Document Type : Original Article
1 Department of Obstetrics and Gynecologic Nursing, Gulhane Military Medical Academy, School of Nursing, Ankara, Turkey
2 Department of Public Health, Gulhane Military Medical Academy, School of Medicine, Ankara, Turkey
Violence is an important community health
problem commonly observed among all cultures
worldwide regardless of geographical boundaries,
economic development and educational level (
Numerous studies have emphasized the importance
of violence-related factors that trigger the
initiation of marital violence (
The combination of causes negatively influence the
couple's psychosocial and physical well-being (
Childbearing is an important goal for couples.
Thus, infertility is one of the most important
causes for a crisis, as it negatively affects a couple's
Wang et al. have reported that the diagnosis
and treatment of infertility significantly decreases
marital quality, by having a negative effect
on the couple's sexual life, their communication
with family and friends, role distribution in the
family, and conflict resolution (
The aim of this descriptive study was to determine the level of marital violence in a group of Turkish women and establish if infertility was a risk factor for experiencing marital violence. The evaluation was achieved by considering the following questions. Is there a difference between infertile and fertile women regarding the level of marital violence? Is there a difference between infertile and fertile women regarding the type of marital violence? What are the risk factors responsible for marital violence in infertile Turkish women?
This descriptive study was conducted during January-July 2009 at a training hospital in Ankara, Turkey. The women included in the study were separated into two groups, infertile and fertile. The fertile and infertile group were not matched with respect to certain variables; all eligible women who met the criteria for participation were included.
The infertile group (n=228) consisted of women who referred to the Infertility Center of the training hospital during the study period, who were treated for primary infertility because of male, female or unexplained problems. A total of 300 women in the infertile group were seen at the Infertility Center during the seven-month data collection period; 260 who met the criteria for participation were asked to participate in the study. Of those selected, 234 (90%) consented to participate. However, 6 out of the 234 women had incomplete data, therefore the final sample comprised 228 (87%) in the infertile group.
The fertile group (n=204) consisted of married women with children and no history of fertility problems who attended the Gynecology Outpatient Department of the same hospital during the same period. A total of 1000 fertile women visited the Gynecology Outpatient Department during the data collection period; 400 met the criteria for participation and were selected to participate in the study. Of those selected, 355 (89%) consented to participate. However, 125 of the 355 consenting women had incomplete data, thus we reduced the final sample to 204 (51%) in the fertile group.
We administered the Descriptive Information Questionnaire and Scale for Marital Violence against Women (SDVW) for data collection.
The SDVW was developed by Betül Kılıç in 1999
for Turkish women to determine the level of marital
violence. The alpha values obtained during the
development of the scale ranged from 0.73 to 0.94.
The SDVW is a 50-item self-reported scale, wherein
each item consists of three statements in five
subscales of violence: physical, emotional, verbal,
economic, and sexual. Numerical values from 1 to 3
are assigned to each item in the marked statements.
The total violence scores are obtained by adding
these points and range from 50 to 150. The total
score demonstrates the level of marital violence experienced
by the woman. There is no specific cutoff
score in this scale to determine women who have
experienced marital violence (
The Descriptive Information Questionnaire was developed by the present investigators after evaluation of the relevant literature. Obstetrics experts examined the questionnaire's content validity to confirm general appropriateness and applicability. The questionnaire consisted of 12 socio-demographic questions that included the ages of the women and their spouses, level of education, occupational status, age at first marriage, and infertility characteristics. The prepared questionnaire was first administered to 20 fertile women at the Gynecology Outpatient Department of the hospital, as a pilot study to ascertain whether the items could be easily understood.
The hospital Institutional Review Board approved this study. Participating women provided verbal consent after the aim and method of the study were explained. The investigator completed survey forms through faceto- face interviews with each woman. The average time for an interview was approximately 20 minutes.
The SPSS 11.0 software package was used for statistical analysis. The distribution of the data was expressed as counts and percentages. Chi-square, Kruskal-Wallis, and t tests were used for statistical comparison between groups, as appropriate. The Kruskal-Wallis test compared variables that were not normally distributed. Linear regression analysis was used to explore the relationship between Predicted variables on the levels of marital violence. We chose the backward method for linear regression analysis. Descriptive statistics were presented using the arithmetic mean and standard deviation. A p value of less than 0.05 was accepted as statistically significant.
Totally, there were 228 infertile and 204 fertile women included in the study. The mean age of women was 29.54 ± 4.268 years in the infertile group and 30.40 ± 4.907 years in the fertile group. Table 1 presents the descriptive features of the women in fertile and infertile groups.
Table 2 presents the infertility characteristics of women in the infertile group of which 37.7% were diagnosed with unexplained infertility. A total of 28.1% underwent infertility treatment for three or more years.
Table 3 presents the mean scores from both groups of women for the SDVW total and violence subscales. The mean total violence score of women was 67.23 ± 8.037 in the infertile group and 64.49 ± 5.166 in the fertile group, according to the SDVW. There was a statistically significant difference between the infertile and fertile women in the total violence score and mean scores of emotional, economic and sexual violence. Although the infertile group had higher emotional, economic and sexual violence scores, however their verbal violence score was lower. There was no statistically significant difference between the groups for the physical violence score.
Socio-demographic features of the study participants
|Infertile group n=228||Fertile group n=204|
|29.54 ± 4.268||30.40 ± 4.907|
|22.76 ± 3.427||22.22 ± 3.235|
|Duration of marriage (Y)|
The infertility characteristics of infertile women
Comparison of SDVW scores
|Infertile group n=228||Fertile group n=204|
|Mean ± SD||Mean ± SD||t||P value|
|67.23 ± 8.037||64.49 ± 5.166||4.157||0.000|
|10.46 ± 1.648||10.38 ± .652||0.599||0.550|
|16.16 ± 1.956||15.02 ± 1.255||7.105||0.000|
|13.71 ± 2.072||14.37 ± 2.115||2.970||0.003|
|14.37 ± 2.612||12.93 ± 1.818||6.562||0.000|
|12.53 ± 2.200||11.84 ± 1.490||3.458||0.000|
SDVW score. Education status, age at first marriage
for couples, and couples' fertility status were included
in the model as they had a statistically significant relationship
with SDVW. This indicated that infertility
was a contributing factor for experiencing marital violence
when combined with other risk factors such as
women’s' educational status and age at first marriage.
The correlation between total SDVW score and variables
obtained from the model was 0.385. The Durbin-
Watson coefficient had a value of 1.739, which demonstrated
that our model was well formed (
Results of regression analysis between the independent variables effecting total SDVW score
|n=228||Total SDVW score|
In the infertile group we observed a statistically
significant relation between SDVW total score and
infertility cause (p=0.023) and duration of infertility
treatment (p=0.000). Infertile women with femalerelated
or unexplained problems had a higher SDVW
total score as did those who underwent infertility
treatments for three or more years (
Comparison of the infertility features of couples in the infertile group and SDVW scores
|n=228||SDVW total score|
|Mean ± SD||X2/t||P value|
|64.55 ± 6.057||9.575||0.023|
|67.30 ± 9.162|
|65.83 ± 7.036|
|68.92 ± 7.916|
|66.14 ± 6.440||-3.344||0.000|
|70.02 ± 10.699|
*; Kruskal-Wallis test and ** ; t test.
We have presented data regarding the experience of violence from infertile and fertile women, the types of violence experienced, and comparisons regarding these characteristics. There are few studies of infertile women who have experienced violence. These studies have included only infertile women in their studied population, whereas the current study included both infertile and fertile women. We evaluated all types of violence, not just the general concept of violence. Thus, our study was unique.
We found the mean violence score of the infertile
group to be higher than the fertile group. The few
studies on this subject have also reported higher
levels of marital violence experienced by infertile
women compared to fertile women, which supported
the current study (
Violence can be divided into economic, emotional,
sexual and verbal in addition to physical
Some studies have estimated the physical violence
rate to be 14-33% for infertile women (
We found higher levels of sexual, economic and
emotional violence among infertile women compared
to fertile women in this study. Leung et al.
also reported a rate of 55.6% for emotional violence
in infertile women (
We have found that infertility is a factor which
contributes to marital violence when combined with
other risk factors such as women’s' educational
status and age at first marriage. In this study, infertile
women with less education who married at a
younger age were more likely to have experienced
marital violence. Similarly, Akyüz et al. (
Unexpectedly, we found a lower level of verbal
violence experienced by infertile women compared
to fertile women. Generally, it has been presumed
that verbal violence among infertile women is possibly
higher than fertile women. In support, other studies
report that verbal violence is one of the common
forms of violence experienced by infertile women.
According to one study, most infertile women have
stated that their husbands humiliated and insulted
them because of their infertility (
Women may suffer from a feeling of low self-esteem, guilt, and embarrassment about not being able to become pregnant. They may feel, on some level, that they deserve verbal violence and these feelings may cause them to ignore verbal violence. We believe this can be the reason for the low verbal violence scores.
In this study, the level of marital violence was
higher in infertile women with unexplained and
female-related problems. This result showed that
infertile women with unexplained or female-related
problems might be at increased risk for marital violence
compared to those with male or male-female
problems. It was stated that the prevalence of domestic
violence against women with female factor
infertility ranged between 33.6% and 61.8% (
The level of marital violence was higher in
those women who had longer durations of infertility
treatment in this study. However, by contrast,
some studies reported no significant relationships
between domestic violence and infertility duration
In the study, we observed that infertile women were at an increased risk for marital violence compared to fertile women. The experience of physical violence was similar in both groups. However, the level of experiencing sexual, economic and emotional violence in infertile women was higher than fertile women. The level of verbal violence was lower among infertile women compared to fertile women. It was found that marrying at a young age and less education in infertile women were factors that affected marital violence. It was also found that infertile women with unexplained or female-related problems and longer duration of infertility treatment had increased risk for marital violence, compared to those with male or male-female problems.
The results of this study have demonstrated that
infertile women are more likely to have experienced
violence. The violence experienced by infertile
women, who are already psychosocially negatively
affected will lead to more destructive changes in
these women. It is therefore necessary to carry out
observations aimed at uncovering the presence of
any violence from the data collection stage to the end
of treatment in infertile couples and to include questions
to this effect in the care plan. Both infertility
and violence experience may be affected by social
structure and culture. In the male dominant society,
particularly women with female-related or unexplained
problems can be under more pressure due to
not being able to maintain family continuity. The role
of maintaining family continuity by childbearing is
considered the woman's primary role. Even in some
societies such as Turkey, in which continuing bloodline
is an important aim for a marriage, infertility can
be a reason for divorce. Similarly, Yıldızhan et al. in
a Turkish study, have stated that 87% of abused, infertile
women were threatened with divorce by their
Healthcare staff must provide the necessary education and recommendations to emphasize that this behavior is unacceptable for those who experience violence.
There are a number of limitations inherent in this study, thus these findings cannot be generalized. Our study sample consists of a group of Turkish women conducted at a single center. The measurement instrument used for the study provides a violence score for the violence experienced and type of violence. However, it is not possible to use a classification that qualifies study subjects as experiencing/not experiencing violence. It therefore does not provide a percentage for women experiencing violence. Studies in the literature use various measurement instruments that evaluate the rates of experiencing violence and the type of violence. This makes it more difficult to compare the results of different studies.
The violence measurement instruments used vary among the few studies in the literature. There is no cut-off point for the violence measurement instruments used in this study. We suggest that other studies that compare the violence rate in infertile and fertile women to be performed with instruments that have a cut-off point.
Both violence and infertility can be influenced by sociocultural differences. We therefore strongly suggest that studies, similar to those already performed, determine the rate of being subjected to violence by infertile women be undertaken in groups with other sociocultural characteristics.