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Exploring women's experiences of domestic violence: Injury, impact and

infant feeding

Article  in  British Journal of Midwifery · December 2012

DOI: 10.12968/bjom.2012.20.12.843

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 Exploring women’s experiences of domestic violence: Injury, impact and infant
feeding

Abstract

This research paper reports on a qualitative study involving fifteen women who had

experienced domestic violence in pregnancy. Findings from the general literature on this

subject have illuminated many of the effects of domestic violence. There is, however, a gap

in the literature on how this violence affects a woman’s perceptions towards herself, and the

resultant impact on infant feeding. The women participants in this study were resident or

supported by women’s refuges within the United Kingdom, and consented to a narrative

interview. Following verbatim transcription, the process of thematic analysis assisted in the

development of themes. Three interlinking themes emerged and are presented in this paper;

physical injuries sustained through domestic violence, the impact of these injuries on a

woman’s self-perception, and the influences of the injuries self-perception on infant feeding.

The findings suggest that women may experience a body dysmorphia as consequence of the

physical effects of domestic violence which may then affect the woman’s choice on infant

feeding.

Introduction

Violence against women is increasing on a global scale, identified by the World Health

Organisation as a problem of pandemic proportions (World Health Organisation (WHO)

2011). Globally, approximately one in three women have been physically assaulted,

abused or coerced into sex at some stage in their life, by a known perpetrator in the

majority of incidents (United Nations Human Rights 2011). Within developing and

industrialised countries, women experience a divergence in both their experiences of, and

1
responses to domestic violence (Ceballo et al 2004). The accountability for these

discrepancies may lie within their specific ethnic groups (Goodwin et al 2000);

commissioning of services (Goulding & Duggal, 2011) and lack of inter-agency

coordination (Keeling & van Wormer, 2011).

In the USA, it has been estimated that 9.8% of women had experienced abuse within the

previous two years (Walton-Moss et al 2005). However in the UK, the British Crime Survey

of 2009-2010 identified 29% of women experienced some form of domestic violence during

their lifetime (Hall 2011), whilst Feder et al (2009) identified rates of between 13 to 31%.

The effects of domestic violence also have significant cost implications, in excess of £1.2

billion (Walby 2004).

Perinatal domestic violence refers to any violence occurring before, during and after

pregnancy (up to one year after childbirth) and being committed by an intimate partner

(Sharps et al 2007). During this period of time the violence may commence or worsen

(Garcia-Moreno et al 2006) with some studies suggesting prevalence rates of between 6-21

% in pregnancy and between 13-21% prevalence in the post partum period (Campbell et al

2000). Moreover, a synthesis of results from 13 studies found prevalence rates of domestic

violence in pregnancy ranging between 0.9% (Sampselle et al 1992) and 20.1% (Gazmararian

et al 1996).

The birth of a baby may lead to a rise in tensions in a relationship where domestic violence

features, especially if the woman does not comply with the perpetrators demands for sex

immediately after childbirth (Dutton and Goodman 2005). In this postnatal period new

mothers may face unique challenges (Averbuch & Spatz 2009) including breastfeeding

problems (Sarker 2008), re-traumatization of sexual abuse (Domestic Violence Resource

Centre Victoria 2012), and domestic violence (Keeling & Mason 2011). The juxtaposition of

2
domestic violence onto existing postnatal challenges serves to further complicate the

mother’s situation.

Breast feeding rates in the UK have increased from 76% in 2005 to 81% in 2010 with rates

increasing across all socio economic groups (The NHS Information Centre, 2011). Although

infant feeding may be complicated by the presence of violence in a relationship, many other

factors are also influential. Women with a higher Body Mass Index are less likely to breast

feed (Krause, Lovelady & Østbye 2011); women in lower socio economic groups (Kelly &

Watt 2005), women who leave full time education before the age of 18 years and women

under 30 and multiparous women (The NHS Information Centre 2011).

The Royal College of Obstetricians and Gynaecologists (2001), the Royal College of

Midwives (1999) and the Department of Health (DH, 2010), have all advocated the inclusion

of education and training for all professionals working in the health care arena, and the

routine investigation for domestic violence. Davison (1997) identified that the personal

experiences of violence within the context of an intimate relationship will have a direct effect

on the health professional’s capability of making a clinical decision, and further, that health

care professionals do not want to ask about domestic violence due to lack of awareness

(Mezey et al 2004). Stark et al (2007) argues that the responses afforded to victims of domestic

violence by the health service serve to ensure it remains a private issue, with Feder, Hutson,

Ramsay and Taket (2006) highlighting the issue that only of survivors of domestic violence are

identified by health professionals. Aston (2004) argues that midwives usually do not raise the

subject of domestic violence, leaving women to take the lead in initiating discussion about it

with their midwife. This lack of communication between the woman and the midwife may

3
revolve around the midwives' own personal experiences of domestic violence (Mezey et al

2004).

Whilst there is a plethora of evidence identifying the negative sequalae to the physical effects

of domestic violence to both non pregnant and pregnant women (Bair-Merritt et al 2006,

Kendall-Tackett 2007), there are few studies that explore whether domestic violence directly

impacts on a woman’s perception of her own body and how this affects her choice of infant

feeding.

Research Aim

The aim of this study was to gain a deeper understanding of the impact of domestic violence

in pregnancy; how the violence affects a woman’s perceptions towards herself, and the

resultant impact of this on her decision towards infant feeding.

Method

The study was initially discussed with the managers of two refuges at different locations

within the United Kingdom. Due to the experiences of subordination and coercion by an

abusive and controlling partner in the context of domestic violence, the autonomy of the

woman remained of concern. Therefore, any woman who chose to participate self-referred to

the manager who then contacted the primary researcher, ensuring an autonomous choice in

participation.

A qualitative approach using a single narrative interview was chosen for this study. With no

preset questions, this approach enabled the woman herself to decide on what to disclose and

when to terminate the interview with the locus of control remaining with the woman. Supported by

4
Riessman (1993), this approach is relevant for exploring difficult life transitions, gender inequalities

and other practices of power.

Ethical issues

The World Health Organisation (1999) considerations when researching violence against

women were implicit in the research study development. These specifically address

maintaining the safety of the women. Following verbal consent to participate and audio

record their stories, all meetings took place within a women’s safe house or refuge that

offered twenty four hour security. Ethical approval was granted by the author’s academic

institution prior to commencement of the study. No compensation was offered for

participation and all participants were informed to the choice to opt out at any stage. The

study was independent of the refuge. Anonymity was assured with women choosing their

own pseudonym. The potential for individual researcher bias impacting on thematic analysis

was addressed through supervision of the project.

Sample

A total of fifteen women aged between twenty one and fifty four participated in the study, all

of whom had lived with domestic violence perpetrated by a male partner. Of these 15 women,

six chose to talk in detail about how the physical violence had impacted on both their self-

image and attitudes to infant feeding. Twelve of the women had left their violent relationship

in the preceding twelve months; whist three had left longer than twelve months before. All of

the women had children by the violent partner, or a previous partner. The duration of this

violence lasted between twelve months and thirty six years. Based on women being classified

5
into socio-economic groups based on either their current or previous jobs, all were from a

lower socio-economic group.

Data Collection

Using a narrative approach to interviewing, all the participants were interviewed once. The

interviews lasted between twenty five minutes and one and a half hours, at the discretion of

the woman. All interviews were conducted within a refuge/safe house, and audio recorded

with the participant’s permission, followed by verbatim transcription.

Data Analysis

Braun and Clarke’s (2006) six phases to thematic analysis was used to analyse the transcripts.

After immersion within the data by reading and re-reading the transcripts, initial codes were

generated. From these initial codes, themes were developed in a continuous and iterative

process. The use of a thematic map enhanced the clarity of the developing themes, which

were themselves checked for relevance to the coded data and entire data set by the principle

investigator and a supervisory team. Through the iterative process of analysis, the themes

emerged from the data itself, each theme remained strongly linked with the data itself (Patton

2002)

Findings

The findings presented are main themes that emerged from the data. The headings within the

findings sections represent each theme. The findings revealed the women’s emotional

complexities of considering disclosure of domestic violence when being attended by a

midwife. Further, the women’s narratives reveal the impact of domestic violence in

pregnancy and how this has affected their choice of infant feeding.

6
Physical violence in pregnancy

Pregnancy may, for some women, be a period in their lives in which domestic violence

begins or escalates (RCOG 2001) and these narratives reveal the violence within a specific

period of time, during pregnancy. This violence has a causative effect on two lives, the

mother and the fetus.

I have lost two children previously at three months but he was violent to me

when I lost those as well. But now my cervix doesn't shut properly because

like I went through so much violence, so, that's why my cervix doesn't shut

so I had to have the stitch in and everything (P1).

My mum died… and I were pregnant and two days after she died he did a

rocky on me, right on my stomach when I was pregnant hitting either side

and ended up the baby died and I had to have it removed (pause) I was 16

weeks (P2).

There was a time when I was pregnant with my daughter when he threw,

you know those big bottles of juice, he threw one of those at me, he threw

cups at me, hit me in the face with a remote, he's flicked ciggies at me and

erm he has dragged me out of the bathroom by my hair. He hit me in the

tummy once when he just walked past me and elbowed me (P3).

When I was six months’ pregnant, the beating me up, that was the worst

because it got to the point where I thought ‘I can't let him do this when I

have a child inside me’… you know I thought what if I stay here, he is

going to end up delivering the baby you know what I mean. He would say I

need a Caesarean and cut me open and stuff, something sick like that (P4).

7
Two of the women explicitly revealed the impact of the physical violence directed against

their pregnancy. Pregnancy is a particularly high risk life event for women experiencing

domestic violence with some suggesting that actual physical violence may be initiated or

escalate at this time (Amaro et al 1990; McGee 2000). All these women talked of their

experiences and the effects on the pregnancy, with two women experiencing miscarriages

following domestic violence.

Woman’s perceptions of the body following domestic violence

A psychological revulsion to the women’s own bodies was a direct consequence of the

physical abuse and associated scarring. The longevity of the psychological effects of these

injuries was evident from the women’s narratives. The women talked of their perceptions of

their body following injuries sustained from the physical violence. They revealed an

appearance related dislike of parts of their body following scarring and injuries resulting from

physical assaults.

I wouldn’t show my legs and I wouldn’t show a bit of my body… I'm all

horrible with all the scars on me basically from the violent relationship.

There's just so many I wish they would just go really. It's the contact and

touching. At the time I had him [baby] I couldn't let anyone touch me I

would just rather keep me to myself in my own (P1).

I hate myself. I hate my body. You see I have to wear things like this

[baggy trousers and top] all the time. I have scars on me and my legs have

permanent bruises. I always wear shell suits or long pants and baggy tops. I

8
 can’t wear tops and shorts. You see some people out who hardly wear

anything, but I can’t even wear shorts. I hate my body. I am even worried

about if I find someone else how will the bed thing be because he has made

me feel dirty (P4).

I hate it [body]. I hate everything about me. I think it is probably the way he

has made me fee… I feel disgusting. I think you know how much you have

washed, they are still there. You want a new body to get rid of them… and

the fact of being a perfect size that he [partner] wanted me to be, I don’t like

my waist, I don’t like my chest. I don’t like nothing about me (P6).

Some of the women experienced a generalised negative effect on their body image following

domestic violence, a repulsion of their own bodies. To explain this phenomenon, in the

context of a violent relationship, Weaver argues that a woman’s appearance may be altered

due to scarring and injury following domestic violence, and this may result in an appearance-

related residual injury (Weaver et al 2007). Women appear to experience some residual

dislike towards their bodies after pregnancy generally, based on BMI (Mednelson et al 2001)

and urinary symptoms (Pauls et al 2008). For the women in this study, they talked of a more

specific or zonal body dysmorphia relating to the site of the physical violence perpetrated by

their male partner. The first two excerpts both identify the causative factor of zonal

dysmorphia as being the resultant effects from scarring following physical injuries.

Physical violence has been acknowledged as a component of domestic violence (Krug 2002),

and been the focus of contemporary literature (Beck, Freitag and Singer 1996; Bacchus et al

2004). However, the excerpts from the women’s narratives illuminate the psychological

impact, and the longevity of the effects of physical violence.

9
How women feel about breastfeeding their baby

Whilst the women did not talk of the partners feelings towards infant feeding, they shared

their own feelings towards breast feeding in the context of their violent relationships.

I didn't want to breastfeed because I had to cover up (P1).

I tried breastfeeding but I couldn't, I couldn't look at myself, and I couldn't

touch myself or anything (P1).

I bottle-fed her…that was my choice. I didn’t feel like breast feeding

because of the abuse (P5).

He used to grab my breasts, he used to grope me and pull my breast all the

time. Every time we sat down he would do it. So I feel they are dirty now

and I can’t even think about breastfeeding (P4).

The women experience a dislike towards their own bodies, specifically directed towards at

their own breasts. The previous section illuminated women’s aversion of their own bodies

following physical violence. This dislike appears to extend beyond personal feelings,

projecting onward towards their baby influencing their feelings towards breast feeding.

DISCUSSION

Breastfeeding requires the woman to be self confident enough to protect her needs, including

support whilst feeding (Van Esterik 2006). Based on the premise that women living with

domestic violence experience a range of controlling and coercive behaviours thereby limiting

autonomy and undermining self confidence (Harne & Radford 2008), these women’s

narratives reveal how the experiences of domestic violence have impacted on breast feeding

10
through a psychological revulsion to a part or parts of their bodies. This negative perception

of their body appears to impact on a woman’s choice to breast feed and the longevity of the

psychological effects of these injuries are evident from the women’s narratives. The women

talk of their perceptions of their body following injuries sustained from the physical violence

revealing an appearance related dislike to the areas targeted and scarred. These findings may

be considered as significant markers of the resultant effects of physical assault associated

with a violent relationship.

Limitations

The main limitation with this study is the small sample size. However despite this study’s

limitations in generalizability, the women’s narratives do offer a useful insight into how their

experiences of domestic violence negatively affected their decision to disclose the abuse, and

its impact regarding breast feeding.

CONCLUSION

Despite the plethora of literature regarding the effects of domestic violence, there has been

minimal attention regarding how physical abuse in the context of domestic violence, has

affected women and their feelings towards breast feeding. Indeed, there are few studies that

explore a correlation between domestic violence and a woman’s choice of infant feeding.

This paper suggests that women experience a body dysmorphia as a direct result of domestic

violence, with their excerpts revealing a dislike of their breasts being linked to the physical

violence and assaults. It is not known if pre existing body dysmorphia existed before

11
pregnancy, or preceded the violence. Future research may focus in the transposition of

violence throughout a relationship to understand these dynamics more fully.

The complexities surrounding a women’s desire to breast feed are not yet fully understood

(Lau & Chan 2007). These women’s narratives have however contributed to this arena by

illuminating their feelings towards their bodies and choice in infant feeding. This study then

offers healthcare providers a useful perspective on this important issue. Furthermore, the

subtle signs of domestic violence that revolve around body image and breast feeding may

illuminate deeper psychological trauma worthy of further investigation by the attending

midwife.

Acknowledgments

The author wishes to thank the women who participated in the study and the staff within the

two refuges for their support. The author is also grateful to the study’s supervisory team for

their support and guidance.

Key Phrases
1. The subtle signs of domestic violence recognised by a woman’s body
dysmorphia may be indicative of a deeper psychological trauma for which the
woman requires support and intervention from the multi-disciplinary team.
2. The effects of domestic violence may negatively affect a woman’s self
perception of her body.
3. Women may experience a dislike to a specific part of the body as a direct
result from physical violence experienced within a violent relationship.

12
 4. Experiencing body dysmorphia may impact on a woman’s’ choice of infant
feeding.

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