Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 62-69

The Effectiveness of group counseling based on problem-solving on experiencing domestic violence among pregnant women: A clinical trial

1 Students' Research Committee, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran
2 Department of Midwifery, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran
3 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran; Instructor of Biostatistics, Health Products Safety Research Center, Qazvin University of Medical Sciences, Qazvin, Iran

Date of Submission21-Feb-2020
Date of Decision25-Mar-2020
Date of Acceptance07-May-2020
Date of Web Publication9-Jun-2020

Correspondence Address:
Mrs. Maryam Taherpour
Midwifery, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SHB.SHB_13_20

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Introduction: Domestic violence is highly prevalent during pregnancy and affects both the mother and fetus. Problem-solving training showed to be useful in controlling different crises of life including anger and aggression. Thus, the present study aimed to investigate the effectiveness of group counseling based on problem-solving on experiencing domestic violence among pregnant women. Methods: This study is a clinical trial which was conducted on eighty pregnant women referred to Buin Zahra urban centers in 2019. The individuals were randomly divided into intervention (n = 40) and control (n = 40) groups. Six 45-min sessions for five groups of eight people were implemented for the intervention group. The violence was examined before, immediately, and 3 months after the intervention using the Revised Conflict Tactics Scale instrument. Sociodemographics and obstetrics characteristics were compared using Chi-square. Data were analyzed using repeated-measures analysis of variance at a significance level of < 0.05. Results: The baseline characteristics were homogeneous between the two groups. After intervention, the mean score of violence decreased statistically significantly for the intervention group versus control group immediately after (159.28 vs. 190.98, P < 0.001) and 3 months after the intervention (117.85 vs. 198.9, P < 0.001). Conclusion: Group counseling based on problem-solving is effective on the level of domestic violence among pregnant women. Therefore, using this method of counseling during pregnancy can be associated with positive results in reducing domestic violence.

Keywords: Domestic violence, group counseling, pregnant women, problem-solving

How to cite this article:
Alamshahi M, Olfati F, Shahsavari S, Taherpour M. The Effectiveness of group counseling based on problem-solving on experiencing domestic violence among pregnant women: A clinical trial. Soc Health Behav 2020;3:62-9

How to cite this URL:
Alamshahi M, Olfati F, Shahsavari S, Taherpour M. The Effectiveness of group counseling based on problem-solving on experiencing domestic violence among pregnant women: A clinical trial. Soc Health Behav [serial online] 2020 [cited 2023 Dec 1];3:62-9. Available from:

  Introduction Top

Family violence refers to the type of aggression that occurs in the couple's relationships, which is characterized by spousal abuse, relationship abuse, wife abuse, and other similar terms.[1] Domestic violence or violence by a spouse is the most common form of violence against women,[2] and it is defined by the World Health Organization as any act of violence committed by a spouse that causes sexual, physical, and psychological harm.[3]

All women are at risk of violence, but some groups including pregnant women are at greater risk.[4] Domestic violence during pregnancy is defined as physical, sexual, or psychological/emotional violence or threat of physical or sexual violence inflicted on a pregnant woman by a spouse or partner, father, mother, sister, brother, or a relative.[5] Not only does pregnancy protect women at risk of violence, but also violence often begins or increases during this period.[6] Factors such as the transition to being a parent, the disturbance of the balance and peace of the couples, changes in previous relationship patterns,[4] reduced sexual intercourses, misconceptions about pregnancy, spouse's abnormal feelings about pregnancy,[7] women's dual emotions during pregnancy, women's vulnerability during pregnancy, and increased economic pressure are among the factors contributing to the increased incidence of violence during pregnancy.[8]

Prenatal domestic violence, which is done with the aim of controlling and dominating, is a serious cause of death or disability for women of childbearing age as well as severe and incurable diseases worldwide.[1] It can lead to uterine and abdominal trauma, fetal bone fractures,[4] abortion,[7],[9] preterm labor,[4] the rupture of membranes, low birth weight,[10] intrauterine growth restriction, and increased perinatal mortality as well as cesarean delivery.[11] Hence, it is proposed that despite the best prenatal care, violence is one of the contributing factors to the worst maternal outcomes.[12]

Domestic violence against pregnant women in developing countries is reported to be between 4% and 29%.[13] The prevalence of violence against Iranian pregnant women is reported to be between 19.3% and 94.5%, in which the prevalence of physical violence ranges between 1.5% and 44.1%, emotional violence between 7.2% and 60.5%, and sexual violence between 1.5% and 55.1%.[14]

Violence against women in the family is so significant that the declaration on the elimination of violence against women was adopted at the United Nations General Assembly in 1993, and it has called different countries to control, maintain, and reduce its physical and psychological consequences, in accordance with their cultural characteristics.[15] Various interventions including cognitive-behavioral therapy, stress management and life skills trainings, and emotion-focused group therapy were suggested to reduce the domestic violence.[16] One of the suggested solutions to reduce violence against women is the use of problem-solving,[17] as it is the most important skill that can maintain and enhance mental health when faced with a conflict.[18]

When a conflict arises in a marriage, the parties in the relationship usually try to take actions and measures into consideration to eliminate these conflicts. Individuals' experiences, knowledge, beliefs, and values provide different ways of resolving conflicts. These ways are called conflict management styles and tactics. When these tactics are used a lot, they become patterned responses or styles.[19] Problem-solving focuses on a cognitive-behavioral process that provides potentially effective responses to problematic situations and increases the likelihood of selecting the most effective response out of multiple ones. In fact, problem-solving training can be defined as helping a person develop his or her learning by increasing the likelihood of effective coping across a range of situations.[20]

Studies have shown that problem-solving training can be effective in reducing conflicts between couples.[19],[21] According to Rasoli and Falahat,[19] problem-solving training reduced marital conflict of couples. Taghizadeh et al.[22] reported that problem-solving could decrease physical and psychological violence among pregnant women; yet, it does not have any effect on reducing sexual violence. Reich et al.[23] also suggested that problem-solving skills including avoidance problem solving served as an intermediating variable for posttraumatic stress disorder and abuse exposure; however, rational and impulsive/careless strategies were not associated with abuse exposure.

Given the importance of prevention and control of violence among pregnant women and scarce of studies using problem-based training in Iran, the present study was designed to investigate the effectiveness of group counseling based on problem-solving on experiencing domestic violence among pregnant women.

  Methods Top

Design and participants

This study was a randomized controlled trial conducted in five urban comprehensive health centers (CHCs) in Buin Zahra (Shal, Danesfahan, Sagz Abad, Buin Zahra, and Ardak) during February to November 2019.

Participants recruited from pregnant women referred to the above-mentioned CHCs. They were included when the following criteria were met: aged between 18 and 35 years, gestational age between 10 and 30 weeks, willingness to participate in the study, and diagnosed violence against pregnant women based on the Conflict Tactics Scale (CTS2). They were excluded if they or their spouse had confirmed mental illnesses or received any psychiatric drugs during the past 6 months based on individual's statements and electronic records; experienced stressful life events, for example, the death of a first-degree relative; or an accident that caused physical or mental injury during the past 3 months. In addition, infertility or receiving assisted reproduction treatments, history of using drug and alcohol, being separated from each other, failure to attend all the interventional sessions, pregnancy loss, and failure to complete the questionnaires were excluded. [Figure 1] shows CONSORT flow diagram.
Figure 1: Consort chart: Selection and intervention process of pregnant women in the study. *Conflict Tactics Scales (CTS2): The revised scale has 52 items in three subscales of negotiation, psychological aggression, and physical violence. Items should be respond on a 7-point Likert scale ranging from 0 = never to 7 = more than twenty times in the past year

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Sample size estimation

The sample size was estimated based on a previous study by Rasoli and Falahat.[19] Considering α =0.05, effect size = 0.59, power of 80%, and a dropout as 10%, eighty pregnant women for both groups of intervention and control were invited to participate in the present study.

Sampling procedure

The electronic records of pregnant women referred to Buin Zahra urban CHCs were reviewed to identify potential pregnant women. First, 680 eligible pregnant women were identified. After explaining the study's aims to the participants, all participants completed the demographic and pregnancy information questionnaire as well as CTS2. Based on demographic and pregnancy information questionnaire, 270 mothers were excluded. Then, CTS2 instrument was reviewed to identify domestic violence. Of the remained 410 questionnaires, 52 incomplete questionnaires were excluded, and 106 were identified as nonviolence. Finally, 254 pregnant women met the inclusion criteria, of which 80 individuals were selected using a random number table.


Eligible participants were randomly assigned to intervention and control groups. The letters “A” and “B” were considered for the two groups and were written on shredded pieces of paper. The participants were asked to select a paper without replacement. If “A” letter was selected, they were assigned into the intervention and if “B” letter was selected, they were allocated to the control group.

Main endpoint and measures

The main outcome was experience of domestic violence based on the acquired score on CTS2.

Conflict Tactics Scales (CTS2)

This instrument was first designed in 1995 which consists of two sets of repeated items. Half of the items contain descriptions of aggressive acts and the other half measures the actions of the spouse toward the aggressive behavior. This scale measures the physical and psychological violence of couples against each other during the past 12 months. The CTS2 instrument consists of 78 items divided into five subscales of negotiation, psychological aggression, physical violence, sexual coercion, and injury.[24] However, the revised scale has 52 items in three subscales of negotiation, psychological aggression, and physical violence. Items should be respond on a 7-point Likert scale ranging from “0 = never to 7 = more than 20 times in the past year.” The participants completed the tools self-reportedly, and the items of this instrument were negatively scored except for the items of the subscale of “negotiation” which were scored positively. The total score is sum of all items with a possible range of 0–364. Panaghi et al.[25] verified the psychometrics properties of Iranian version.

In the present study, CTS2 was completed in three time points of before, immediately after, and 3 months after the intervention.

Sociodemographics and obstetrics checklist

A checklist was designed to collect sociodemographics and obstetrics characteristics including age, education, occupation, income, duration of marriage, residence, number of children, number of pregnancies, current gestational age, type of previous delivery, and wanted or unwanted pregnancy. Faculty members of psychological department approved this questionnaire.


The intervention which was implemented in six 45 min sessions was held weekly. Participants of the intervention group were divided into five groups of eight people.[26],[27] During each session, the topic was determined at the beginning and then related information was provided in simple language. The participants were encouraged to ask their questions. Therefore, their needs and problems were identified, and necessary explanation based on problem-solving was provided. An expert with MSc degree in clinical psychology conducted all the sessions, and at the end of each session, individuals were given some homework assignments. The content of each session is provided thoroughly in [Table 1].
Table 1: Contents provided in each session

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During the study, 15 mothers received psychiatric counseling due to the identification of suicidal thoughts. Seven were referred to a neurologist for a visit; these visits were made free for these 7 participants, 15 mothers received psychological counseling due to physical injuries during pregnancy, 8 mothers received free ultrasound after coordination, and 8 mothers were visited freely due to complications of gynecology during the study by gynecologist. The intervention package, the Ministry of Health and Medical Education of the “self-care week-to-week pregnancy” package, was provided to the pregnant women. Finally, the results were evaluated twice immediately and 3 months after the intervention.

Ethical consideration

The proposal of study was reviewed and approved by the institutional review board and ethics in biomedical research committee affiliated to Qazvin University if Medical Sciences. Decree code of IR.QUMS.REC.1398.027 was attained from the ethics committee. In addition, the protocol was registered prospectively in the Iranian Registry of Clinical Trials with reference ID of IRCT20191022045202N1. All ethical considerations including explaining the aims of the study, emphasizing the confidentiality and anonymity of collected information when recruiting participants, and written informed consent were acquired from both pregnant women and their spouses. Furthermore, after completion of the study, all the members of the control group received the same counseling sessions.

Statistical analysis

Data were analyzed using SPSS v24 (IBM SPSS Corp, New York, USA). Mean and standard deviation were used to present the results of quantitative demographic variables; and frequency and percentage were used to present the results of qualitative variables. Repeated-measures analysis of variance was used to assess the effectiveness of the intervention. The normal distribution of the CST2 scores was examined using Kolmogorov–Smirnov test. The results of this test confirmed the normal distribution of CTS score (P > 0.05). In addition, the sphericity of variance-covariance was checked and verified. The statistical significance level was considered to be <z0.05.

  Results Top

In this randomized controlled trial, eighty pregnant women participated. The baseline sociodemographic and obstetrics characteristics including education, occupation, residence, type of pregnancy, and income were not significantly different between the two groups. [Table 2] provides the baseline characteristics.
Table 2: Comparison of individuals' personal and social characteristics in the two groups of intervention and control

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As shown in [Table 3] and [Figure 2], CTS2 scores changed over time (before the study, immediately after the intervention, and 3 months after the intervention); in other words, the mean score of pregnancy violence varied significantly at different times, and this change was visible at all levels of violence (negotiation, psychological aggression, and physical violence) and in the aggressor and victim. However, this was true only for the intervention group (P < 0.001), and in the control group, there was no statistically significant difference in response variable over time (P > 0.05).
Table 3: The results of analysis of variance with repeated measures for pregnancy violence and its subscales

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Figure 2: The average pregnancy violence by study groups and follow-up time

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  Discussion Top

The result of this study showed that group counseling based on problem-solving is effective on decreasing domestic violence among pregnant women. The mean scores in the intervention group significantly changed; while, no difference was observed in the control group.

There is growing evidence that problem-solving training can protect individuals against stress, such as depression, violence, and anxiety and accelerate the recovery process. One of the related reasons can be that the exposed individuals are in the same group. Being in a group increases individuals' awareness of themselves, and interaction with other people in the group and receiving feedback from other members of the group increases one's ability to adapt to the environment. Participating in a group and receiving social support can help promote social and interpersonal skills.[22],[28] This study can be a kind of speculation in this regard.

Consistent with our results, some previous studies reported promising effects of problem-solving training in decreasing violence and improving mental health. In this regard, Launius et al.[29] observed that battered women had scored less in all the three subscales of problem-solving (brainstorming, number of effective options, and choosing the best option) and did not have sufficient problem-solving skills in violent situations compared to both counseling and control women. In addition, Reich et al.[23] suggested that problem-solving skills including avoidance problem-solving served as an intermediating variable for posttraumatic stress disorder and abuse exposure; however, rational and impulsive/careless strategies were not associated with abuse exposure. Farnam.[17] found that problem-solving training and anger management were effective in reducing parent–adolescent conflicts, physical and verbal aggression, and increasing students' reasoning, which continued during the follow-up period. Consistently, Arjang and Dari[30] reported that problem-solving training increased the overall scores of mental health and its subscales and decreased the incidence of violence subscales. Problem-solving training reduced the scores of marital conflict in a study by Rasoli and Falahat[19] Taghizadeh et al.[22] found that problem-solving could decrease physical and psychological violence among pregnant women; yet, it does not have any effect on reducing sexual violence. The results of this study are consistent with the overall results of all studies.

In contrast to our findings, Morrison et al.[31] reported that female victims of physical violence compared to nonviolent women provided significantly more solutions to problem-based strategies. These differences may be due to the study settings. Violated women who visited clinics had experienced severe emotional and psychological stress that could affect the power of problem-solving in them. Other factors, such as economic poverty, having violent parents, and lack of training on how to deal with violence, make violent women not to have the skills needed to deal with the serious problems of their daily lives. In addition, violence is a major obstacle to use problem-solving strategies. As a result, this strategy should be recommended for people exposed to violence to reduce violence.[32]


Some limitations should be considered interpreting the results of the present study. Due to some cultural beliefs, violence against women is underreported. In other words, the sense of defeat that results from a kind of helplessness learned in Iranian women can affect this issue. In addition, they were afraid of disclosure of their answers and being exposed to more violence by their spouses. Due to these barriers, the self-reported nature of assessing the outcome is compromised. The researchers tried to overcome this limitation by ensuring the participants about anonymity and confidentiality of their information via increasing the sense of intimacy and mutual trust. Another limitation of this study is the lack of access to spouses as the initiator of violence. Therefore, it is recommended to conduct future studies with participation of both pregnant women and their spouses.

  Conclusion Top

The present study showed that problem-based counseling methods can have positive effects on decreasing domestic violence among pregnant women. Hence, it is recommended to hold such counseling sessions for pregnant women at risk of violence during pregnancy. Extending this training to preconception counseling might be more beneficial for women and let them to start pregnancy in mentally and physically healthier situation.


Hereby, we sincerely thank the pregnant women who agreed to participate in this project and completed all training sessions.

Financial support

The research vice-chancellor of Qazvin University of Medical Sciences financially supported this project.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]

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