Reviewer's report
Title:Prevalence of domestic violence during pregnancy and related risk factors:
a cross-sectional study in southern Sweden
Version:1Date:17 February 2014
Reviewer: Kathleen Franchek-Roa
Reviewer's report:
In this article, the authors aim to determine the prevalence of domestic violence
victimization among pregnant women in a southwestern region of Sweden.
I congratulate the authors on tackling this complex issue and recruiting nearly
2000 pregnant women as participants. I feel that this research could be beneficial
to healthcare providers in Sweden; however, the presentation of the results
needs to be more well-defined and described. A strength of the study was the
use of a validated questionnaire that had been used in a Nordic population. In
addition, the finding that “Women having EDS scores > 13….were 13.4 times
more likely to be exposed to ‘DV during pregnancy’ “ is a significant and helpful
finding for most healthcare providers caring for women during pregnancy and in
the postpartum period.
General Comments include:
1) Major Compulsory Revision: The authors switch between calling this intimate
partner violence (IPV) and domestic violence (DV). They need to be consistent
with terminology.
2) Major Compulsory Revision: I am concerned that the premise of the study
needs to be re-evaluated. The authors state: “Also, studies from different regions
in the country are needed in order to be able to generalise to the entire
population in the increasingly multicultural society of Sweden, Results from a
survey concerning DV during pregnancy would highlight the problem and would
hopefully increase awareness and action for identification and prevention.”
Regional studies of prevalence rates are probably more beneficial in order to
properly allocate resources to those regions that have higher prevalence rates of
DV not in order to generalize to the entire population.
3) Major Compulsory Revision: The quality of the English is a major impediment
in the flow and the writing style of this manuscript.
4) Suggestion: Suggest the authors arrange the results section in the order of the
specific aims by adding subheadings. This is a lot of data and it would help the
reader if this was more clearly organized.
Specific Comments:
Abstract:
Generally the abstract conveys the important findings.
Specific Aims
1) Major Compulsory Revision: The specific aims of the project should be better
clarified.
Methods
1) Major Compulsory Revision: A major omission in this section is the description
of the protocol of what is done once a victim of DV has been identified. It appears
that the completed questionnaires were placed in a sealed envelope and looked
at 3 weeks later. It appears that the healthcare provider at the time of the visit
was unaware of the questionnaire results; therefore it appears that no
intervention was given.
2) Major Compulsory Revision: Another important safety issue is whether a
participant was recruited even if she presented to the clinic with her partner.
3) Discretionary Revision: Suggest listing the questionnaires at the beginning of
the Questionnaires sections and then describing the tests under subheadings.
4) Major Compulsory Revision: Definitions section: The authors’ definitions of IPV
and DV are confusing and are not supported by the reference given. The Krantz
paper is not referenced.
5) The Statistical Section I will defer to a statistician. The authors might consider
putting the definitions in the beginning so readers will have knowledge of how the
authors are defining IPV/DV.
6) Major Compulsory Revision: The authors should characterize the ANCs that
refused to participate in the study to see if there were any differences between
the ANCs that did participate vs. those that did not.
7) Major Compulsory Revision: This statement needs a reference: “Symptoms of
depression were assessed using the Edinburgh Postnatal Depression Scale
(EPDS), an instrument covering common symptoms of depression and that is
designed to screen for risk of depression during the postnatal period, but can
also be used during pregnancy (EDS).” Reference 35:
35. Rubertsson C, Borjesson K, Berglund A, Josefsson A, Sydsjo G: The
Swedish validation
of Edinburgh Postnatal Depression Scale (EPDS) during pregnancy. Nord J
Psychiatry
2011, 65(6):414-418 should be placed after this sentence. In addition, is there a
difference between EPDS and the EDS? If so, this should be clarified. If not then
the authors need to use the same abbreviation.
Results
Comment: The authors dichotomized weight as under-/normal or
overweight/obese. It would be interesting to see how many women were
‘underweight’ because being underweight during pregnancy can affect maternal
and fetal health.
1) Major Compulsory Revision: The number of midwives who attended the first
training and the second should be stated, the time elapsed between the two
trainings should be stated, and the percent of midwives who received the training
vs those who did not should be stated.
2) Discretionary Revision: Would recommend including the OR in the Tables for
easier access for the reader.
3) Major Compulsory Revision: Table 1 abuse during pregnancy would not be
lifetime abuse it would be current abuse.
4) Major Compulsory Revision: Table 1 – in some cases the numbers in the text
do not match the table or the authors need to be clearer on what they are
reporting.
5) Major Compulsory Revision: In this paragraph describing Table 2: Table 2
shows the distribution of the socio-demographic factors for the total cohort (n
=1939)
of women with or without experience of “history of violence” (OR with 95% CI not
presented
in the table). Statistical differences were obtained between the groups with
regard to
cohabiting status, whereby women who were single or living apart from the
partner were 1.6
more likely to report experiences of ‘history of violence’ (OR 1.6; 95%
CI:1.36-1.9). Also,
women were 2.2 times more likely to report history of violence if they were
unemployed or
who had financial distress were 1.5 more likely to report history of violence (OR
2.2; 95% CI:
1.5-3.3; OR 1.5; 95% CI:1.2-1.8, respectively).” This would benefit from
rewording to complete the thought regarding which demographic characteristics
were statistically different. For example, “Statistical differences were found
between the groups with regards to cohabiting status, employment status and
financial distress.” If the authors listed the OR in the table they would not need to
mention them in the text.
6) Discretionary Revision: Table 3. Not sure I would call smoking, snuffing a
maternal characteristic; suggest maybe labeling it as a high risk health behavior
7) Major Compulsory Revision: Did the authors compare those midwives involved
in the study who attending the educational section with those who did not?
Discussion
1) Major Compulsory Revision: These findings: “Of those women who reported
lifetime emotional abuse, 66.3 % (n = 248) were exposed to DV; the perpetrator
was male in all cases and in six cases also female. Among the women who
reported lifetime physical abuse, 74.2 % (n = 416) were exposed to DV; the
perpetrator was male in all cases but one, and in 28 cases female were also
involved. Among those who reported lifetime sexual abuse, 37.1 % (n = 112)
were exposed to DV; the perpetrator was male in all cases, and in one case also
female. In 11 cases the sex was not reported.” are important and the authors
should comment on this in the discussion.
2) Major Compulsory Revision: First sentence in discussion states: “This study
showed that the prevalence of DV during pregnancy was 1%.” Table 1 states
1.5% - so authors should clarify if they mean DV during current pregnancy
3) Discretionary Revision The authors state that “Women born outside of Nordic
countries were over-represented” in the beginning of the discussion. This should
be reserved for the limitations section since some of their questionnaires were
validated for Nordic populations.
4) Major Compulsory Revision: As mentioned previously, the authors should
indicate what was done if a women reported being a victim of DV. If nothing was
done then this should be stated.
5) Major Compulsory Revision: The results of their research do not support this
statement: “However, the current results indicate the need for null tolerance
towards violence against women to improve maternal health and reduce
maternal and child health morbidity and mortality due to such violence.” Table 4
shows no significant difference between ‘self-reported poor health’ and ‘DV
during pregnancy.’ The health of the participants and their children was not one
of their aims or at the very least they did not indicate that clearly if it was (except
for depressive symptoms).
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I declare that I have no competing interests.