Bicol University Graduate School

Master of Arts in Nursing

Legazpi City

ROUTINE DOMESTIC VIOLENCE SCREENING FOR PREGNANT WOMEN IN

JOSEFINA BELMONTE DURAN MEMORIAL DISTRICT HOSPITAL

____________________________

A Thesis Presented to the

Faculty of the Master of Arts in Nursing Department
Bicol University
____________________________

In Partial Fulfillment
of the Requirements for the Degree
Master of Arts in Nursing

____________________________

Shaira Marise E. Letada, RN

 CHAPTER 1

THE PROBLEM AND ITS BACKGROUND

Domestic violence (DV) is a lethal crime, a social peril and a costly public health care

problem.

Fortinash and Holoday Worret (2004) define domestic violence (DV) as:

“Learned behaviors used by one or more persons in an intimate or family relationship for the

purpose of controlling the behavior of others. Violence may take the form of physical,

psychological, sexual, or emotional abuse, intimidation, threats, isolation, economic control, or

stalking.”.1

Unknown to many, it can explode anywhere, any time and within any economic class.

DV can take the form of threats, verbal abuse, battering, rape and murder. On a report

published by the World Health Organization (WHO), it is clearly stated that half of all women

died from homicide killed by their current or former husbands and partners. 2

DV is deeply rooted in our culture, sanctioned by religion and codified by common law,

wife-battering and corporal punishment were considered a legitimate exercise of a man’s power

over his wife and his children. Although laws nowadays no longer allow a husband to beat his

wife and children, too often DV is still considered a private affair. This attitude has changed

somewhat in recent years. However, old attitudes and “habits” are hard to break and bury.

Worldwide, approximately one in every three women will be victimized by DV in their

lifetime.3 In the Philippines, while the documentation of all forms of VAW has yet to be

achieved, existing data indicate that VAW is still a pervasive social problem. Due to the

sensitivity of the issue and its impact on women and their families, many cases of violence often

go unreported.
 According to some studies, incidence of DV can escalate during pregnancy. This raises a

concern for healthcare providers, including nurse practitioners, because it can lead to

complications of pregnancy and potentially the death of expectant mothers and their unborn

infants. Second only to car accidents, homicide is the most prevalent cause of traumatic death

during pregnancy and is responsible for 20% of maternal deaths in the United States. 4

In these instances, nurses, doctors and other health care practitioners cater medical

services to the victims for health assistance. They are often the first ones who respond to the

bloody wounds and painful bruises, often unaware that these were caused by abusive partners

unless otherwise reported.

On March 27, 2004, the RA 9262 or otherwise known as “Anti-Violence Against Women

and Their Children, Providing for Protective Measures for Victims, Prescribing Penalties thereof

and for other Purposes of 2004” took effect and has legally addressed this issue. 5 It has been

instituted to criminalize brutal behavior and improve the safety of women. It is a concrete

response to a call of the United Nations (UN) in promoting gender equality and peace. This law is

also being supported and strengthened by the Philippine Millennium Development Goal (MDG)

5 which aims to promote gender equality and empower women.

Despite implementation of these laws against VAW and increased awareness that

violence against women is a common occurrence, only a few general health care facilities pay

attention to this issue. Regular screening for DV is conducted by less than half of reproductive

healthcare providers.6 Little attention is paid to the shortcomings of health care systems that

struggle to help victims of domestic violence.

Therefore, it is not enough to pass laws that mandate reporting DV and arresting

batterers or that make criminal penalties tougher. We should urge building strong, preventive

and protective support systems for the victims. Since nurses are at the front lines of the health
profession, they should be trained on how to properly assess and screen women specifically

high risk pregnant women for DV during their visit in order to avoid long-term negative effects

of violence. Partnerships with different agencies such as the Philippine National Police (PNP) and

the Department of Social Welfare and Development (DSWD) that can be partners to resolving

such heinous crimes must also be established.

Although healthcare practitioners have awareness and understanding of the important

roles they play in addressing domestic violence, very few of them live out these responsibilities

mainly due to lack of training or experience when it comes to this matter. Added to this is the

notion that domestic violence is a private matter and should be kept a family affair. The current

study is designed to gather data on the perception of patients and nurses on routine domestic

violence screening for pregnant women.

During the researcher’s first year in graduate school, she together with the class in

Maternal and Child Health organized the Seminar Workshop entitled, “Violence Against Women

and Children: Health Practitioner’s Role”. Here, speakers from the Philippine National Police

(PNP) and Department of Social Work and Development (DSWD) discussed pertinent

information regarding violence against women. Upon listening to these discussions, the

researcher realized how limited the nurses’ roles are in addressing domestic violence especially

in pregnant women. Looking back to the researcher’s experience as a nurse at Josefina

Belmonte Duran Memorial District Hospital (JBDMDH), there was not one incident when she or

other colleagues questioned about a pregnant woman’s experience of abuse from her partner

since this is not part of the hospital’s protocol. This occurrence is what inspired the researcher

to venture into this rather sensitive subject matter.

Statement of the Problem

This study will look into the implementation of routine domestic violence screening for

pregnant women in Josefina Belmonte Duran Memorial District Hospital (JBDMDH). Specifically,

it will seek answers to the following inquiries:

1. What is the profile of pregnant patients and nurses in terms of:

1.1 age

1.2 sex

1.3 civil status

1.4 highest educational attainment

1.5 religious affiliation?

2. What are the perceptions of the pregnant patients and nurses towards routine domestic

violence screening?

3. Is there any significant difference between the perceptions of the patients and the nurses?

4. What measures may be proposed relative to the implementation of routine domestic violence

screening for pregnant women?

Scope and Delimitation

This study will be primarily focused on the implementation of routine domestic violence

screening for pregnant patients of Josefina Belmonte Duran Memorial District Hospital

(JBDMDH). The profile of the respondents who will be pregnant patients and nurses was

delimited to age, sex, civil status, highest educational attainment and religious affiliation

because they are the ones that have bearing on the perception towards routine domestic
violence screening. All pregnant patients brought to JBDMDH and all nurses employed in the

said hospital are respondents of the study.

The perception will focus on the respondents’ overall stance on the implementation of

routine domestic violence screening for pregnant patients. Also included in the study will be the

determination of the significant difference among the perceptions of the patients and the

nurses. In the end, measures relative to the implementation of routine domestic violence

screening for pregnant women would become part of the overall output of the study.

This study will involve all pregnant women brought to the hospital for a week regardless

if admitted or not and all the staff, job order and volunteer nurses working in the hospital. All

other factors not mentioned are excluded in the investigation.

Significance of the Study

Domestic violence has become a pandemic. This does not exclude the Philippines and in

particular the province of Albay. Women today are becoming more aware of their rights. They

demand equality and disdain anything that violates their womanhood. With these demands,

laws have been passed and implemented regarding the persecution of perpetrators who violate

women. However, these laws are not enough. What we need is a system of preventive health

care interventions which will screen the victims in order to stop the violence before it gets

worse.

This study therefore, is intended to benefit the following:

Women and their Families

The women will be the ultimate beneficiaries of the study’s results as this will help them

help themselves. Family is the primary support system of the victim and so, this research can aid

in educating family members on how to provide support to the target of abuse.

Health Care Workers

Being in the front line of the health care team, nurse practitioners are usually the first

ones to observe the effects of DV. Therefore, they should be well-equipped with knowledge and

training regarding proper approach and documentation of DV. With this research, they will be

able to guide the victims and advocate the early detection and prevention of DV.

Government Officials and Organizations (Inter-Agency Council on Violence Against Women

and Their Children- IAC-VAWC)

Part of a woman’s support system is the government. Through this research, the

government will realize that DV is not just a family affair but, a social problem as well that needs

to be immediately and properly addressed. Full and strict implementation of laws concerning

VAW must be strictly implemented. This research can be used as a reference material on how to

correctly approach and document a DV case.

Law Makers

This study’s review of the current laws employed against DV can direct policy makers in

amending present regulations. They can implement laws which include more specific roles and

responsibilities of the health care team when presented with a victim of abuse.

Community Leaders

Protection of their constituents from harm and danger is one of the prime obligations of

barangay officials. The related literature presented in this research can serve as their guide in

promoting safety and in preventing menace in their communities.

Teachers and Academicians

This study would underscore the significance of awareness against VAW, DV in

particular. In school, awareness can be promoted by educators by incorporating topics against

VAW in lectures. Specifically for the nursing course and other allied health care courses,

advocacy for anti-violence can be done through organization of seminars and symposia.

General Public

The general public is part and parcel of the whole in the prevention, control and solution

to DV. Domestic violence is not a private matter anymore. It affects the whole community. For

this reason, reporting and calling for help and in behalf of the victim could be possible with their

help.

Future Researchers

Other researchers who are motivated and dedicated to stopping violence against

women can use this research as a reference material in their future endeavors.
 Notes

1
Katherine Fortinash et.al. Psychiatric Nursing Care Plans. USA: Mosby, Inc., 1995, p.
667.

2
World Report on Violence and Health: Summary. Geneva, World Health Organization,
2002, p. 15.

3
Valerie Nicole Crawford. Best Practice Screening Women for Domestic Violence in
Primary Care Settings, 2007, p. 8, available at
http://www.nursing.arizona.edu/Library/Crawford_Valerie.pdf

4
Chang, J., Berg, C., Saltzman, L., & Herndon, J. (2005). Homicide: A leading cause of
injury deaths among pregnant and postpartum women in the United States, 19911999.
AmericanJournalofPublicHealth, 95(3), 471-477.

5
Republic Act No. 9262 available at
http://www.lawphil.net/statutes/repacts/ra2004/ra_9262_2004.html

6
Valerie Nicole Crawford. Best Practice Screening Women for Domestic Violence in
Primary Care Settings, 2007, p. 25, available at
http://www.nursing.arizona.edu/Library/Crawford_Valerie.pdf
 CHAPTER 2

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter is a presentation and discussion of related literature and studies that have

been conducted locally and abroad. These were found to have bearing on the present study that

is why they are cited in this chapter in condensed form. It also includes the synthesis of the

state-of-the-art, gaps bridged by the study, theoretical and conceptual frameworks, and the

definition of terms.

Related Literature

According to the WHO, “Violence” is defined as “the intentional use of physical force or

power, threatened or actual, against oneself, another person, or against a group or community

that either results in or has a high likelihood of resulting in injury, death, psychological harm,

mal-development or deprivation’’.1

Two of the most common forms of violence against women are abuse by intimate male

partners and coerced sex. Intimate partner abuse also known as domestic violence, wife-

beating, and battering is almost always accompanied by psychological abuse and in one-quarter

to one-half of cases by forced sex as well. The majority of women who are abused by their

partners are abused many times. In fact, an atmosphere of terror often permeates abusive

relationships.

The United Nations Declaration on the Elimination of Violence against Women includes

a widely accepted definition of violence against women as “any act of gender-based violence

that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to
women, including threats of such acts, coercion, or arbitrary deprivations of liberty, whether

occurring in public or private life.”2

The Declaration defines violence against women as encompassing, but not limited to,

three areas: violence occurring in the family, within the general community, and violence

perpetrated or condoned by the state.

These have bearing to the study since it emphasizes our society’s need to be aware of

Violence Against Women. It stresses that women be given a voice, a chance to speak up and an

opportunity to cry for justice and equality in a society where women face a stigma of being the

weaker gender. It also widens the definition of violence against women as not only physical but

also psychological and that it is not merely a private affair but a public matter as well.

This study will particularly center on violence against women in the family. Violence in

the domestic sphere is usually perpetrated by males who are, or who have been, in positions of

trust, intimacy and power – husbands, boyfriends, fathers, fathers in-law, stepfathers, brothers,

uncles, sons, or other relatives. 3 Domestic Violence can be manifested through Physical abuse,

Sexual abuse, Psychological abuse and Economic abuse.

Physical abuse refers to acts that include bodily or physical harm 4 such as slapping,

beating, arm twisting, stabbing, strangling, burning, choking, kicking, threats with an object or

weapon, and murder.

Sexual Abuse pertains to an act which is sexual in nature, committed against a woman 5

such as coerced sex through threats, intimidation or physical force, forcing unwanted sexual acts

or forcing sex with others. Sexual abuse and rape by an intimate partner is not considered a

crime in most countries, and women in many societies do not consider forced sex as rape if they

are married to, or cohabiting with, the perpetrator. 6 The assumption is that once a woman is
married, her husband has the right to unlimited sexual access to her. Some countries have

begun to legislate against marital rape including the Philippines. Although provision of such laws

represents considerable progress, it is still often difficult for a woman to press charges.

Psychological abuse are acts or omissions causing or likely to cause mental or emotional

suffering of the victim such as but not limited to intimidation, harassment, stalking, damage to

property, public ridicule or humiliation, repeated verbal abuse and mental infidelity. 7 It includes

behavior that is intended to intimidate and persecute, and takes the form of threats of

abandonment or abuse, confinement to the home, surveillance, threats to take away custody of

the children, destruction of objects, isolation, verbal aggression and constant humiliation. 8 This

kind of violence is harder to capture and is less evident than physical battery. Victim- survivors

report that ongoing psychological violence – emotional torture and living under terror – is often

more unbearable than the physical brutality, with mental stress leading to a high incidence of

suicide and suicide attempts.9

While the impact of physical abuse may be more ‘visible’ than psychological scarring,

repeated humiliation and insults, forced isolation, limitations on social mobility, constant threats

of violence and injury, and denial of economic resources are more subtle and insidious forms of

violence. Plus, the intangible nature of psychological abuse makes it harder to define and report,

leaving the woman in a situation where she is often made to feel mentally destabilized and

powerless. It takes place in situations where a woman may seem free to leave, but is held

prisoner by fear of further violence against herself and her children, or by lack of resources,

family, legal or community support.

Economic abuse refers to acts that make or attempt to make a woman financially

dependent which includes, but is not limited to the following: 1) withdrawal of financial support

or preventing the victim from engaging in any legitimate profession, occupation, business or
activity; 2) deprivation or threat of deprivation of financial resources and the right to the use

and enjoyment of the conjugal, community or property owned in common; 3) destroying

household property; 4) controlling the victims' own money or properties or solely controlling the

conjugal money or properties.10 It also comprises acts such as the denial of funds, refusal to

contribute financially, denial of food and basic needs, and controlling access to health care,

employment, etc.11

Healthcare should always focus on a person’s overall wellness. Therefore, healthcare

professionals need to bear in mind that a woman’s wholeness is damaged by domestic violence

and so, efforts should be made to help women pick up every piece of them and put them back

together again.

Women are more at risk of experiencing violence in intimate relationships than

anywhere else.12 According to a UNIFEM report on violence against women, out of 1,327

incidents of violence against women collected between January 2003 and June 2005, 36 women

had been killed in 16 cases (44.4 %) by their intimate partners. 13

Each year, over 324,000 pregnant women are victims of domestic violence in the United

States. A number of countries have sought to statistically analyze the amount of adult women

who have experienced domestic violence during pregnancy: 1) UK Prevalence: 3.4% 2) USA

Prevalence: 3.4 – 33.7% 3) Ireland prevalence: 12.5% 4) Canada, Chile, Egypt and Nicaragua: 6-

15%. Incidence rates are higher for teenagers. The incidence rate for low-income, teen mothers

is as high as 38%.14

Within the six weeks following birth, 11 new mothers were known to have been

murdered by their male partners during 2000-02, and 14% of all the women who died during or

immediately after pregnancy (43 women) had reported domestic violence to a health

professional during the pregnancy. Between 4 and 9 women in every 100 are abused during
their pregnancies and/or after the birth. Thirty percent (30%) of domestic violence starts in

pregnancy and 12% of the 378 women whose death was reported to the Confidential Enquiry on

Maternal Deaths had voluntarily reported domestic violence to a healthcare professional during

their pregnancy. None had routinely been asked about domestic violence so this is almost

certainly an under-estimate.15

This literature goes to show that violence against women can happen to anyone, occur

anywhere and at any point in time. It also reveals a high statistics of pregnant victims who do

not seek treatment or assistance due to the double standard of society and cultural norms

which may lead to maternal death and stillbirth. It also stresses the deficiency and the improper

documentation of these cases which then hinders its resolve. Unless this crime is brought to a

halt, cases would continue to escalate and long term effects such as denial of fundamental

rights, undermining of human development goals and health consequences would persist.

International human rights instruments such as the Universal Declaration of Human

Rights (UDHR), adopted in 1948 and the Convention on the Elimination of All Forms of

Discrimination Against Women (CEDAW), adopted in 1979, affirm the principles of fundamental

rights and freedoms of every human being. The CEDAW is guided by a broad concept of human

rights that stretches beyond civil and political rights to the core issues of economic survival,

health, and education that affect the quality of daily life for most women. 16 The Convention calls

for the right to protection from gender-based abuse and neglect. The strength of these treaties

rests on an international consensus, and the assumption that all practices that harm women, no

matter how deeply they are embedded in culture, must be eradicated. Legally binding under

international law for governments that have ratified them, these treaties oblige governments

not only to protect women from crimes of violence, but also to investigate violations when they

occur and to bring the perpetrators to justice.

 Millennium Development Goals are developmental international goals that were agreed

upon during the Millennium Summit in 2000. It consists of eight specific and concrete targets

that focus on the reduction of the worst forms of human deprivation. There were 193 United

Nations member states that committed to achieve it by the year 2015, the Philippines included.

We are doing well with some of the goals; however, MDG Five, the Improvement of Maternal

Health, is the least likely to be achieved by the target year.

The targets under Goal Number 5 are the reduction of maternal mortality rate (MMR)

by three quarters by 2015 (half by 2000, half by 2015) and increased access to reproductive

health services to 60% by 2005 (80 percent by 2010, and 100 percent by 2015).

Maternal Mortality Rate is defined as the number of maternal deaths per 100,000 live

births.17 The 1993 and 1998 National Demographic and Health Survey (NDHS) showed that the

MMR in the Philippines went down to 172 from the 1993 baseline of 209 deaths. In 2006, the

Family Planning Survey (FPS) demonstrated that it declined to 162. Because of MMR’s dwindling

progression, it is still far from the 2015 target of 52 deaths per 100,000 live births. This slow

pace of achieving the target is due to the disturbing reproductive and maternal health situation

of women in our country.18

The Department of Health (DOH) has identified the main culprits of maternal deaths,

around which they have developed the ‘three delays’ model. The model consists of the

following: (a) delay in deciding to seek medical care; (b) delay in reaching appropriate care; and

(c) delay in receiving care at health facilities. 19

The discussion of the MDG 5 has a bearing to the study because clandestine cases of

domestic violence which are improperly reported and most of the time undocumented

especially in pregnant women can and will add up to the burden of the government in hastening

the pace towards achieving the MDG 5. We may not know or prove it yet but, domestic violence
may be one of the causes for the “three delays” model identified by the DOH. Recognition of the

fact that as long as women’s potentials to participate fully in their society is denied, countries

cannot reach their full potential. The Philippine government must therefore commit itself to

instigating actions to eliminate violence in all its forms and in all areas of life.

In comparison with non-abused women, abused women have a 50-70 per cent increase

in gynecological, central nervous system and stress-related problems. 20

While physical injury represents only a part of the negative health impacts on women, it

is among the more visible forms of violence. The United States Department of Justice has

reported that 37 percent of all women who sought medical care in hospital emergency rooms

for violence-related injuries were injured by a current or former spouse or partner. Thirty-two

(32) assaults result in injuries ranging from bruises and fractures to chronic disabilities such as

partial or total loss of hearing or vision, and burns may lead to disfigurement. 21

The impact of violence on women’s mental health leads to severe and fatal

consequences. Battered women have a high incidence of stress and stress-related illnesses such

as post-traumatic stress syndrome, panic attacks, depression, sleeping and eating disturbances,

elevated blood pressure, alcoholism, drug abuse, and low self-esteem. For some women, fatally

depressed and demeaned by their abuser, there seems to be no escape from a violent

relationship except suicide.22

Domestic violence is more common than any other health problem among women

during pregnancy.23 During pregnancy, domestic violence is categorized as abusive behavior

towards a pregnant woman, where the pattern of abuse can often change in terms of severity

and frequency of violence. Abuse may be a long-standing problem in a relationship that

continues after a woman becomes pregnant or it may commence in pregnancy. 24

 Experts say that pregnancy is more likely to have an aggravating effect on an abusive

partner. One in 6 abused women reports that her partner first abused her during pregnancy and

according to the Centers for Disease Control, at least 4 to 8 percent of pregnant women report

suffering abuse during pregnancy. Pregnancy can cause stress in any relationship, and it's a

common trigger of domestic violence.25

A violent pregnancy is considered high risk because verbal, emotional, and physical

abuse all lead to adverse health consequences for both the mother and fetus. Women battered

during pregnancy were more frequently and severely beaten throughout the course of their

relationship compared to women who were not abused during pregnancy. Intimate Partner

Violence also accounts for a large portion of maternal mortality. 26

Domestic violence’s deleterious impact on the maternal and child health is alarming.

What is more disturbing is that these effects often go unnoticed. Health care practitioners

should pay close attention to these because it has a bearing not only to the mother and child’s

health but, also to the measures we take as health care professionals in the prevention of

maternal and child death. Physical, mental and emotional preparation and stability is a

requirement when handling such cases. Clinical eye, vigilance, rationality and fast decision-

making skills are vital qualities that a health care practitioner must possess when dealing with

these situations. These skills can only be put to good and frequent use if protocols for domestic

violence screening for pregnant women are created and adopted by health care facilities.

It is important that healthcare providers know how properly screen women for domestic

violence. Many women have a relationship with a health care provider, particularly during

pregnancy, well-baby visits and even after birth. What still needs work is making sure that the

care providers and emergency room workers know the signs of abuse and what to do about

them. In the U.S., about 17% of all routine health care providers screen for domestic violence at
their first visit, with only 10% screening at subsequent visits. 27 Routine enquiry about domestic

violence during antenatal booking is infrequent despite such enquiry being included in clinical

practice recommendations and is made less frequently than any other aspect of social history

taking. Healthcare professionals have a duty to record anything that might impact on the health

of their patients including domestic violence.

NSF (National Standard Framework) for Children, Young people and Maternity Services

includes points on identification of and response to domestic violence in pregnancy. From these,

it is mentioned that women should be offered "a supportive environment and the opportunity

to disclose" and maternity service staff should be "aware of the importance of domestic

violence and competent in recognizing the symptoms and presentations" and "able to make a

sensitive enquiry" and "provide basic information" and referral to local services. 28

Battered women often seek medical attention for abuse-related injuries as well as

health problems that appear unrelated to any specific injury or predisposing health condition.

In many cases a physician or nurse may be the only person women feel comfortable talking to

about their partner’s violence. This provides health care providers with a unique opportunity to

identify and assist domestic violence survivors. 29

Health care professionals need to become involved in the prevention and treatment of

domestic violence—a public health dilemma. Having a sound knowledge base in this matter is

crucial. To intervene in domestic violence requires the HCP to be proactive and to plan

interventions. An instant "cure" may not be achieved with the woman in a violent relationship;

however, success may be defined as small steps toward empowerment.

Screening for domestic violence provides a critical opportunity for disclosure of

domestic violence and provides a woman and her health care provider the chance to develop a
plan to protect her safety and improve her health. Recent experience with AIDS, smoking

cessation and improved outcomes in breast cancer and cardiovascular disease support the

efficacy of early identification and intervention. The prevalence and the health, social and

economic costs of domestic violence require equivalent attention and equally effective action by

the health care system.

A publication produced by “The Family Violence Prevention Fund” states that the need

for a set of clear guidelines for screening practice [of domestic violence] has become apparent.

It also presents recommendations for how screening should occur within the healthcare system.

The FUND also mentions a general policy statement that all healthcare institutions and

practitioners should follow.30 (See Appendix 1)

Over the past decade, domestic violence has increasingly been recognized as an

important issue for the health system because it has adverse negative impacts on women’s

physical and psychological health in both the short- and long-term. Abused women use health

services at rates higher than other women, with costs to the health system increased when

domestic violence is not recognized as the underlying problem. Since most abused women do

not present to primary health care settings with injury-related complaints, their history of

domestic violence is not commonly identified. While most women do not disclose their

experience of violence to health care providers, they will do so when asked directly about

violence and abuse in their lives.31

The debate over routine screening is a debate about how best to improve rates of

identification of abused women within health care settings: whether it is better to ask all women

routinely, or whether the health care provider should have a high index of suspicion and ask

when there are indicators that a woman may have a past or current history of domestic
violence. With either approach, the response of the health provider is critical. Survivors report

that a sympathetic and informed response is extremely valuable and can be a catalyst to change.

The Philippines has enacted several laws protecting women from violence which

includes the Republic Act 9262 also known as, "Anti-Violence Against Women and Their Children

Act of 2004". The Act declares that, “The State values the dignity of women and children and

guarantees full respect for human rights. The State also recognizes the need to protect the

family and its members particularly women and children, from violence and threats to their

personal safety and security… the State shall exert efforts to address violence committed against

women and children in keeping with the fundamental freedoms guaranteed under the

Constitution and the Provisions of the Universal Declaration of Human Rights, the convention on

the Elimination of all forms of discrimination Against Women, Convention on the Rights of the

Child and other international human rights instruments of which the Philippines is a party.” 32

Section 31 of the said act positions that, “Any healthcare provider, including, but not

limited to, an attending physician, nurse, clinician, barangay health worker, therapist or

counselor who suspects abuse or has been informed by the victim of violence shall: (a) properly

document any of the victim's physical, emotional or psychological injuries; (b) properly record

any of victim's suspicions, observations and circumstances of the examination or visit; (c)

automatically provide the victim free of charge a medical certificate concerning the examination

or visit; (d) safeguard the records and make them available to the victim upon request at actual

cost; and (e) provide the victim immediate and adequate notice of rights and remedies provided

under this Act, and services available to them.” 33

In order for HCP’s to perform these duties, Section 42 of the abovementioned act states

that training of persons involved in responding to violence against women and their children
cases shall be mandated. 34 They shall be required to undergo education and training to acquaint

them with aids they can offer to victims.

However, the healthcare team is not alone in this endeavor. Section 39 of this act also

established the Inter-Agency Council on Violence Against Women and Their Children (IAC-

VAWC).35 (See Appendix 2)

Section 40 is about the Mandatory Services and Programs for Victims. The DOH shall

provide medical assistance to victims. 36 However, these medical assistance is often just for

Medico legal cases which usually focus on physical harm. Treatment, rehabilitation and referral

are the typically practiced assistance. Early identification however, is more often than not,

missed.

The enactment of the RA 9262 and other laws which aim to protect and empower the

woman is a concrete step towards the elimination of societal discrimination. Despite its full and

strict implementation, amendments to this law should be taken into consideration to specify

and improve the healthcare professional’s roles.

Related Studies

Local Studies

From a case study by Bernardita D. Patacsil entitled, “Violence Against Women: Their

Implications to Nursing Practice”, she mentioned that (ABSTRACT/RESULTS/SALIENT POINTS).37

“Lumen”: A Case Study on Domestic Violence by Fleoy Ysmael revealed that a woman

victim’s behavior has a pattern before and after the incidents of abuse. There is a sense of low

self-esteem which was later reinforced by the abuses she experienced, defiance at the first

instance of abuse which later on turned into helplessness and adaptation to the abuses
acquired. Furthermore, cultural factors contribute to the development of abuse in the family

and the reactions of a woman towards an abusive relationship. Moreover, psychological factors,

such as the low self-esteem, lack of assertiveness of a woman in a relationship can both be the

cause or the effect of the abuse. Finally, abuses can lead to the distortion of the decision-making

abilities of a woman victim and the possibilities of seeking for crisis intervention is sometimes

vague unless other members of the family have become victims of violence themselves. 38

A study by Gil Tuparan entitled, “Building a Partnership to Overcome Domestic Violence

in the Philippines: The Case of Tessie Fernandez and Bantu Banta” talked about the founding of

the Lihok-Pilipina Foundation and also briefly discussed the role of Medical Institutions when

working with victims of abuse.

The study shared a victim’s early run-in with the medico-legal section of the Cebu City

Medical Center (CCMC), the city government hospital. Apparently, the attending female

physician berated the rape victim sent for medico-legal certification thus: "You have been raped

already and yet you refuse to spread your legs!" Ms. Fernandez, Lihok-Pilipina founder and

Executive Director could only shake her head in disbelief. She calmly went to see the doctor and

invited her to attend their NGO's gender sensitivity workshop, which the doctor did. Her frank

discussions with Lihok-Pilipina led to a series of training sessions for the medico-legal staff of

CCMC, the PNP Crime Laboratory and even private hospitals like the Vicente S. Sotto Medical

Center (VSSMC). The sensitization seminars underscored that afflictions could be more than

physical, so interventions should be more than medical.

The study later revealed that the CCMC later on established its "Violet Room" and the

VSSMC its "Pink Room", to provide the victims of physical and sexual abuse privacy, treatment

with sensitivity to their feelings and immediate attention. The hospitals also integrated violence
against women (VAW) with their medical curriculum. Meanwhile, the Silliman University in

Dumaguete City made VAW part of its nursing curriculum. Tessie Fernandez joined the panel

that critiqued the modules.

Tessie Fernandez also encouraged the Department to look into the women's

relationship with their spouses, particularly in cases where the woman sought medical attention

but did not show any obvious medical problem. She pointed out that the problem could possibly

be due to stress or trauma in the home. Eventually the City Health Department became adept in

detecting such cases and referred them to Lihok-Pilipina. 39

The local researches mentioned above focused mainly on 1) improving nursing care in

all aspects of clinical practice for women victims of violence 2) patterns of behavior before and

after incident of abuse and 3) programs that could help healthcare provided and other allied

agencies in identifying and referring victims of abuse. Part of this study’s objective is to elevate

the current nursing practices for domestic violence cases through mandatory screening of

pregnant women for domestic violence.

Foreign Studies

Bontha V. Babu and Shantanu K. Kar (2004-2005) of their study on abuse against women

in pregnancy in Eastern India, they showed that the prevalence of physical, psychological and

sexual domestic violence during a recent pregnancy was found to be 7.1%, 30.6% and 10.4%

respectively, and the lifetime prevalence during all pregnancies was 8.3%, 33.4% and 12.6%

respectively. Urban living, higher maternal age and husbands’ alcoholism were the factors

associated with domestic violence in pregnancy. Women belonging to lower social groups were

less likely to have physical domestic violence. Factors such as higher prevalence of undesirable
behaviors like denying adequate rest and diet, demand for more sex, not providing antenatal

care and pressure for male child were also associated with domestic violence in pregnancy.

They concluded that Considerable proportions of women experience some type of

domestic violence during pregnancy. Health-care providers should be able to recognize and

respond to pregnant women’s victimization and refer them for appropriate support and care. 40

Babu and Kar’s research has a bearing to the present study because it gives paramount

importance to the healthcare provider’s role in identifying, responding common signs of

domestic violence and in referring them to the applicable support persons.

Amornrat Sricamsuk (2006) conducted a study on the Thai perspective on domestic

violence against pregnant women. The results of the study showed that 53.7% of women

reported psychological abuse, 26.6 % experienced threats of and/or acts of physical abuse, and

19.2 % experienced sexual violence during the current pregnancy. In the postpartum period,

35.4% of women reported psychological abuse , 9.5% reported threats of and/or acts of physical

abuse, and 11.3% experienced sexual abuse. Women who were abused during pregnancy

showed significantly poorer health status compared to non-abused women in role-emotional

functioning, vitality, bodily pain, mental health and social functioning. Women who experienced

postpartum abuse reported significantly lower mean score in mental health and social

functioning than women who did not. Antepartum hemorrhage was found to be statistically

associated with physical abuse. No statistical differences were found between abuse status and

neonatal outcomes. There were several strategies used by abused women in dealing with

domestic violence to maximize their safety including crying, keeping quiet, leaving violent

situations and temporarily staying with relatives, seeking help from others, and notifying local

authorities. Support services that would be helpful for abused women in dealing with the

problem included emotional support, social legal assistance, and community health promotion.
Domestic violence during pregnancy and after birth is an increasing but under-recognized

problem in Thailand. It has pervasive consequences on maternal health. The findings from this

study suggest more interventions and urgent domestic violence support services need to be

established in this remote area of Thailand. This study also suggests routine screening for

domestic violence should be established to provide effective early intervention and prevention

of adverse consequences of violence, as pregnancy is a time when most pregnant women seek

health care.41

The research mentioned above focused on the following: a) effects of abuse to the

woman’s health b) strategies and support services they utilize c) domestic violence is an

increasing but rarely documented phenomenon d) screening of women for domestic violence.

These are significant to the present study because it encompasses the primary considerations

that HCP’s must look into when faced with a case of domestic violence such as women’s health

status, services that they can offer to women and early detection and proper recording.

Another related study was conducted by Castro, et al, entitled (RESEARCH TITLE). It

aimed to identify the prevalence and types of violence experienced by pregnant women 12

months before and during pregnancy. His respondents were 914 women in their 3 rd trimester of

pregnancy in 27 prenatal health clinics in the State of Morelos, Mexico. He found out that; 1)

24.4% and 24.5% experienced abuse in the 12 months period before and during pregnancy

respectively 2) 12.2% and 10.6% were physically abused before and during pregnancy

respectively 3) 18.2% and 20.5% were emotionally abused before and during pregnancy

respectively 4) 10.0% and 8.1% were sexually abused before and during pregnancy

respectively.42

Sysavanh Phommachanh on a study about Domestic Violence Against Women by Male

Partner during Pregnancy in Laos. The researcher found that women had experienced multiple
forms of domestic violence since before pregnancy and during pregnancy. This is due to

patriarchal social and cultural structure; because of given gender inequality in terms of the rigid

role of male authority as the head of the family, females take submissive roles under the control

of the husband. Patriarchal control over [the] female body and sexuality, it is seen pregnant

women are much more passive to sex than women without pregnancy. Also, according to the

study, although the socio-economic characteristics of informants were not direct factors related

to domestic violence, their education and occupation influenced the way they solved problems.

Most informants blamed themselves for the violence; this means that they were not able to see

the patriarchal social structure as the root cause of domestic violence during pregnancy. Hence,

they simply kept silent and tried to conform to patriarchal expectations because the perception

in Lao society of domestic violence as a private matter. Other factors associated to domestic

violence during pregnancy were unwanted pregnancy, alcohol use, unemployment of husband,

jealousy and mother in-law support of the husband. 43

The Philippines, like many developing countries still conform to a number of sometimes

unjustifiable and discriminating community norms and statures. Domination of men in the

family and lack of educational opportunities for women leading to domestic battery and abuse

are just some of them. The abovementioned study relates how empowerment is a vital tool in

eliminating cultural standards that undermine women. This study therefore, holds a noteworthy

position in the present study since its goal is to empower women through effective and efficient

nursing interventions in the health care delivery system.

These studies attest that domestic violence is not only a threat to the woman but also to

her children, her family and the society where she lives in. As such, all of the members of the

community especially people working in the field of healthcare must take part in the prevention

and control of domestic violence. Much like communicable diseases, DV too, can be eradicated.
 In a study conducted by Bonnie M. McClure entitled, “Domestic Violence: The Role of

the Health Care Professional (HCP)” (LOOK FOR IN THE NET), he stated that routine screening of

women for domestic violence at initial office visits and annual exams should be encouraged. For

some health care professionals (HCPs), asking about domestic violence is synonymous with

"opening Pandora's Box" or "opening a can of worms", considering this problem "too

complicated" to address. The American Medical Association reported that many professionals

are falsely influenced by societal misconceptions including: (a) Domestic violence is a rare

occurrence; (b) Domestic violence is a private matter; (c) Domestic violence does not occur in

normal relationships; and (d) The woman is somehow responsible for her abuse.

Also according to McClure, lack of knowledge and training in domestic violence may

contribute to the inability of providers to recognize and correctly interpret behaviors associated

with domestic violence. These deficiencies in the education included the inability to identify,

assess, document, and manage the care of clients experiencing domestic violence. Also,

limitations in the education of obstetrics/gynecology residents related to domestic violence

including: (a) lack of faculty interest; (b) underestimated prevalence; and (c) failure to recognize

common presentations.44

In an Australian study entitled (TITLE), Bates (2001) explored the factors which enabled

women to tell their story. (RESEARCH FOR MORE DETAILS AND RESULTS)45

With Gerbert et al. (1999) in an investigation entitled (TITLE), she found that women

identified the attitude of the health care provider to be very important. An attitude which

conveyed trust, compassion, support and understanding facilitated women talking about their

abuse. Among environmental factors, women mentioned: 1) the size and appearance of the

waiting room 2) privacy in the waiting room 3) the triage situation and the consulting area and

4) length of wait for service. Barriers to women discussing their situation included negative
service provider attitudes, lack of continuity of service providers and time constraints on service

providers.46

Ease in the evaluation and management of sensitive cases such as domestic violence

entails a thoughtful and profound physical, mental and emotional preparedness for healthcare

workers. It also necessitates the accommodating and amiable ambiance of the health service

unit. These studies have a connection to the present research because they point out the

deficiency and scarcity in the education of HCP’s in matters concerning domestic violence and

the deficiency of health services unit in providing a welcoming environment for its DV clients.

These researches also argued how healthcare professionals could have an ultimate chance to

gauge and arbitrate in the case of domestic violence if they only knew how to proactively and

pre-emptively address this healthcare dilemma.

Although concluding that, on the available evidence, it is premature to recommend

routine screening programs, the researcher emphasizes that domestic violence is an important

issue for the health system, and that health care providers should attempt to identify and

support abused women. This is consistent with the recommendations of many medical

organizations for case finding with referral when cases of domestic violence are identified.

(RESEARCH FOR ADDITIONAL RELATED STUDIES RELATING DV TO PREGNANCY)

Synthesis of the Art

Routine domestic violence screening is certainly a topic of discourse since some might

say that this is borderline invasion of privacy.

The abovementioned literature and studies discussed about Violence against Women,

specifically Domestic Violence. Redefinition of Violence Against Women as an epidemic that is

due to a wide range of interconnected causes which results to physical and psychological harm

and injustice to women, their families and the society was established.

The efforts of the Philippine government in committing itself to instigating actions to

eliminate violence against women through theRepublic Act 9262, was also emphasized.

However, a need to improve and to amend this law to indicate a more detailed description of

HCP’s roles and responsibilities is recommended. Attention was also given to the poor progress

of the country in reaching the target for MDG 5 because of incomplete and improper

documentation of domestic violence cases especially in pregnant women.

Most importantly, the aforementioned literature and studies underscored the health

care’s noteworthy role in women empowerment and domestic violence prevention and

eradication. They cited high statistics of victims who do not seek treatment or assistance due to

1) society’s standards, norms and traditions that demoralize women, 2) deficiency in the

education and training of HCP’s in matters concerning domestic violence and 3) lack of health

services unit in providing a welcoming environment for its DV clients. With these, it has also

been highlighted that; 1) agencies must work hand in hand to protect and empower women 2)

health care practitioners should be physically, mentally and emotionally trained in preventing,

questioning, documenting and referring DV cases and that 3) to elevate the current nursing

practice in DV cases, routine enquiry and screening should be made available in health agencies.

All in all, the literature and studies stress that domestic violence is a reality that should

be faced. Women empowerment can be achieved through enhanced nursing assistance which

does not merely focus on treatment and rehabilitation but on prevention and early

identification.
Gap Bridged by the Study

Numerous studies and surveys about violence against women have been conducted to

determine its causes and effects to the woman, to her family, to the perpetrator, and to the

community as a whole. Almost all of these studies’ results point out to similar conclusions and

recommendations. Nearly all studies done in the past conclude that violence against women is

rampant, that it has interrelated origins, and that it has devastating consequences. Most of

these studies likewise recommend that measures be taken by the healthcare agencies and other

organizations in order to combat domestic violence.

With this said no study of similar nature or scope that bear resemblance to the present

study has been found. In more specific terms, no study has yet been conducted to determine

and compare the perceptions of pregnant patients and nurses towards routine domestic

violence screening at Josefina Belmonte Duran Memorial District Hospital. These are gaps that

the present study attempted to bridge.

Theoretical Framework

According to Hildegard Peplau’s Interpersonal Relations Theory, “Nursing is an

interpersonal process of therapeutic interactions between an individual who is sick or in need of

health services and a nurse especially educated to recognize and respond to the need for help. It

is a maturing force and an educative instrument”. 47

Peplau enumerated the Roles of the Nurse: 1) Stranger receives the client. He/she

provides an accepting climate that builds trust. 2) Teacher who imparts knowledge in reference

to a need or interest. He/she gives instructions and provides training. 3) Resource Person one

who provides a specific needed information, answers questions, interprets clinical treatment

data and aids in the understanding of a problem or a new situation 4) Counselor helps to
understand and integrate the meaning of current life circumstances, provides guidance and

encouragement to make changes 5) Surrogate helps to clarify domains of dependence,

interdependence and independence and acts on clients behalf as an advocate. 6) Leader helps

client assume maximum responsibility for meeting treatment goals in a mutually satisfying way.

She also identified 4 Phases of the Nurse-Patient Relationship: 1) Orientation where an

individual or a family has a “felt need” and seeks professional assistance from a nurse (stranger).

This is the problem identification phase. 2) Identification where the patient begins to have

feelings of belongingness and a capacity for dealing with the problem, creating an optimistic

attitude from which inner strength ensues. Here happens the selection of appropriate

professional assistance. 3) Exploitation where the nurse uses communication tools to offer

services to the patient, who is expected to take advantage of all services. 4) Resolution where

patient’s needs have already been met by the collaborative efforts between the patient and the

nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away

from identifying with the nurse as the helping person. 48

Nurses are at the front line of health care and are sometimes considered the “shock

absorbers” of the profession. Because of the critical roles that nurses play in assisting pregnant

victims of domestic violence, it is imperative that difficulties met during the assistive process be

identified and methods to resolve these issues should be instigated. The aforementioned

principles serve as the framework of the study.

Theoretical Paradigm

Stranger Has a felt need.

Teacher
Has a problem.
NURSE-PATIENT
Leader RELATIONSHIP
Has questions.
Orientation
NURSE PATIENT
Identification

Exploitation
Surrogate
Resolution Needs assistance.

Counselor
In need of health
Resource Person services.

Figure 1. Hildegard Peplau’s Interpersonal Relations Theory

Conceptual Framework

This study attempted to gather empirical data on the implementation of routine

domestic violence screening for pregnant women in hospitals. As depicted in the conceptual

paradigm, the profile of the two sets of respondents – patients and nurses, included age, sex,

civil status, highest educational attainment and religious affiliation. These variables were

perceived to affect their perception towards routine domestic violence screening for pregnant

women in hospitals. Age refers to the length of time one has existed. Sex is the condition of

being male or female. Civil status pertains to (research). Highest educational attainment refers

to the highest degree of education an individual has completed and religious affiiation pertains

to an organization of religion one is associated with.

The perceptions of the patients and nurses focused on the concept of the

implementation of routine domestic violence screening in the hospital as part of the routine

history taking and assessment. The determination of whether the two sets of respondents agree

or disagree with the implementation of routine domestic violence screening in hospitals is based

on the questionnaire designed for the purpose.

Another component of the research in the verification of the significant difference in the

perceptions o the two sets of respondents. The study is also designed to determine if there

exists a significant difference in the perceptions of patients and nurses towards the aim of

routine domestic violence screening for pregnant women. Finally, the measures which would

come from the respondents and researcher herself, will be the ultimate output of the study.

Expectedly, they will help in the successful implementation of routine domestic violence

screening in hospitals.
Conceptual Paradigm

Profile of pregnant Significant differences of

patients and nurses: the perceptions
Perception of patients Suggested measures in
 Age and nurses towards the implementation of
 Sex routine domestic Patients routine domestic
 Civil status violence screening for violence screening for
 Highest pregnant women in pregnant women
educational JBDMDH
Nurses
attainment
 Religious
affiliation

Figure 2. Conceptual Paradigm of the Study

Definition of Terms

To facilitate better understanding of the research, the following terms have been

conceptually and/or operationally defined:

Domestic Violence. Refers to any act of gender-based violence that results in, or is likely to

result in, physical, sexual, or psychological harm or suffering to women, including threats of such

acts, coercion, or arbitrary deprivations of liberty, whether occurring in public or private life. 49

The present study adopts the same definition.

Routine Domestic Violence Screening.

Josefina Belmonte Duran Memorial District Hospital. The locale of the study, is a (short

history), located at Tuburan, Ligao City.

Profile. As used in this study, it refers to age, sex, civil status, highest educational attainment

and religious affiliation of the respondents of the study.

Perception. Pertains to the conscious recognition and interpretation of sensory stimuli that

serve as a basis for understanding, and knowing or for motivating a particular action or

reaction.* As used in this study, it refers to the agreeability or disagreeability of the pregnant

patients and nurses on the implementation of routine domestic violence screening in hospitals.
Measures. Refers to the steps toward a goal.* In this study, they refer to the recommendations

designed to facilitate implementation of hospital-based domestic violence screening for

pregnant women.
 Notes

(REVIEW!!!)

CHAPTER 3

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents the entire design and procedures that will be undertaken during

the conduct of the study. Specifically, it indicates the research method, research respondents,

research instrument and statistical treatment that will be used in the analysis of data.

Research Design

This study will be basically a descriptive-comparative type of research because “it

involves description, recording, analysis and interpretation of condition that now exists”.* In

more specific terms, the description-comparative survey will be used in this study. The

descriptive component involves the description of perception of two sets of respondents while

the comparative component covers the determination of significant differences in the

perception of the two sets of respondents. A questionnaire which will be formulated by the

researcher based on the available literature will be the main instrument in obtaining the needed

data.

Sources of Data
 There are two sources of data that will be used in this study. The pregnant patients and

nurses of JBDMDH, who will serve as respondents, will be the primary sources of data. Internet

sources, books, journals, theses and dissertations that have bearing on the study served as

secondary sources of data.

Respondents

The respondents of the study are the pregnant patients and the nurses of JBDMDH. The

patients are those pregnant women who was brought to the Outpatient Department and/or

admitted at JBDMDH. The nurses refer to all the nurses employed at JBDMDH either by

appointment or voluntarily. The respondents of the study is presented in Table 1.

Table 1
Respondents of the Study

Types of Respondents Number of Respondents

Patients -
Nurses -

Research Instrument

The survey questionnaires which will be designed by the researcher using the retrieved

literature and studies as bases, will be divided into three parts. The first part will be dealing with

the profile of the respondents inclusive of age, sex, civil status, highest educational attainment

and religious affiliation.

The second part which will be dealing with the perception of patients and nurses

regarding routine domestic violence screening will consist of (wala pa ko maisip) will be using

the following rating scale:

 5 – Strongly Agree (80 – 100%)

4 – Agree (61 – 80%)

3 – Undecided/Uncertain (41 – 60%)

2 –` Disagree (21 – 40%)

1 – Strongly Disagree (0 – 20%)

When quantified relative to the perception of the two groups of respondents, the

computed weighted mean will be referred to the following:

4.51 – 5.00 – Strongly Agree

3.51 – 4.50 – Agree

2.51 – 3.50 – Undecided/Uncertain

1.51 – 2.50 – Disagree

0.51 – 1.50 – Strongly Disagree

The third part will be the portion where the respondents can suggest measures relative

to implementation of routine domestic violence screening in hospitals.

Validation of the Instrument

The same instrument will be subject to pre-testing. The researcher will ask permission

from the Chief of Hospital of Dr. Sofronio B. Garcia Memorial Hospital to conduct validation

process among 10 nurses and patients. Suggestions will be incorporated to facilitate better

understanding and easy administration of the instruments among the respondents.

Data Gathering Procedure

Permit to conduct the study was secured from the Chief of Hospital of Josefina

Belmonte Duran Memorial District Hospital.

 The copies of the questionnaires will then be distributed and administered personally by

the researcher to the respondents. The respondents will be given time to answer the

questionnaires during their free time in the presence of the researcher so whatever queries they

may have regarding the questionnaire could be answered immediately. The questionnaires will

then be collected on the same day they were distributed to prevent a low retrieval rate.

Statistical Treatment

After all the questionnaires are retrieved, that data will be tabulated, collated and

interpreted. The data that will be gathered through the questionnaires will be subjected to

simple statistical tools. Frequency count, weighted mean and ranking will be used in the analysis

of problems one and two. To determine the significant difference of the two sets of

respondents, (stat tx).

The formula used for the computation of weighted mean follows:

Fx
X=
N

Where: X= weighted mean

= summation
N= total population
F = frequency
Notes