Detección y abordaje de la violencia de género durante el embarazo por parte de las matronas en atención primaria: Un abordaje desde la Investigación Acción Participativa

Abstract

INTRODUCCIÓN. La violencia de género es un grave problema de salud en el mundo, por su elevada prevalencia y por las complicaciones que puede tener en la salud de las mujeres. Especialmente si la mujer está embarazada, puesto que la violencia puede ocasionar complicaciones del curso del embarazo, parto y/o posparto y repercutir a su vez en la salud del feto y el futuro/a hijo/a. Las matronas son a menudo el primer punto de contacto asistencial de las mujeres gestantes, por ello se encuentran en una posición que favorece la detección y el abordaje de la violencia de género. Pero para ello necesitan la formación adecuada y superar las posibles dificultades que puedan surgir durante la asistencia a estas mujeres. OBJETIVOS. Los objetivos fueron: (1) Conocer las características y la realidad de la formación inicial y continuada de las matronas en el ámbito de la detección y abordaje de la violencia de género. (2) Promover cambios de mejora en la detección y abordaje de la violencia de género en el embarazo por parte de las matronas. METODOLOGÍA. Se realizó un estudio de investigación acción participativa. En un primer momento, se procedió a realizar un análisis documental de los planes de estudio del grado de Enfermería de todas las Facultades y Escuelas de Enfermería, así como del programa de especialización de Matrona en Cataluña. Con posteriores entrevistas semiestructuradas a dieciséis profesores/as universitarios/as. Seguidamente, se realizó un estudio de caso en una comunidad de práctica (dos centros de atención primaria en L´Hospitalet de Llobregat- Barcelona), donde se realizó entrevistas semiestructuradas a las doce matronas asistenciales, se diseñaron e implementaron sus propuestas de mejora y se valoró su utilidad. El desarrollo de la investigación mostró la pertinencia de conocer la prevalencia de la violencia de género y los factores asociados a la misma entre las mujeres gestantes que continúan el embarazo y aquellas que solicitan una interrupción del mismo en el ámbito de estudio. Para ello se realizó un estudio cuantitativo observacional, longitudinal, analítico, prospectivo de cohortes. La investigación guio el diseño de un programa de formación continuada sobre detección y abordaje de violencia de género en el embarazo, el cual se validó siguiendo la metodología de juicios de expertos. RESULTADOS. En Cataluña se imparte formación inicial en violencia de género con una media de 5.5 horas en el grado de Enfermería y con 2 horas en la especialidad de Matrona. La metodología de enseñanza principal es la activa. El profesorado se siente personalmente comprometido con la capacitación sobre violencia de género del alumnado pero solicitan más tiempo para tal fin. Todas las matronas entrevistadas habían recibido formación inicial y continuada sobre violencia de género, pero no se sienten seguras a la hora de detectar y abordar los casos y demandan ampliar su formación en el tema. Durante la investigación se diseñaron e implementaron dos acciones de mejora: (1) una actividad formativa sobre violencia de género; (2) la aplicación de un instrumento validado para la detección de la violencia de género (el Index of Spousal Abuse). Ambas acciones fueron valoradas como útiles tanto por aumentar los casos detectados de violencia de género por parte de las matronas como por mejorar sus habilidades y su seguridad en la asistencia de los casos. La prevalencia de violencia de género según el cuestionario validado empleado fue del 25% entre las mujeres que solicitan una interrupción del embarazo (n=120) y del 8.92% entre las mujeres que continúan con la gestación (n=381), existiendo una

asociación estadísticamente significativa entre exposición a la violencia y complicaciones durante el parto (p=0.025). La exposición a la violencia incrementa de forma significativa el riesgo de realizar una interrupción del embarazo (OR=4.06; IC=2.23-7.48; p<0.001) y que el/la recién nacido/a tenga complicaciones de salud (OR=2.68; IC= 1.02-6.48; p=0.035). El programa de formación continuada diseñado fue valorado de forma positiva por los seis expertos/as con puntuaciones medias en los ítems evaluados entre 5.8 y 10 (sobre 10) y un coeficiente de concordancia de Kendall= 0.44. CONCLUSIONES. Es necesario dedicar más tiempo a la formación de estudiantes de Enfermería y Matrona en violencia de género de una forma transversal y sistematizada, que incluya la práctica clínica, desde las perspectivas sanitaria, psicológica, social, ética y legal. De igual forma, es conveniente responder a la demanda de las matronas en cuanto a desarrollar la formación desde una perspectiva multidisciplinar, con metodologías activas que proporcionen conocimientos específicos y habilidades comunicativas. Es necesario incorporar el cribado sistemático tanto a las mujeres que continúan con el embarazo, como a las que deciden interrumpirlo.

INTRODUCTION: The high prevalence of domestic violence and the health complications it creates for women make it a severe public health problem throughout the world. Complications increase when the woman in question is pregnant; violence can provoke complications during pregnancy, childbirth and/or the post- partum period, as well as compromise the health of the child before and after birth. Because midwives are often the first point of contact for pregnant women seeking assistance, they are well-positioned to detect and address domestic violence over the course of a pregnancy. However, midwives need adequate training and to be able to overcome the difficulties that may arise while helping these women. OBJECTIVES: The objectives were to: (1) Observe the defining features and the practical reality of midwives’ basic and continuous education on detecting and addressing domestic violence. (2) Encourage actions that improve midwives’ abilities to detect and address domestic violence during pregnancy. METHODOLOGY: A participatory action research study was performed. First, the curricular plans for nursing degrees at all university nursing departments and nursing schools, as well as midwifery specialisation programmes in Catalonia, Spain were analysed. Sixteen university professors then participated in semi- structured interviews wherein they provided information on the degree to which domestic violence issues are addressed, suggestions for improving health care personnel’s skills and suitable teaching-learning methodologies to that end. Next, a case study was performed in communities of practice (two primary care centres in L’Hospitalet de Llobregat, Barcelona) where twelve midwives underwent semi-structured interviews. During these interviews, factors that facilitate or obstruct the detection and address of domestic violence during pregnancy were discussed in-depth and proposals for improvement based on the midwives’ experiences were designed and implemented. Their proposals were evaluated based on usefulness (through focus groups involving the participating midwives and by comparing the cases of domestic violence detected before and after improvements were implemented). Within the context of a study, this participatory action research project demonstrated that it is important to know how prevalent domestic violence is and to be able to identify its presence and associated factors among pregnant women who carry their pregnancies to term as well as those who request termination. A quantitative, observational, longitudinal and analytical prospective cohort study was performed for that purpose. Likewise, this research study steered the design of a continuous development programme for midwives and other health care professionals that focuses on detecting and addressing domestic violence during pregnancy. The programme was validated according to expert judgement. RESULTS: In Catalonia, an average of 5.5 hours of basic training on domestic violence is given during undergraduate nursing programmes with 2 dedicated hours during the midwifery specialisation programme. The primary pedagogical methodology employed is active learning. Professors feel personally committed to enhancing students’ skills in relation to domestic violence but would like to be able to dedicate more time to this goal. They believe that it is very important for students to acquire not only biomedical knowledge, but also psychological and social skills. All midwives interviewed had received basic training and continuous development on domestic violence, yet they do not feel confident about detecting and addressing these situations. They have little experience assisting women who have experienced domestic violence and want to reinforce their training in this regard. Midwives believe that as they monitor pregnancies, they develop relationships of trust with these women that contribute to their ability to detect and address domestic violence. However, time limitations, language barriers and their own fears constitute obstacles for them. Some suggestions made by midwives include improving time management and scheduling, having interpreters available, implementing objective tools for detection, availing of informative materials during consultations and incorporating information on domestic violence into health education group activities. Two plans of actions for improvement were designed and implemented during this research project: (1) a training activity on domestic violence (based on the experiences of university professors and the needs perceived by practicing midwives); (2) the implementation of a validated tool for detecting domestic violence (the Index of Spousal Abuse) with prior training on how to use it, as well as the development of a circuit for helping women in domestic violence situations. Both actions were deemed useful for both increasing the number of cases of domestic violence detected by midwives and enhancing their skills and confidence level when assisting in these cases. The validated survey used indicated that, in terms of the prevalence of domestic violence, 25% of women who requested that their pregnancy be terminated and 8.92% of women who continued with their pregnancy (n=381) were exposed to domestic violence (n=120). The relationship between exposure to domestic violence and complications during childbirth (p=0.025) was statistically significant. Similarly, exposure to violence significantly increased the risk of miscarriage or termination of the pregnancy (OR=4.06; CI=2.23-7.48; p<0.001) and health complications for the new-born (OR=2.68; CI=1.02-6.48; p=0.035). The continuous development programme designed was positively evaluated by the six experts. Their average scores for the items evaluated ranged between 8.3 and 10 (out of 10) except for one item, which had an average score of 5.8 and a Kendall's coefficient of concordance (W) of 0.44. CONCLUSIONS: More time must be dedicated to training nursing and midwifery students about domestic violence from healthcare, psychological, social, ethical and legal perspectives in a systematic, transversal way that includes clinical practice. Likewise, a response to midwives’ requests concerning training from a multidisciplinary perspective should be provided using active learning methodologies that endow students with a specific knowledge set and communication skills. The Index of Spousal Abuse survey has been shown to be useful for detecting violence during a pregnancy when prior training on its use and on approaching cases of domestic violence has been provided. Systematic screening must be implemented for both women who carry their pregnancies to term and who decide to terminate them.