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Domestic Violence During Pregnancy in an Eastern City of Turkey : A Field Study

Hlya Arslantas, Filiz Adana, Filiz Ergin, Neriman Gey, Nejla Bier and Nilfer Kiransal J Interpers Violence 2012 27: 1293 originally published online 11 November 2011 DOI: 10.1177/0886260511425248 The online version of this article can be found at: http://jiv.sagepub.com/content/27/7/1293

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Domestic Violence During Pregnancy in an Eastern City of Turkey: A Field Study

Journal of Interpersonal Violence 27(7) 12931313 The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260511425248 http://jiv.sagepub.com

Hlya Arslantas ,1 Filiz Adana,1 Filiz Ergin,1 2 al2 Neriman Gey, Nejla Bier,2 and Nilfer Krans

Abstract Violence is an increasing and important community health problem that can be seen in any area of human life. Limited studies were found about domestic violence among pregnant women and its relation with social status of women. The aim of this study was to determine the prevalence and types of domestic violence during pregnancy, factors affecting it, womens thoughts about violence, and relation between social status of women and domestic violence.This cross-sectional study was conducted on 253 pregnant women, using cluster and simple random sampling methods. Chi-square test and logistic regression analysis methods were used to analyze the data. Women who indicated that they have been exposed to violence at some point of their lives were 24.1% and who indicated that violence continued while they were pregnant were 11.1%. Physical violence was the most common type of violence reported (18.2%). It was found that women who had primary school or lower level of education and who made unwanted marriage suffered from more violence during pregnancy. It can be said that violence against pregnant women is still a social problem. In societies where gender roles are dominant, decision
1 2

Adnan Menderes University, Aydin-Turkey Kafkas University, Kars, Turkey

Corresponding Author: Hlya Arslantas , Adnan Menderes University Aydn Health School, Department of Nursing of Mental Health and Illnesses, Aydin-Turkey 09 100 Email: hulyaars@yahoo.com; harslantas@adu.edu.tr

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makers have to take necessary steps such as supporting education of girls to improve social status of women, increasing awareness among women in regard to personal rights and legal regulations which will contribute to the solution of the issue. Keywords domestic violence, pregnant women, attitude, Turkey

Introduction
Violence is an increasing and important community health problem that can be encountered in any area of human life. Domestic violence is defined as a pattern of coercive behavior designed to exert power and control over a person in an intimate relationship though the use of intimidating, threatening, harmful or harassing behavior (World Health Organization, 2010). Domestic violence against pregnant women results in much more serious impact on the quality of life of the mothers and their children because of severe adverse consequences. Miscarriages, placental abruption leading to birth asphyxia and death, premature labor, stillbirths, low birth weight, fatal fractures, long-lasting psychological trauma, postpartum depression, and weakening of family support systems are some of the examples of adverse effects of domestic violence during pregnancy (Abasiubong, Abasiattai, Bassey, & Ogunsemi, 2010; Espinosa, & Osborne, 2002). In industrialized countries, the prevalence of domestic violence against pregnant women was reported between 10% and 30%. Higher rates were reported in African countries where male dominance is a norm. The differences in prevalence rates depend on sociocultural characteristics of study samples and the method of data collection. Higher prevalence rates have been reported in studies that used repeated face-to-face interview method during the pregnancy. The lowest prevalence rates were reported in studies using self-report questionnaires administered by non-health care providers (Abasiubong et al., 2010; Espinosa, & Osborne, 2002; Gazmararian et al., 1996). Exact prevalence rates are difficult to be estimated due to the absence of a standard definition of violence as well as the lack of a standard method of measurement. Although some studies reported domestic violence regardless of culture, geographical location, economic development, and educational level (Korur, 2003; Ludermir, Lewis, Valongueiro, Barreto, & Araya, 2010; Yankkerem, Karada, Adigzel, & Sevil, 2006; Yurdakul, 1996), many others found financial

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problems as the most important reason for domestic violence (Abasiubong et al., 2010; Altnay, & Arat, 2008; Ergin, Bayram, Alper, Selimolu, & Bilgel, 2005; Jewkes, Levin, & Penn, 2002; Kocack, & Doan, 2006; Mayda, & Akku, 2004; Muhajarine, & DArcy, 1999; Okyay et al., 2009; Tokdemir, Deveci, & Ack, 2003; Yankkerem et al., 2006). Violence against women is an important social problem in Turkey as well. In 1990, Turkish Republic Prime Ministry Directorate General on The Status of Women (DGSW) was established to provide support to all types of activities that aim to eliminate all forms of discrimination against women, to eliminate all forms of violence in family and social life, to advance womens human rights, empower women in economic, social, and cultural areas, increase the educational level of women, and to develop strategies, plans, and programs to contribute to the establishment of fundamental policies. Although some significant attempts such as political arrangements (regulations to protect family, establishing women shelters, establishing DGSW, and so on) have been made since 1990s, the problem is far from being solved yet. As women gained more independence and equality in Turkey, acceptance of violence against women has begun to decrease. DGSW conducted a populationbased survey called the National Research on Domestic Violence Against Women in Turkey 2008. According to this survey, prevalence of domestic violence at some point of a womans life from their childhood to actual time was 39% for women (DGSW, 2009). To date, limited data relevant to domestic violence during pregnancy have been available in Turkey. The aim of this study was to determine the prevalence and types of domestic violence during pregnancy, factors affecting it, womens thoughts about violence, and relation between social status of women and domestic violence.

Method Sample Selection

This cross-sectional study was conducted in Kars, a Northeastern city of Turkey with a population of 312,205. There are high immigration rates from Northern Caucasia to Kars, because these immigrants have cultural characteristics similar to those of Western culture in general. Also it has got traditional Eastern values. In Kars, there are four health centers, two of which were within the city and the other two in suburban areas. Multistage sampling methods including cluster and simple random methods were used for sampling. Areas of health centers were determined as cluster units; one

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suburban and one urban health center area have been chosen via random sampling. Reaching all of the pregnant women who were living within the areas of the selected health centers has been aimed. Addresses of pregnant women were found from their health care records and all pregnant women were visited at their houses between March and April 2007. From a total of 266 pregnant women living in the selected areas, 253 women could be reached. Permission to carry out the study was obtained from the Provincial Health Directorate, and informed consents of the women who accepted to take part in the pilot study and the subsequent research were taken. To ensure privacy, the interviews were conducted by female nursing students at womens houses at the times of the days when their husbands were not at home. Researchers paid house visits together with the midwife monitoring the pregnant women, introduced themselves before the interview, and clearly expressed the purpose and importance of the study. The duration of the interview ranged from 30 min to 2 hours, depending on the type of experiences. Women, who had a history of violence, were recommended to receive counseling.

Definitions
Types of abuse were defined as following: 1. Verbal violence; using degrading sentences, blaming, swearing, humiliating, insulting, shouting loudly; 2. Physical violence; slapping, hitting, pushing, breaking bones, hitting against wall, tearing hair, kicking, pulling out a knife, injuring, killing; 3. Economic violence; not taking care of house expenses, not letting women work, taking money from working women, controlling assets/possessions of women; 4. Emotional violence; cutting direct communication with spouse, not talking to women, souring, preventing her from expressing herself and explaining her opinions and ideas, preventing from seeing her family; 5. Sexual violence; raping, forcing her to a sexual act which she cannot accept, having incestuous relationships, using sexual implications, saying words with sexual content. These definitions were taken from National Research on Domestic Violence Against Women in Turkey 2008 (DGSW, 2008; TDHS, 2003).

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Measurements
Data were collected using the questionnaire prepared on the basis of literature (Atl, & zvar, 1998; Dermen, 2004; DGSW, 2001; Gnll, & li, 2001; nan, 2003; WHO, 1998). The semistructured questionnaire was revised by three health specialists interested in this topic; two nurses working in psychiatry and obstetrics clinics, and a public health specialist nurse. Prior to data collection, the questionnaire was pretested in a pilot study by interviewing 10 women who were not included in the original study, and necessary modifications were made in a few questions to make them easily understandable by women. Questionnaire included 16 questions categorized under three sections. The first section included seven questions about sociodemographics (age, marital status, education, and family type), presence of social insurance, and living conditions. The second section included five questions about opinions of participants related to social status of women such as womens role in the community, views of women about who is responsible for household expenses, views of women about women working, girls education and benefits of girls education. The third section included four questions about reasons for violence from the perspective of women and exposure to violence during pregnancy, as well as factors affecting domestic violence. Questions except sociodemographics could be chosen from more than one choice.

Statistical Analysis
SPSS 19.0 for Windows Software (Chicago, IL, USA) was used for statistical analysis of the data. Means, standard deviations, and percentages were used in the evaluation of descriptive statistics. In the analytical evaluation, chisquare test was used for comparison of the data collected by counting; Students t-test was used to compare the means obtained from continuous data. Logistic regression analysis was done to determine the possible risk factors that could affect the domestic violence in pregnancy. In this analysis, presence or absence of domestic violence during pregnancy was taken as dichotomous variable whereas the educational level, type of marriage (wanted or unwanted), spouse selection (by herself or not), role of women (acceptance of gender roles or not), and right to decide about the household expenditures (by the spouse/elderly people) were taken as independent variables. Data collected by measurement were presented as mean standard deviation; data collected by counting were showed as percentages (%), and the results of logistic regression analysis were showed as relative risk (odds ratio [OR]) and 95% confidence interval (CI). The Backward-Wald method was

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Table 1. Some of the Characteristics of Pregnant Women (n = 253) n Age group 1520 years old 21 years old and above Educational status Primary school or lower Higher education Family type Immediate Extended Marital status Married Divorced Age of marriage 1525 years old 26 years old and above Type of marriage Willing Unwilling Person who decide spouse selection Herself Her family 48 205 140 113 163 90 250 3 164 89 213 40 200 53 % 19.0 81.0 55.4 44.6 64.4 35.6 98.8 1.2 64.8 35.2 84.2 15.8 79.1 20.9

used as the regression model. The p value of <.05 was used to determine the level of statistical significance.

Results
Social and demographic characteristics of participants were given in Table 1. The findings revealed that 19% of the pregnant women were between 15-20 years old, 98.8% of them were married and 55.4% of them had an educational level of primary school or less. Out of 253 participants, 64.8% of the pregnant women indicated that they got married when they were younger than 25 years old,15.8% indicated that they made unwanted marriages (forced to marry by their families),and 20.9% of them said that their family had chosen their spouses.

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Opinions of Pregnant Women About the Social Status of Women

Approximately one of two women (45.5%) expressed that the duty of women was to provide moral support to her spouse and children. Out of 253 participants, 53.3% of the participants indicated that they decided about their house expenses together with their spouses and tried to convince their spouses when they did not agree. Three out of four women (75.1%) expressed that women could work in a paid job or carry out some outdoor work besides domestic work. Out of 253 participants, 79.8% of them indicated that girls should be educated as long as they can, to have a chance of good profession in future life. Opinions of pregnant women about social status of women were given in Table 2.

Domestic Violence Among Pregnant Women

From a total of 253 participants, 62 women (24.3%) indicated that they have experienced domestic violence at some point of their lives including childhood. Of those 62 abused pregnant women, 47 (75.8%) experienced physical violence, 7 (11.3%) emotional violence, 6 (9.7%) verbal violence, and 2 (3.2%) experienced both economic and sexual violence. Women who said that violence continued when they were pregnant were 28 (11.1%). Percentages of women experiencing violence and the types of violence were given in Figure 1.

Womens Views on the Reasons for Domestic Violence

Most of the women stated that men mostly commit violence and women mostly suffer from it. Financial problems (38.3%), interpersonal conflicts (19.8%), and alcohol use (10.7%) were reported as the most important factors leading to violence. Other factors mentioned were bad habits (8.7%), jealousy (6.3%), and bad relationship with the spouses family (5.9%), lovelessness (5.5%), anger (2.4%), and psychological problems (2.4%). Out of 253 participants, 51.4% also expressed that the most important problem of Turkish women was being deprived of education. One out of two women (53.8%) said that the problem of violence and deprivation of education could be solved by allowing women to work in a paid job and allowing them to advance in a profession.

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Table 2. Opinions of Pregnant Women About Social Status of Women (n = 253) Opinions of pregnant women Role of the women To provide moral support to spouse and child Domestic work/giving birth to a child To arrange social relations of the family To take care after the elderly in her husbands family Contribution to budget The person who decides about household expenses Together with her spouse Her spouse Elderly people in the house Herself Everybody decides individually Views on womens working Women can work as paid employees Women can carry out some outdoor works like shopping Women can only carry out domestic work Women can work at farms or gardens Views on girls education Have education as long as she can Graduate from university Graduate from high school Graduate from primary school I do not want them to have education Views on the benefits of girls education Having a profession Being useful for country and society Carrying on her marriage orderly and raising her children well Being enlightened n 115 70 31 20 17 136 65 42 6 4 126 64 55 8 202 37 7 5 2 100 65 60 28 % 45.5 27.7 12.3 7.9 6.6 53.8 25.7 16.6 2.4 1.5 49.8 25.3 21.7 3.2 79.8 14.6 2.8 2.0 0.8 39.5 25.7 23.7 11.1

Factors Affecting Domestic Violence During Pregnancy

Univariate analysis showed that age, family type, age of marriage, employment status of the woman, and the reasons that increase violence did not affect exposure to violence during pregnancy (p > .05). Women who had an educational

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Those who does not suffer from violence 75.9%

Those who suffer from a violence 24.3 % a

Physical Violence 18.2%

Emotional Viol. 2.8% Verbal Violence 2.4%

Figure 1. Violence rates of women and distribution of the type of violence, 2007.
a. Two women (3.2%) experienced both economic and sexual violence.

level of primary school or less, who had to accept the decisions of her spouse or parents, who thought that the role of women was to do house work/giving birth to a child/take care of the elderly at home, who had to obey the decisions of the spouse, who married unwillingly and who experienced violence in a period of their lives, suffered more from violence during pregnancy (p < .05; Table 3). In the final model of the logistic regression analysis, it was found that womens educational level and desired marriage status affected violence during pregnancy. Having a primary school or lower level of education increased the risk by 4.039 (95% CI [1.274, 12.806]; p = .018) and making an unwanted marriage increased by 5.117 (95% CI [2.040, 12.836]; p = .001) in terms of exposure to domestic violence.

Discussion Opinions of Pregnant Women About the Social Status of Women

Approximately half of the participants (45.5%) stated that the duty of women was to provide moral support to the spouse and child (ren), and

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Table 3. Factors Related to Exposure to Violence during Pregnancy Violence (+) (%) Violence () (%) 2 p

Age 15-20 years old 3 (6.3) 45 (93.8) 1.397 .237 21 years old and older 25 (12.2) 180 (87.8) Educational status Primary school and lower 24 (17.1) 116 (82.9) 11.756 .001* Higher education 4 (3.5) 109 (96.5) Family type Immediate 14 (8.6) 149 (91.4) 2.859 .091 14 (15.6) 76 (84.4) Extended Age of marriage 20 (12.2) 144 (87.8) 0.603 .438 15-25 years old 26 years old and older 8 (9.0) 81 (91.0) Spouse selection 13 (24.5) 40 (75.5) 12.343 .000* By her family By herself 15 (7.5) 185 (92.5) Who decides about expenses of the house Spouse/elderly people 20 (18.7) 87 (81.3) 10.951 .001* Herself/together with her 8 (5.5) 138 (94.5) spouse/everybody decides individually Role of woman House work/giving birth to 18 (20.0) 72 (80.0) 11.325 .001* a child/take care after the elderly at home To provide moral support to 10 (6.1) 153 (93.9) spouse and child / to arrange social relations/contribution to budget Labor Farm and garden works/house 15 (11.8) 112 (88.2) 0.143 .705 works/shopping To be employed with wage 13 (10.3) 113 (89.7) Behaviors of the woman when the spouse does not agree with the decisions of the woman Try to persuade 6 (4.4) 131 (95.6) 17.026 .001* Change the decision 5 (25.0) 15 (75.0) (continued)

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Table 3. (continued) Violence (+) (%) Violence () (%) 13 (72.2) 67 (83.8) 2

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Do as she wishes 5 (27.8) Have to obey the decisions of 13 (16.3) the spouse Marriage Willing 16 (7.5) Unwilling 12 (30.0) Exposure to violence in a period of their lives Yes 28 (45.9) No Factors increasing violence Financial problems Conflict Othera

197 (92.5) 28 (70.0) 33 (54.1) 192 (100.0) 88 (90.7) 46 (92.0) 91 (85.8)

17.303

.000* .000*

99.099

9 (9.3) 4 (8.0) 15 (14.2)

1.817

.403

a. Bad habits, jealousy, lovelessness, anger, psychological problems, and engagement by families of the spouse in relations within the family. *p < .01.

53.3% said that they decided to do household expenses together with their husbands. Results showed clearly that one out of two women accepted traditional views about social gender roles especially in family life. However, three out of four women (75.1%) said that women should work in a paid job and perform some outdoor works, 79.8% stated that they wished their daughters went to school as long as they can, mostly to have a good profession. In Turkey, limited number of studies was found on this subject. Studies about the thoughts of students on traditional gender roles revealed that male students were more traditional than female students in respect to the gender roles (Gven, 1996; Vefikuluay, Demirel, Takn, & Erolu, 2007; Ylmaz et al., 2009). Ylmaz and colleagues (2009) reported that 87.6% of female students disagreed with the statement women could work only if their husbands give permission, whereas 45.3% of male students agreed with it strongly. Furthermore, 30.4% of male students said that women should not go out in the evenings. These findings also supported the traditional attitudes of the males.

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In Turkish Demographic and Health Survey, although 84% of the Turkish women thought that women should work, 31% of them stated that the reason for not working in a paid job was child care. Also, 32% of women stated that their spouses did not allow them to work. Half of the women approved that they should not be engaged in discussions with their husbands, 84% stated that girls should have education and 28.3% stated that they had to take permission from their husbands to go out at nights (TDHS, 2008). The findings of this study in respect to traditional gender roles were similar with 2008 Turkish Demographic and Health Survey. As in many developing countries, like in Turkey, women highly adopted traditional roles related to being a woman. When the reflections of these roles were examined, it was seen that women should receive permission for going outside to work, and that they should be engaged in child care and domestic works. In Turkey, almost 45% of women had above secondary school education. Women participation in work force that had primary school education or less was below 30%. It could be said that educational background of women, low social status, traditional cultural approaches, and gender-based perspectives affected women to adopt these traditional roles (TDHS, 2008).

Domestic Violence Among Pregnant Women

The findings of this study revealed that one out of four women experienced domestic violence in a period of their lives. Physical violence was the most reported one (18.2%). Additionally, 11.4% of the participants stated that the violence continued during pregnancy. A population-based study in Aegean Region of Turkey indicated that 9.7% of women were exposed to physical violence during pregnancy (Yankkerem et al., 2006). Another study at the same region showed that the rate of physical violence experienced throughout their lives was 33.4% whereas it was found to be 17.6% during pregnancy. National Research on Domestic Violence Against Women in Turkey stated that the rate of women who suffered from violence during pregnancy varied according to the geographic regions. Domestic violence against pregnant women was 5.3 % in Western regions, whereas this rate reached up to 17.6 % in North-Eastern parts of the country (DGSW, 2009). Regional characteristics affected the womens approval of domestic violence. In the Eastern regions of the country, womens social status is worse than Western region, in general. Not only the rate of educational level, but also the rate of women in working life is very low (almost four-fold low). In the Eastern region, approval of

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violence was 40%, whereas this rate was 18% in the Western parts (TDHS, 2008). With women who have higher levels of education and involvement working life, the traditional roles undertaken by women and men have started to change in favor of women (Attanapola, 2003). According to Karaam, alr, Dndar, Altunta, and Avc (2006), women were in opinion that men might beat their wives in case of conflict with the husband (10.2%) and in cases of spending too much money (7.6%), refusing sexual intercourse (7.1%), or neglecting care of children (7.1%). Ayranc, Gnay, & nlolu and colleagues (2002) reported that 71.4% of women experienced at least one of physical, sexual, and psychological/verbal violence during any time prior to or throughout pregnancy. Similar to our findings, Mc Farlane and colleagues (1996) reported that 17% of pregnant women in America suffered from physical and sexual violence. Abasiubong and colleagues (2010) reported 33.1% of pregnant Nigerian women had experienced abuse in their lifetime, whereas 22.9% were abused during their current pregnancy. In the developed countries, rates for abuse varied between 10% and 30% (Campbell, Garcia-Moreno, & Sharps, 2004; Castro, & Ru, 2004; Gazmararian et al., 1996; Johnson, Haider, Ellis, Hay, & Lindow, 2003; Subramaniam, & Sivayogan, 2001). Higher rates ranging from 20% to 70% have been documented in many African countries including Nigeria, where women are culturally subservient and male dominance is the norm (Ameh, & Abdul, 2004; Ezechi et al., 2004; Idika, Okonkwo, & Adogu, 2002; Kaye, Mirembe, & Bantebya, 2002; Okemgbo, Omideyi, & Odimegwu, 2002; Udo, Udofia, Ekott, & Udoma, 2008). Studies about domestic violence in our country showed different prevalence rates because of the varying social status of women among regions. In the Eastern regions including Kars province in which the study was carried out, there were families with patriarchal structure, low educational status of men or women and high rates of unemployment. Also, gender discrimination was observed more frequently in Eastern regions (DGSW, 2009; TDHS, 2008). These factors may explain the frequent occurrence of violence in the East. However, our findings were similar to those of the studies performed in the Western regions. One of the reasons might be high immigration rates from Northern Caucasia to the Kars, because these immigrants had cultural characteristics similar to those of western culture in general. Also, the concepts and contents of violence and the meaning underlining these concepts may affect violence reports because of educational differences.

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An outstanding point both in Turkey, where the role specified for women is mostly childcare and other countries is that exposure to violence becomes less frequent but it still continues during pregnancy at the rates between 5.3% and 17.6%. The results of this study showed that one out of ten pregnant women experienced some type of domestic violence. As one looks from mens perspective in our country, reasons such as considering violence as a usual event, attitudes and behaviors that the male children witnessed in their youth, witnessing parents violence in the house, conceiving such things natural and legitimate might result in normalization of violence as a concept and usage of domestic violence.

Women' Views on the Reasons for Domestic Violence

Participants stated financial problems as the major reason for violence (38.3%). In the National Research on Domestic Violence Against Women in Turkey, the reasons for violence were reported as problems with the husbands family (32%) and financial problems (22%; DGSW, 2009). Similarly, many local studies reported economic problems or economic distress as the most important reasons for domestic violence (Ayranc et al,, 2002; li, 1994; Karaam et al., 2006). Poverty might cause domestic distress, intolerance to events, psychological problems, and lower threshold of stress (Altnay & Arat, 2008; Ayranc et al., 2002; DGSW, 2009; TDHS, 2008) and may consequently play a determining role in violent behavior. Half of the participants indicated the deprivation of womens education as the most important problem of women in Turkey. Because of lower levels of education, women dont have a right to explain themselves, dont have a right to speak during decision processes and accept mens dominance. Women were aware that education has a key role in improving womens social status.

Factors Affecting Domestic Violence During Pregnancy

The findings of this study revealed a significant relationship between the educational level of women and their exposure to violence. Generally, it is well-documented that the exposure to violence of women was less prevalent among those with increased education levels (Abasiubong et al., 2010; Altnay, & Arat, 2008; Ergin et al., 2005; Jewkes et al., 2002; Kocack, & Doan, 2006; Mayda, & Akku, 2004; Muhajarine, & DArcy, 1999; Okyay et al., 2009; Tokdemir et al., 2003; Yankkerem et al., 2006). Ergin and colleagues (2005) reported that illiterate women suffered from 2.6 times more violence compared to women that had university education or a relatively

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higher education. In this study, this ratio was two times higher; women with lower educational level had experienced 4.039 fold higher domestic violence. Because educational level is one of the most important factors that affect the status of woman in the family socioculturally, less education increases the possibility of exposure to violence (DGSW, 2009). Women with lower educational level may have no right to speak during decision processes, and they may be forced to marry with less educated men mostly with low income. All these factors may lead to miscommunications between partners and exposure to domestic violence. Women who selected their spouses by themselves and who had a desired marriage experienced domestic violence less. It was found that making an unwanted marriage increased the risk by 5.117 folds in the exposure of domestic violence. In Turkey, traditionally, some girls and boys still get married under the pressure of their families and/or relatives. Also in some regions, when babies were born, families promise each other to engage them when they grow up. This traditional attitude called cradle notch-besik kertmesi. Altnay and Arat (2008) reported also that women who got married with the approval of their families experienced less physical violence than those who got married without the approval of their families. The lack of family support leads to social isolation of the married women and possibly encourages the spouses to show violent behaviors. Studies carried out in different countries showed also that there was a strong relationship between isolation of women and domestic violence, especially physical violence (Altnay, & Arat, 2008; Johnson, 1998; UNICEF, 2000). The limitation of our study was that, we did not examine whether there was a social isolation. However, it was clear that women who made a wanted marriage were exposed to less violence compared to others. Another point was that, domestic violence in extended families was more common than others, although the difference was not confirmed statistically. Turkish Family Research Institution reported that violence becomes more common in extended families. Especially conflicts with mother-in-law lead to conventional bride and mother-in-law dilemma and therefore cause conflicts between spouses. Similar results were found in different local studies in Turkey (DGSW, 2009; TDHS, 2008; Turan, zkan, Telciolu, & Kucur, 2000). In developing countries like in Turkey, parents of the spouses got involved in almost all decisions of the spouses in extended families because of their traditional attitudes, and they even got involved in subjects such as childbearing. In such families, the couples were not able to decide individually, they constantly felt themselves under pressure and this led to domestic violence. In cases where the social gender roles of women became more significant such as considering the role of women as house work/giving birth to

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children, have no right in the decision of household expenses, obey the decisions of the husband in an argument, violence in pregnancy became more frequent. In National Research on Domestic Violence Against Women in Turkey, two out of three women stated that they could not individually decide about their household expenses. In Turkey, girls are growing up with conventional, traditional values and they accept men as the leader of the house, therefore they kept these values in marriage. When a woman leaves such traditional attitudes, violence occurs inevitably. Legal regulations in Turkey stated that any verbal or physical act of violence shall be punished by 3 months to 2 years of imprisonment or pecuniary fine, but the woman must submit a complaint about this. Unfortunately, in patriarchal societies where male dominance is prominent, woman accepts the roles assigned by the population to them and do not complain about being discriminated, suppressed, or even exposed to violence by men in most cases. Therefore, prevalence of violence does not reflect the reality, so we can just provide information about the visible parts of an iceberg. A significant relationship was found between exposure to violence at some point of life and exposure to violence during pregnancy. The National Research on Domestic Violence Against Women in Turkey also reported that exposure to violence at some point of life increased the possibility of exposure to violence in marriage (DGSW, 2009). Existence of violence, its reoccurrence and acceptance by those who experienced or witnessed it, were very important in development of personality, attitudes, and behaviors in general. If fathers violence was accepted as a normal behavior, this would affect personality development of the children (Gne, Kaya, & Pehlivan, 2000). This situation may lead to very dangerous results such as violence aptness, lesser self-esteem, loss of self confidence, having depressive symptoms, or an obeying behavior pattern. A logistic regression analysis conducted to predict violence during pregnancy revealed having a primary school or lower level of education and making an unwanted marriage as important factors. Several studies revealed similar results (Abasiubong et al., 2010; Altnay, & Arat, 2008; DGSW, 2009; Ergin et al., 2005; Jewkes et al., 2002; Kocack, & Doan, 2006; Mayda, & Akku, 2004; Muhajarine, & DArcy, 1999; Okyay et al., 2009; Tokdemir et al., 2003; Yankkerem et al., 2006).

Limitations of the Study

As this study was conducted in a small local area, the findings can not be generalized for entire country. Furthermore, no standard scale with a known validity and reliability was available at the time when this study was carried out and thus we used personal statements of women to assess domestic

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violence. Another point was that, we did not interview with men and examine mens view about the subject. It would be better if the study was done on both parts.

Conclusion
It can be said that many pregnant women have to live with a tragedy of domestic violence. Exposure to violence at some point of life, having a low level of education, marrying with a person who was selected by the family and making an unwanted marriage, acceptance of gender-based roles lead to higher rates of domestic violence. To overcome this problem, antenatal follow-ups in primary health care settings offer a unique chance to reach pregnant women and identify women who have been under the risk of violence. Health care providers, especially midwives and nurses have an opportunity to reach pregnant women during antenatal care activities. Thus, they should be aware of this issue and take responsibility to act on many levels against domestic violence, especially in risky groups like those with low educational background, having unwanted marriages, and having more traditional values. They should direct them to the consultation units. In societies where gender roles are adopted, decision makers must also take necessary steps such as supporting education of girls, informing women about personal rights and legal procedures to improve social status of women. Acknowledgments
The authors would like to thank the pregnant women who were willing to participate in the study.

Authors Note
This study was presented as verbal statement at 6th Summer school symposium in Romania and a part of this study was published in Journal Medical Braovean in Romania.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

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Bios
Hlya Arslantas is assistant professor in Mental Health and Psychiatry Nursing Department. His research interests: Burden on schizophrenia patients relatives, postpartum depression, psychoeducation in schizophrenia, psychoeducation in mood disorders, expressing emotion on schizophrenic patients relatives, social support in elderly, violence against women. Filiz Adana is assistant professor in Public Health Nursing Department. His research interests: School health, anger in students, violence in students, recklessness in students and nurses, immigration, violence to women, social support in elderly and life quality, psychoeducation in schizophrenia, burden on schizophrenic patients relatives, violence against women. Filiz Ergin is assistant professor in Medicine Faculty. His research interests: Environmental health, elderliness, postpartum depression, womens health, violence against women, childrens health, epidemiology, biostatistics. Neriman Gey is Kars Health School lecturer in Kafkas University. His research interests: Assertivenes in nurses, burnout in nurses, violence against women. Nejla Bier is Kars Health School lecturer in Kafkas University. His research interests: Assertivenes in nurses, burnout in nurses, critical thinking in nurses, and eating habits in primary school students. Nilfer Krans al is Kars Health School lecturer in Kafkas University. His research interests: Assertivenes in nurses, burnout in nurses, critical thinking in nurses, and eating habits in primary school students.

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