him, too, but he just, it was already gone and too late, and I didn't really want to face that it was too late, our relationship was gone really. I was trying to cling and hold onto it.

The ability to continually navigate perilous circumstances is fueled by unrealistic expectations and ideals of the family life that a woman envisions. Navigating peril in her relationship is a balancing act of protecting her child(ren) and maintaining harmony with her partner. Although there is awareness and a certain level of denial of the danger to herself and her children, the women appear to be operating in synch with the cycle of abuse. The desire for family unity often coincides with the honeymoon stage when circumstances are good, but they simultaneously plan and prepare for the dangers of the battering stage.

Unstable Environment

The real-life situations described by the women in this sample constitute environments in which their ability to secure basic human needs such as shelter, food, affection, and validation is constantly threatened. Many of these threats stem from the abusive situation itself and are often compounded by multiple vulnerabilities such as housing, transportation, employment instability; low and limited income levels; and minimal social supports that these very vulnerable women frequently face. When combined with abusive histories and the consequences of such, it is understandable how together these obstacles seriously encumber a woman's ability and capacity to set and follow through with life goals and maintain responsibilities as well as impede the achievement of their dreams.

The context of these women's lives is also marked by mental health challenges, substance use, emotional and economic lability, and an inadequate support system. These challenges occur within a constantly changing, unstable reality that is reified by their abusive partner, tenuous family relationships, and the broader system at large. As a result, the women experience serious threats to their already compromised physical, psychological, and emotional integrity. Their stories indicate that long before the current pregnancy and current abusive relationships, they were surviving in unstable environments often laden with a history of cumulative trauma and resulting PTSD; all an existing source of peril in their lives. The instability described by the women, similar to the overarching theme of negotiating peril, exists in both their external and internal environments.

External environment

Several patterns were identified in the women's external environment such as financial and housing instability, food insecurity, fluctuating employment, ubiquitous violence, and structural violence. Financial instability was evident in these women who were at best, living paycheck to paycheck, whereas others were underemployed or dependent on public assistance to survive. As a result, women made decisions about their lives that were driven or directly influenced by their lack of finances to sustain their lives, as related by a participant when asked about stressors:

. . . Like finances, I guess, are the biggest problem right now, and sometimes I almost want to go back with him just so I have help with finances, but I just know everything will work out in the end, and I just don't look at the big picture and just handle each bill as it comes in and budget as much as I can, and we've made it work, you know.

Another woman spoke of needing to maintain her relationship with her abusive partner to meet babysitting needs that she could not have otherwise met, even with help from social safety nets or her family.

I wanted to know if they [DFS] could help me with my babysitting. ’Cause if I got rid of him and didn't have a babysitter, I can't rely them on my parents. It's not my parents’ responsibility. I asked for help, and “Well, Mrs. W, you make a lot of money. You make around $2,000 a month.” You're damn right, without taxes. Okay, well that's not what I bring home. I bring maybe 14, 15 hundred dollars home a month and it's all gone ’cause my bills . . . you just don't have any money.

In the midst of financial challenges, it is not surprising that the majority of these women also struggled to sustain stable housing. During the 2½ years of the study, most women moved from their original place of residence multiple times. Several of the women were living somewhere different at each of the five interview time points. One of the participants spoke of having to move to another home before the next scheduled interview explaining that her new home is “a three-bedroom house and its 50 dollars cheaper a month.”

Confounding the women's precarious financial circumstances is the issue of transportation. This posed significantly more difficulties in rural communities that have very little, if any, public transportation alternatives. Not having transportation affects several aspects of women's lives. According to one participant, transportation created a barrier in her ability to not only attend appointments but also resulted in a cascade of events that affected her child's ability to obtain health care support.

I wasn't being taken to my appointments, so I had to scrounge for my rides to get to appointments. I had to find my own way to do everything because they [her mom and dad] were too busy. One day I took him to Medic, to try to apply for Medicaid, and they told me I needed to come back with footprints and I needed to come back with their pay stubs . . . they [her parents] agreed to take me and I told them all week just to remind them, and then when that time came around, that same day, I said “Remember, I go to DFS today and I need to have the pay stubs.” Nobody took me that day . . . two weeks after that I got a notice saying they denied his Medicaid because the requested verification wasn't provided, which was the pay stubs and the footprints. And I tried to call and reschedule . . . the lady wouldn't call me back.

Reliable employment that provided benefits and steady hours eluded most of these women. Most of the women were unskilled or had limited earning potential. They often managed multiple issues, including substance abuse, mental illness, unreliable child care, and transportation, making it difficult for the women to maintain steady employment. In addition to their own employment difficulties, the women also reported partner unemployment, experiencing recurring interrupted employment, or the perilous situation in general being disruptive to their partner's employment in some way:

He didn't lose his job yet. He switched jobs from working for his cousin to a roofing company. The roofing company shut down so he had no job for a while. I quit KFC where I was working at. I started babysitting full-time for my aunt down the road, and then I had to stop babysitting for her because he had gotten to the point to where he was breaking things in the house with the kids in the house because he was mad at me over things.

Internal environment

The internal dynamics of the abusive relationships detailed by the women are complex and involve many dimensions that affect and/or threaten her emotional, physical, or psychological safety. One such factor is the substance use that was endemic in their environment. Some women spoke of escalating violence when their abusive partner drinks. One woman states, “He's very violent when he's drunk and he likes to drink.” In the midst of this volatility, the woman's family dynamics become clouded by family members not wanting to support the woman, either as a result of being with the abusive partner or pre-existing issues of family dysfunction. “I haven't had that much help from my parents since I've been out on my own,” stated one participant. These relationships with family and friends are strained to the point that the woman no longer socializes with her friends and limits the extent of what she discloses to her family.

At times, women expressed anger about their circumstances and the impact that the abusive relationship has on their overall emotional well-being. One participant stated, “I wish I'd never met my son's dad at all. I wish I never met him” and that the abusive relationship she had made it hard for her to trust people:

I have trouble trusting people anyway; so that [the abuse] makes it even harder . . . I have a really hard time trusting people. I'm very secretive. I don't like letting people know, you know, nothing about me really. It takes me a long time to get comfortable around people, and it's just made it worse.

The participants experienced a cascade of emotions ranging from anger, to resentment, and to feeling diminished as described:

I hate him. Why did I get myself into this? What do I do to keep the kids out from this type treatment, you know. Why is God punishing me? Why do I need this? . . . I was mad at the world, and I was mad at myself . . . so really . . . you can't be angry at everybody else. You done it. You slept with him. Not anybody else. They didn't force me to lay down with him . . . take responsibility for your actions. If you choose not to, then you suffer.

Psychologically as the abuse took its toll, one woman found that she struggled to restrain herself by not resorting to physical violence when provoked.

I try not to like lose control of myself ’cause I don't want to stress myself out, at least not at this point with me being pregnant. It's very unhealthy, and I used to be very physical. Now I'm not physical anymore. I'm more verbal.

Another described how the abuse affected her sense of self and self-worth: “Well, you always feel hurt. You always feel disgusted when somebody degrades you. I mean, being put down and being pushed around and stuff makes you feel weak. It makes you feel like you're very vulnerable.”

Still, although living with such internal struggles, the women were resourceful in coping with the abuse and found ways to create personal agency. Whether choosing how to respond to the abuse, that is, fighting back, yelling, not engaging, or finding ways to take care of their children in the midst of the turmoil, the women did seem to demonstrate their agency:

I never want my kids to experience, I have two daughters, never want them to experience, what I have been through. So if I don't stick up for myself and show them that you don't deserve this, that females don't deserve it . . . when they get older and they get beat up by their husbands . . . but I won't take it.

Ironically, some of the women felt they could control the abuse either through controlling themselves or by not overtly exposing the children to the abuse:

I try not to like lose control of myself ’cause I don't want to stress myself out, at least not at this point with me being pregnant. It's very unhealthy, and I used to be very physical. Now I'm not physical anymore. I'm more verbal.

And another woman shared,

If I can control it (the abuse), then it's fine. If, I have to be a strong enough woman to say “No, I'm not dealing with it no more.” And my personal opinion is, is it's not around my kids. It may be towards me, but it's not around my children, you know.

According to the women, if their children were not directly around the abuse, they were somehow not exposed or affected. This seemed to provide a level of comfort to the women in that even though they were staying in the abusive relationship, the children remained relatively uninvolved.

As we followed these women over time, there did not appear to be any substantive or long-lasting change in the stability of their day-to-day lives. Furthermore, women's ability to navigate the peril in their lives was often sabotaged by the internal and/or external circumstances in their environment. Small changes or attempts to establish a more positive environment were not enough to overcome the pervasive and multi-dimensional instability and disruption in their lives. Disruption in the lives of the women often resulted from exposure to violence on multiple levels that takes the form of ubiquitous violence.

Ubiquitous violence

Several of the women spoke about domestic violence as a norm in their communities and that many of them had experienced or were aware of physical and psychological abuse that occurred within their childhood homes. The presence of substance abuse and mental illness either in their families of origin, or in the neighborhoods they lived in, influenced how the women perceived the role of civility in human relations. One woman spoke of her own mother who had experienced abuse in childhood and subsequently committed suicide in adulthood while she was a young girl. This woman recalls visiting her “tin shack home” with no doors, no indoor plumbing that was “pretty nasty.” Another woman shared that her small rural community had “a lot of abuse” where “a lot of people who drink, especially men, are really angry drinkers” who when they “get mad, they get really ugly.” This participant continued by stating that those drinkers “keep going” and that eventually someone will say “something wrong and then there's a fight.”

Multiple women routinely witnessed violent relationships between their parents. One participant stated that she used to see “my mom get beat up by my dad all the time when my dad used to drink.” Another woman spoke of her dad as being “very abusive and having a quick temper.” Prior family histories of abuse exposure and/or personal past abusive relationships were pervasive. As a result of the ubiquitous exposure to violence, women tended to speak about violence with a stark normalcy that was unsettling, yet frank.

Confounding this were the experiences of perceived structural violence expressed by the women. The women reported having very little confidence in “authorities” such as police, social services, and DHS as reliable support resources that they think should be protecting and serving without constraints or judgment. On the contrary, these systems are seen to be more involved in documenting infractions and monitoring the short-term peace punitively, rather than successfully promoting healthy community or family life. For example, child protective service agencies may be envisioned as “experts” in family services, but our participants perceived them as threats who are more accurately understood and characterized by the women as judgmental state enforcers rather than working for families. This potential threat evoked fear of judgment or apprehension of children that resulted in women concealing ongoing abuse in their homes.

You don't want to tell people what's going on inside your home. You don't want people to know, and it's just, you feel like, I don't know. I always felt like it was somehow a reflection on me and people would judge me, you know; and I knew it sounded bad when you said “Oh, I still love him,” you know, “He did this and this, but I still love him,” you know? And I just didn't want to be judged or criticized or anything like that.

Similarly, another woman remarked,

We try to keep our business out of the streets, ’cause that's all we need is someone to label that he beats me or that we have domestic violence going on, and my kids would be gone. And it doesn't even happen around my kids. So, I mean, there's arguments when my kids aren't here, you know. . . . If one person found out that you have domestic with your husband, then they're like “Oh, well, better call DFS,” you know. Here goes hotline central. I don't want that in my life and I'm not going to deal with it. That's the reason we keep our business under wraps.

Given this ongoing perception of threat of exposure to the patriarchal and sexist “system” and its consequences, it is not surprising that these systems are not trusted and can, according to Barnett (2000), contribute to the perception that external resources are not reliable.

Purposive Calibration

In our study, it became evident that, as noted in previous work (Kulkarni, Bell, & Wylie, 2010; Okun, 1986), leaving the abusive situation and getting out is not seen as a conceivable option. These women were living in a state of constant adaptation for survival within abusive relationships. As they would try to control the abusive behaviors within their relationships, the women would often define and redefine what is “normal” in a quest to achieve equilibrium. This was seen in their true coping behaviors as opposed to what they revealed to others.

From living in tumultuous environments, these women develop sensitivity to their context and, over time, develop the ability to modify their behaviors and plans to match the current state of their environment and the needs of their children. The women are highly responsive to volatile situations in efforts to maximize their chances of survival and thriving. When they move for the third time in 6 weeks, or drive to the local convenience store in a car that is not legally registered in order to purchase food for their children to eat, or leave their children with a substance abusing partner so that they can go to work; these are carefully calculated choices that in that moment, appear to best meet the family's survival needs. From the outside, it may appear dysfunctional, but in the midst of the afore-described unstable environment, this purposive calibration actually provides stability. Juggling their behaviors, submissive sometimes and controlling during other times, creates ballast in their lives and keeps them from sinking.

As new mothers, these women all have limited time and energy. They must engender trade-offs to care for their children. Unlike women in more resource-rich environments, the timing of their decisions and behavior may not be optimal for long-term resource acquisition, but there is awareness that the current affairs, although potentially dangerous, could get worse. In some cases, the women expressed fear of things “escalating into something worse” and how they made adjustments in the midst of an unsafe situation or in anticipating an unsafe situation to protect themselves.

I never felt really unsafe with him, so I haven't ever tried anything to keep myself safe. When he gets mad, I take a few steps back if I know that he's gonna, like the chair incident. I seen him pick that chair up and I said “Okay,” and moved back a little bit. . . . He didn't throw it at me. He threw it away from me, threw it in the middle of the floor. So I just try to make sure when I know he's gonna get mad about something and take it out on an object, get as far away back as you can.

And from another woman,

I just avoided him when he was high or drunk and tried to keep my distance, and when I did see him I made sure not to press any of the things I thought would be triggers and just kind of agreed even though I wasn't agreeing. I never voiced my opinion.

Women remained in the midst of the internally and externally unstable environments until they chose to deal with it. Most often, the impetus for dealing with, or planning to end, the abusive situation was to protect the children; this emerged as the theme of primacy of motherhood.

Primacy of Motherhood

The primacy of motherhood was evident in the hypervigilance that the women displayed toward their children by “protecting” the children and doing their best to preserve the integrity of their mothering role. Throughout the various interview time points, women spoke of maternal behaviors they engage in that they believe would shield their children from the abusive relationship. This shielding is considered protective and was reflected in the effort made and careful attention to either not to allow the abuse to occur in the presence of her children or, in one case, to devise an escape plan for her children should the situation escalate beyond her control.

Contradictory to these great efforts to protect her children, most women believe in the value of the father's role in the child's life, often prompting her to pursue a relationship with him despite his abusive behavior. As mothers, they are seeking their ideal “perfect family”—a mother, father, and children together under one roof:

You try; you try to make everybody believe like everything's okay. You want to paint this pretty picture of this white picket fence that you live in and, you know, you've got 2.5 kids and a nice vehicle in the driveway. You live in a nice home, and things just don't work out that way. It's not that American life. We all have spits and spats, spatters; we have problems. So, that's what we deal with.

Although simultaneously trying to maintain this ideal of the perfect family in the context of abuse, the women say they want to raise children differently and hence, pregnancy often becomes a catalyst for seeking resources or protection. Historically, in rural communities, the family unit was essential to sustaining the day-to-day life of the family and familial networks. As a result, marriage and family continue to be deeply rooted values evident in rural communities today. According to Fink (1992), whose book reflects on rural farm life in Nebraska in the 1800s, “Even a bad marriage should be preserved” (p. 83). Therefore, even if the horror of abuse crept into the relationship, the woman was to work harder to fix the problem and to deserve the love of her partner. These values present in the 1800s, and to some extent today, paint a picture of marriage in rural America being sustained at all costs.

In keeping with the notion of a perfect family, women equated their ability to preserve the family with being a good mother, in spite of the abuse she would endure. Being a good mother and continuing to take care of the children was important to the women. “I just wanted, I want the happy family with the mom and dad and the kids, and I just want that, I guess that idea, but I was trying to make anything work.” Another woman declared,

I want to be a mother. I love being a mother. It's the most beautiful thing you can possibly have in your whole entire life is being a mother. And it's very important for me to be a very good mother, and I'm being the best I can.

And a third subject said,

I want him [my son] to know I'm not going anywhere at all, that I always will love him, and I'm always here for him, that I'll be doing anything for him . . . I don't want him to feel that he has nobody like I did . . . I don't want him to be with someone he doesn't know. I don't want my son going through any of that at all. That's what I want for my kid, to be a good mom, and to take care of him like I need to.

Trying to be a good mom by taking care of the needs of the children often meant that the mother would find ways to protect her children, thus, developing a numb acceptance regarding the reality of her abusive situation.

Numb Acceptance

Even as the women described some extremely dangerous and life-threatening conditions, they did so in a “matter of fact” manner that almost appeared to minimize the level of danger they faced. Fear was not at the forefront as they recounted their lived experiences. As they adapted to their situations, fear became second nature as the women accepted it as inevitable and commonplace in their lives. In trying to navigate their abusive circumstances, the women exhibited what could be viewed as a protective front. This front was made visible both in their stories of trying to shelter their children from the magnitude of the situation and in the descriptions of violent experiences they shared across the interview time points.

One woman's description of equipping her children with a secret cell phone to call 911 in case “something was to happen” is an example of this protective aspect of numb acceptance. She acknowledges through her contingency planning that given the history of abuse in the relationship, the potential for harm is very real. On one hand, this woman indicates that she can get her kids out before she would be terribly injured, “If we’re fighting really that bad, my parents will come get the kids. Or I'll take them over there. I'm not too worried about myself, as long as this stuff doesn't happen around my kids.” But later in the interviews, she frankly confesses her circumstances, describing her lived reality in which her husband could very well kill her:

’cause like I told my husband before, “if I don't leave I know you'll end up killing me before then.” And he's like “I'd never kill you. I'd never hurt you like that.” But you do every time you put your hands on me. You never know if you're gonna hit somebody in the head and kill them. You never know.

Another woman demonstrates this numb recognition of her life circumstance when referring to her ex-parte protection order: “I mean that is just a piece of paper, if he is going to come here, he is going to come here, whether I have the paper or not. So, I don't know what to say about that.” It appeared as though the women felt that the abuse and its outcome were inevitable.

Accepting the abuse as inevitable and constantly presenting a protective front for the children drained and affected the women in various ways.

Because after I had the baby I realized that was, I wasn't going to be pushed around anymore. I wasn't pregnant no more. If he was gonna hit me, we were gonna duke it out. I was tired of being pushed on. I was tired of being talked to stupidly. I was tired of being disrespected. You could do it to me while I was pregnant, but you ain't gonna do it to me now. ’Cause I'll fight you back. I ain't got a baby in my tummy.

The psychological effects of abuse on the woman have been well documented in the literature (Campbell, 2002; Golding, 1999; Tjaden & Thoennes, 2000; Tomasulo & McNamara, 2007). Consistent with the literature, these women also displayed compromised integrity related to self-esteem and self-worth. One woman admitted, “Mentally it's tore me down. I'm not the same person, but I would have to say that I'm not the strong . . . I'm not the same person. I'm not the weak person that I used to be.” She is aware of the effect that the abuse has had on her over the years and is able to candidly provide insight for others to understand the impact that it has on their self-esteem and overall feeling about themselves.

A lot of women do feel like they're deprived when they go through a situation like this . . . But a person, an abuser could knock a person down so much—that they feel like they're nothing. Like that's how I felt. I was nothing. I had no self-respect, no dignity, no pride. I had nothing. I mean, when it came to fixing my hair, changing my clothes, putting on my make-up, oh, I'd still get up, but I wouldn't fix myself up. I wouldn't look pretty, and when a woman stops acting and feeling like they're pretty then it takes a toll on them as well. So, that's what abusers have to do. They knock you down so much that they feel, you feel like you have nowhere else to go. You have to stay with them. They're the only ones that love you and the only ones that care. And an abuser will knock you down and hit you and punch you and kick you and call you a bunch of names. Five minutes later it'll be like “Oh, I love you. I'm so sorry.”

It is not surprising that this woman not only stated that she hated her abuser but asked “why did I get myself into this? What do I do to keep the kids out from this type treatment, you know. Why is God punishing me? Why do I need this?” that led to her feeling as though in that moment of being angry she would “kill herself.”

Another woman spoke of not being able to eat due to the stress of the abuse, and as a result, she describes herself as being constantly angry, sad, very clingy, and “needy and stuff and just annoying.”

Discussion

This study explored the experience of women experiencing IPV during pregnancy and the first 2 years postpartum. The prevalence of IPV during pregnancy and the postpartum period fluctuated over the years of this study for the participants and was dependent on the source. Still, our results highlight several of the factors that may explain why interventions designed to help women living with IPV often do not appear to effectively help women leave their situation. The women view the resources designed to help them with ambivalence and contend with generational legacies of abuse that exacerbate their feelings of disenfranchisement with the resources and the broader system. Their interactions with this broader system illuminate perceived experiences of structural violence, referring to the systemic and social inequity and constraining of agency that marginalizes and preys on vulnerability (Farmer, 2004; Kohrt & Worthman, 2009). In addition, their accounts also demonstrate how histories of cumulative trauma and patterns of abuse across generations, coupled with an abusive partner contribute to a life trajectory that often leaves little chance of successful escape. This reality was shown to contribute to numb acceptance of unfulfilling adult relationships void of intimacy and full of peril. Hence, motherhood became the one role in which these women seek and find fulfillment in their intimacy needs, sense of worth, and mission in life. Investing and re-investing in motherhood kept the women in unstable environments and inadvertently bound up in relationships that are not mutually supportive, loving, adult partnerships. Resources in these women's environments are scarce, and the distribution of limited resources is unpredictable. Psychologists have previously examined the role of stability in the environment on the development of resilience and self-regulation (e.g., Sandler, 2001; Weems et al., 2007). Sandler (2001) suggests that when the social context produces a negative sense of self, this leads to negative affect and distress. This was clearly illustrated by the participants in this study.

Many of the life situations described by these women are viewed clinically as highly dysfunctional. In their classic theoretical description of socialization in stressful versus supportive environments, Belsky, Steinberg, and Draper (1991) describe how more highly risk-filled environments encouraged a propensity toward unstable adult relationships and reduced investment in offspring. This traditional viewpoint that environment shapes relationships, attributes dysfunctional social behavior to harsh, socially chaotic family systems. However, it disregards the possibility that there is some benefit to the behavior choices made by people living under stressful conditions. Our study finding reveals that many of these perceived “dysfunctional” behaviors of purposive calibration provide women short-term advantages over the alternatives. According to Ellis and Bjorklund (2012), being raised in a chaotic and stressful environment leads one to develop strategies that are purposive under chaotic and stressful conditions, notwithstanding the potential long-term consequences. These developmental psychologists point to self-regulation behaviors ranging from aggression to reproductive strategy as moldable by the environment in ways that promote an individual's survival. To adapt to the limited resources available to them, the women enact strategies that allow them to continue to exist in abusive circumstance but prevent their escape; contrary to what observers expect the woman to do. Successful negotiation of peril may not look fully functional from the outside. However, one of the strengths of the DOVE Intervention is to listen without judging. This non-judgmental approach recognizes that a woman's purposive calibrations fulfill her commitments to keep her children safe, healthy, and relatively happy.

In contrast to much of the literature regarding the lived experience of motherhood that describes a tremendous conflict that many women feel in assuming the motherhood role and a concomitant loss of personal autonomy (Jacobs & Mollborn, 2012; Sorbo, Beveridge, & Drapeau, 2009; Weaver & Ussher, 1997), the women in this study did not feel that motherhood took anything away from their personhood. In fact, the sentiments expressed by women in this cohort mirrored the thoughts of African American teen mothers interviewed by Kaplan (1997) who use motherhood as a means to meet emotional and spiritual needs that are not fulfilled by other relationships in their otherwise social-intimacy impoverished environments. Motherhood provides the meaning and motivation for these women to keep going, in spite of great challenges in their lives.

Over time, the women experienced a numb acceptance of their life circumstance, even as some of them made relationship changes choosing slightly less violent partners. Emotional numbing is a defining feature of PTSD (Litz & Gray, 2002) and is also a trait noted in populations living in war zones (Green, 1994). In PTSD literature, this numbing has traditionally been viewed as a type of avoidance response, in which the PTSD survivor tries to minimize their exposure to reminders of the trauma. However, in our cadre of women, whose environments sometimes resemble war zones, the exposure to the violence is ongoing and is a constant reminder of their trauma that eventually seems unavoidable.

This repeated exposure desensitizes them to the surrounding peril. Seemingly the women train themselves not to react to the violence, subsequently ignoring or doubting their own perceptions of reality and creating a fragile integrity seen as numb acceptance (Green, 1994). The women appear to reflexively move through their lives, feeling powerless to change their circumstances. They have accepted the threats to their physical and emotional security as part of their daily lives.

Past undisclosed history of abuse was evident, and, indeed, several women in this study, when interviewed at the 12- or 24-month time period, disclosed previously unrevealed violence that had been occurring at earlier time points in the study. Disclosure of abuse to health care professionals and other authority figures draws attention to these perilous situations in ways that may, from the perspective of these women, be harmful. For instance, raising an alarm can agitate the perpetrator or perhaps jeopardize custody of her children, threatening the primacy she gives to her motherhood role and ultimately her already very fragile identity.

Conclusion and Implications for Practice and Research

These findings suggest that rural women who experience IPV during pregnancy and the early postpartum years survive in very complex and perilous circumstances from which they cannot easily escape and that cannot easily be changed. The violence in their lives is ubiquitous and structural. It may be that the potential for most significant impact in this population involves re-sensitizing abused women to the level of abuse they are experiencing. If their understanding of normal could be deconstructed, this might help decrease women's false sense of safety and make the danger stemming from the violence in their lives much more visible and thus, less likely to be numbly accepted.

Health care providers who believe that interventions for women experiencing IPV are only successful if they help the woman leave the relationship and never return do themselves and their patients a disservice. The woman's choice not to leave the abusive relationship should be understood as potential rational solution by the woman as a way of negotiating the visible and invisible complexities of her situation. This study describes incremental changes that occurred in abused women's lives over the course of pregnancy and the early postpartum while they were receiving services from a nurse home visiting program. As they negotiated challenging and often unsafe environments over time, women described how their life histories were filled with, and surrounded by, violence and social dysfunction.

Yet, this environmental instability was normal for these women. They negotiated the peril in their lives for the sake of their children, and to survive, by making calculated judgments about the best options available to them at any given time, to provide for and care for their children. As they made these choices, they accepted the level of threat in their lives as inevitable. The nurse researchers and home visitors came into these women's lives offering information, identifying many of their environmental, behavioral, and communication tenets as unhealthy, including common behaviors that were labeled “red flags” and/or part of a cycle of violence.

For some women, being treated with respect and dignity by study nurses both before and after the abuse was disclosed may have helped to begin to reshape the expectations these women have surrounding issues of self-respect and personal dignity. The continuity of care nurse home visitors provided was clearly described as a benefit by these women. They described nurse home visitors as dependable figures who provided a safe-sounding board for processing past experiences and future decision making.

Over time, information about what constitutes healthy versus inappropriate intimate partner behavior and repetitive screening for IPV throughout prenatal and pediatric care encounters helped these women articulate the danger in their life situations. This seems like a critical first step in being able to navigate toward safer family and intimate partner relationships.

It is important to understand that options that appear to be safe solutions from the outside might actually increase the instability in the lives of these women and their families. One of the challenges faced by health care professionals is to examine and restructure care delivery systems to decrease the perceived barriers to care for women who are exposed to IPV. However, first, through future research, we must learn more about these perceived barriers and the various ways in which they are experienced by the women. In addition to routine identification of IPV exposure, we also need to routinely teach women communication, coping skills, including options for safety planning. Building resilience capacity in these young women needs to be a priority, while respecting that women may make unpopular choices about how to best care for themselves and their children in abusive relationships. Their reality is that they want to protect their children and family unit at all costs and fear their children will be taken away from them.

Contingency planning for care of the children after leaving the abusive relationship needs to be adequately addressed and resourced for women to exert their own agency for the sake of themselves and their children. Otherwise, women, limited by options and resources, remain in the abusive relationship under the perceived threat that their children will be taken away as a result of the abuse. For them, staying with an abuser may appear to be the only way for her to take care of her children.

Our study highlights the primacy of motherhood as the most salient motivator for abused women as they make choices and learn new strategies for survival. We recognize the need to comparatively examine the lived experiences of urban women with this cohort, expanding the work of Bhandari et al. (2015). Future studies should consider women's own definitions of abuse, and additional research is needed from the standpoint of women making choices for their own survival, rather than from the perspective of professionals who view the choices made by these women as dysfunctional. Future IPV research, conducted using theoretical frameworks that recognize the standpoint of women living with IPV, may ultimately elicit possibilities for more effective interventions, leading to safer family environments for women and children. Further research is needed to investigate both urban and rural cultural and environmental differences as well as interventions that could, from the standpoint of women experiencing abuse, be effective.

Author Biographies

Camille Burnett, PhD, MPA, APHN-BC, RN, DSW, is an assistant professor and Roberts Scholar at the University of Virginia School of Nursing.

Donna Schminkey, PhD, MPH, RN, CNM, is an assistant professor and Roberts Scholar at the University of Virginia School of Nursing.

Juliane Milburn, PhD, RN, FNP, is an associate professor of nursing health and life sciences at Piedmont Virginia Community College.

Jennifer Kastello, MSN, RN, WHNP, is a assistant professor at the University of Virginia School of Nursing.

Linda Bullock, PhD, RN, FAAN, is the Jeanette Lancaster Alumni professor of nursing and associate dean of research at the University of Virginia School of Nursing.

Jacquelyn Campbell, PhD, RN, FAAN, is professor and Anna D. Wolf chair in the Department of Community-Public Health at Johns Hopkins University School of Nursing.

Phyllis Sharps, PhD, RN, CNE, FAAN, is professor and associate dean for community and global programs and the director of the Center for Global Nursing at Johns Hopkins University School of Nursing.