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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 314-323

Workplace-related violence among pregnant health care workers


1 Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Zagazig University, Zagazig; Department of Maternal and Newborn Health Nursing, Maternity and Childhood, Nursing College Taibah University, Madina, Egypt
2 Department of Maternal and Newborn Health Nursing, Faculty of Nursing, Menoufia University, Menoufia; Department of Maternal and Newborn Health Nursing, Maternity and Childhood, Nursing College Taibah University, Madina, Egypt

Date of Submission25-Sep-2018
Date of Acceptance16-Oct-2018
Date of Web Publication28-Dec-2018

Correspondence Address:
Eman El Sayed Mohamed Elsabagh
Bsc: nursing science, Msc: Maternity and Child Nursing, PHD: Obstetrics and Gynecology Nursing
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_22_18

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  Abstract 


Background Women in health care represent an ancient and widespread profession. Violence against women is a pervasive violation of fundamental human rights of women. Pregnancy is a risk factor for increase in violence, especially in health care facilities.
Research design A descriptive design was used in this study.
Settings The study was conducted at Zagazig University Hospitals.
Sample A convenience sample was used, including 231 pregnant health care workers (HCWs). A structured questionnaire sheet was constructed by the researchers to collect data of this study and included four parts.
Tools The first part is a structured questionnaire constructed by the investigators to collect the data. The second part is the obstetric history. The third part is the information related to workplace violence assessment. The fourth part included maternal and neonatal assessment sheet.
Results More than two-thirds (68.3%) of pregnant HCWs had been exposed to workplace violence. Pregnant HCWs working in most departments experienced violence, with highest frequency observed in the emergency department. Verbal violence (47.2%) was the most common form of violence followed by psychological (30.7%), physical (19.5%), and finally sexual violence (2.6%). Pregnant HCWs faced many maternal and fetal complications, with the complications of first and second stages of labor and fetal distress being 7.8 and 67.1%, respectively. Approximately 43.3% of pregnant HCWs were more likely to deliver by cesarean. However, 37.7% have premature rupture of membrane (PROM), and 27.7% have low-birth-weight, and 20.8% preterm births..
Conclusion Pregnant HCWs face many maternal and fetal complications because of violence, such as abortion, deterioration in the progress of labor, cesarean delivery, fetal distress, PROM, low-birth weight, and preterm birth.
Recommendation Special attention should be directed to control violence against pregnant HCWs, especially those who have a history of exposure to violence.

Keywords: complication, health care workers, hospital, occupational health, outcome, pregnancy, violence


How to cite this article:
Mohamed Elsabagh EE, Eittah HA. Workplace-related violence among pregnant health care workers. Egypt Nurs J 2018;15:314-23

How to cite this URL:
Mohamed Elsabagh EE, Eittah HA. Workplace-related violence among pregnant health care workers. Egypt Nurs J [serial online] 2018 [cited 2019 Aug 17];15:314-23. Available from: http://www.enj.eg.net/text.asp?2018/15/3/314/248965




  Introduction Top


Workplace violence against health care workers (HCWs) is a widespread phenomenon in health care settings. According to the WHO, workplace violence is known as ‘incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.’ It affects all types of work categories and takes place at various workplace settings (Khoshknab, 2012; Needham et al., 2012). Approximately 25% of violent accidents at work occur in the health sector, and more than 50% of health workers have already experienced violence (Marziale, 2004; Hahn, 2012).

Definitions of violence were adopted in different studies, resulting in wide variation of violence prevalence in the health care settings. Workplace violence includes physical assaults and threats of assaults directed toward a person at work. As violence in health care settings attains special concern, it was specifically defined as verbal, nonverbal, and/or physical behavior that threatens or causes harm to HCWs or to the property (Morrison, 1990; Hahn et al., 2012).

Violence is the most prevailing, complex, and dangerous occupational hazard facing HCWs, especially when directed toward pregnant HCWs. Women represent nearly 80% of the health care work force (Stanko et al., 2002). The real size of the problem is unknown, and recent information shows that there is deficiency of knowledge about violence. The enormous cost of violence at work for the individual, the workplace, and the community at large is becoming more and more apparent. Although incidents of violence are known to occur in all work environments, some employment sectors are particularly exposed to it (USDL, 2012).

Shields and Wilkins (2009) found that many different factors may play a role in the occurrence of violence against HCWs including female sex of worker, relation among HCWs, patients, visitors, emotional stress of client and relatives; and the stressful work environment. As health care work force is in its large majority female, the sex dimension of the problem is very evident (Oliveira and D’Oliveira, 2008).

Violence against women may occur at any time or stage of their lives, including pregnancy. The Pan-American Health Organization defines violence during pregnancy which threats of physical, sexual, or psychological/emotional violence against pregnant women. The prevalence of violence during pregnancy varies from 0.9 to 21% in different societies (Cook and Bewley, 2008). Pregnant women who experience violence have been found to have higher risks of obstetric and other complications to mother and fetus/child that warrant antenatal care (Watts and Zimmerman, 2002).

Violence during pregnancy affects women and might lead to pregnancy complications or adverse birth outcomes (Petersen et al., 1997). Violence can affect pregnancy through direct or indirect mechanisms. A blow to a pregnant woman’s abdomen can cause adverse outcomes directly, such as fetal injury, preterm labor, and death. The indirect mechanisms are related to a woman’s victimization experience from violence and how it can induce intermediary risks such as psychological stress or insufficient access to medical care that could cause poor pregnancy outcomes (Berenson et al., 1994).

Watts and Zimmerman (2002) highlight studies that consider pregnancy as an increment to the risk of violence against women, being able to change the pattern as to the frequency and severity during this period, or even be initiated at this stage of a woman’s life. The implications of this event have an effect not only in the life of the woman but also in the life of the fetus and the future child, among them being bleeding and termination of pregnancy. Regarding the health of the child, increased risks of perinatal death, born with low-birth weight (LBW), and prematurity have been evidenced (Coker et al., 2004).

Altarac and Strobino (2002) have shown an association between physical violence and LBWs or preterm birth, whereas others have found modest increases in risk of LBW among women who experienced violence during pregnancy. An understanding of the relationship between violence during pregnancy and adverse maternal conditions and birth outcomes could have important clinical and public health implications.

Early identification and intervention to prevent violence against pregnant women might reduce adverse outcomes of pregnancy, so the researchers were interested to detect the risk factors and prevalence of violence and aggression against pregnant HCW (Cokkinides et al., 1999).


  Significance of the study Top


Violence at work is one of the major concerns in health care activities, and pregnant HCWs continue to experience injuries and illnesses in the workplace. However, it is possible to prevent or reduce pregnant HCW exposure to different occupational hazards. Cases of nonfatal occupational injury and illness among the HCWs are among the highest in any industry sector. Recently, violence became a major concern in different Egyptian hospitals are largely after the January 25 revolution will increase demand for hospitals. So, the study was conducted to explore workplace-related violence among pregnant HCWs.


  Aim of the study Top


The aim of this study was to explore workplace-related violence among pregnant HCWs.

Research question

To achieve the aim of this study, the following research questions were formulated:
  1. What is the prevalence of workplace-related violence among pregnant HCWs?
  2. What are the risk factors of workplace-related violence among pregnant HCWs?
  3. What are the pregnancy outcomes of workplace-related violence among pregnant HCW?



  Patients and methods Top


Research design

A descriptive exploratory design was used in this study.

Study settings

The study was conducted at Zagazig University Hospitals.

Sample size

The estimated sample size was calculated to be 231 pregnant HCWs. The total respondents included were 231 from a total of 288 HCWs. The confidence level 95%, and a power of study 80%.

Study patients

The study targeted all pregnant HCWs, nurses and workers, who worked in direct contact with patients and/or visitors. Pregnant HCWs were affiliated with the governmental hospital at the main departments of the hospitals, namely, surgery, ICU, internal medicine, outpatient clinics, and emergency department. The total sample size was 231.

Tools of data collection

A structured questionnaire sheet was constructed by the researchers to collect data of this study and included four parts:
  1. The first part was used to collect the demographic data, such as age, level of education, monthly income of the family, and residence.
  2. The second part included obstetric history, such as gravidity, parity, number of previous abortion, and history of previous exposure to violence during pregnancy.
  3. The third part included information related to workplace violence assessment, for example, type of violence faced pregnant HCWs such as verbal, physical, psychological, and sexual; occupational characteristics; circumstances of violence incidents; reported violence incidents to hospital authority; and finally relation between demographic characteristics and types of violence among pregnant HCWs.
  4. The fourth part included maternal and neonatal assessment, which entailed data related to abortion, complications of labor and delivery, and the neonatal complications such as LBW and preterm birth.


Validity and reliability

The tool was developed by the investigator, and then it was tested for content validity by juries of five experts in the field of nursing. Modifications were carried out, and test reliability of the proposed tool was done by Cronbach’s alpha, which showed a strong significant positive correlation between the items of the tool.

Field work

The study was conducted during the period from the 1 May to the end of November 2017. Informed consent to participate in the study was obtained from pregnant HCWs. Modifications of the tools were done accordingly. Each woman was individually interviewed using the previously mentioned tool. Everyone in the sample are assured of confidentiality, asked separately about the information, and motivated to give true answers. Time consumed for each interview ranged from 30 to 45 min. The collected data were categorized, tabulated, and made ready for use.

Ethical consideration

A written letter from the Faculty of Nursing, Zagazig University was directed to the director of Zagazig University Hospitals to get approval for collection of the data. The agreement for participation of the patients was taken after full explanation of the aim of the study to them to get their approval for participation in the study. Moreover, they were assured that the information would be confidential and used only for the research purpose.

Pilot study

It was carried out on approximately 10% of the sample to assess applicability, clarity, and simplicity of the tools and the maneuvers of the interventions, and to estimate the time needed. Based on its results, the final versions of the tools were prepared. It also helped in planning the schedule for field work. The sample of the pilot study was not included in the main study sample.

Data analysis

Data were collected, revised, coded, tabulated, and analyzed by PC computer using statistical package for the social sciences software, version 20. The following statistical techniques were used: frequencies and percentage and personal correlation. The significance level was chosen as P value less than 0.05.


  Results Top


[Table 1] demonstrates the demographic characteristics of the studied patients. Overall, 42% of the pregnant HCWs aged less than 25 years. Moreover, more than two-thirds (66.7%) of the pregnant HCWs had diploma degree. However, 78.8% of the pregnant HCWs did not have enough income. In addition, most pregnant HCWs (84.4%) resided in rural areas.
Table 1 Demographic characteristics of the pregnant health care workers exposed to violence (N=231)

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Concerning pregnant HCWs’ obstetric history, 47.6% of them were gravida 2 and more. However, 42.9% of them had parity from two to three. Moreover, 40.3% of the pregnant HCWs had previous abortion. However, more than two-third (65.8%) of the pregnant HCWs had history of previous violence ([Table 2] and [Figure 1]).
Table 2 Distribution of the pregnant health care workers according to their obstetric history (N=231)

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Figure 1 The prevalence of exposure to workplace violence. More than two-thirds (68.3%) of the pregnant HCWs had been exposed to workplace violence. HCW, health care worker.

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[Table 3] shows the occupational characteristics of pregnant HCWs exposed to violence. Most pregnant HCWs (75.8%) were nurses. Pregnant HCWs were working in different hospital departments such as surgery, ICU, internal medicine emergency department, and outpatient unit. Moreover, 31.7% of the pregnant HCWs were exposed to violence at the emergency department, 25.5% at ICU followed by outpatient clinic, surgery unit, and internal medicine (17.3, 14.7%, and 10.8%, respectively). Meanwhile, 49.8% of pregnant HCWs had duration of work from 5 to 10 years, with mean work duration of 12.2±10.5 years. Overall, 62.8% of pregnant HCWs attended the afternoon shift. Regarding joining an extra job, 72.3% of pregnant HCWs did not have an extra job ([Figure 2]).
Table 3 Distribution of the pregnant health care workers related to occupational characteristics (N=231)

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Figure 2 Types of occupational violence. The findings revealed that 47.2% of pregnant HCWs were exposed to verbal violence, 30.7% exposed to psychological violence, 19.5% exposed to physical violence, and 2.6% exposed to sexual violence. HCW, health care worker.

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[Table 4] illustrates previous exposure to violence. Most pregnant HCWs (89.6%) were exposed to violence more than once, and findings revealed that the perpetrators against pregnant HCWs were patients, relatives, physicians, supervisors, and colleagues (70.1, 88.7, 31.2, 36.4, and 30.3, respectively). Violence was carried out by both males and females (68.4 and 31.6%, respectively). Pregnant HCWs experienced violence during both day shift and night shift (79.7 and 20.3%, respectively). Results of this study showed that the main causes of violence as perceived by pregnant HCWs were being a female, having excess work load, and absence of security guards (91.3, 65.8, and 47.6%, respectively).
Table 4 Distribution of the pregnant health care workers related to previous violence incidents

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[Table 5] displays the report of violence incidents to hospital authority. Approximately half of the sample (52.4%) reported that the violence incidents to hospital authority. Regarding the causes for not reporting the violence incident, 71.8% of them stated lack of reporting policy, 20% of them reported lack of faith in the reporting system, and 8.2% of them reported fear of retaliation. However, most pregnant HCWs who reported the violence incident demonstrated that no action was taken by the hospital authority (62.8%).
Table 5 Distribution of the pregnant health care workers, related to reporting of violence incidents to hospital authority

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Regarding maternal complications and birth outcomes ([Table 6]), it was revealed that approximately 43.3% of pregnant HCWs who experienced physical violence during pregnancy were delivered by cesarean birth. Moreover, 7.8% of them experienced disorders of progression of labor stages (I or II), and 67.1% of them had fetal distress. However, 37.7% of pregnant HCWs who experienced physical violence during pregnancy had premature rupture of membranes. According to adverse birth outcomes, pregnant HCWs had LBW babies and preterm birth (27.7 and 20.8%, respectively).
Table 6 Maternal complications and birth outcomes among pregnant health care workers exposed to violence

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The correlation between demographic characteristics and different types of violence among pregnant HCWs is shown in [Table 7]. There was a significant correlation between age and verbal violence (P=0.005). Moreover, there was a significant correlation between level of education and verbal, physical, and psychological violence (P=0.005). However, there was no significant negative correlation between monthly income of the family and all types of violence. According to the history of previous exposure to violence, there was a significant correlation between history of previous exposure to violence and verbal and physical violence (P=0.005). Finally, there was a significant correlation between parity and verbal and sexual violence (P=0.005).
Table 7 Relation between demographic characteristics and types of violence among pregnant health care workers

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  Discussion Top


The rising rate of workplace violence in health care facilities has become a major problem for health care providers. However, violence against HCW is a complex and persistent occupational hazard especially when directed to female HCWs. Paradoxically, the job sector with the mission to care for people appears to be at the highest risk of workplace violence (Needham et al., 2012). Violence against women is widely recognized as a serious public health problem. Pregnancy is a risk factor for increase in violence (Bessa et al., 2014). So the aim of the study was to assess the prevalence and associated factors of workplace violence and the outcomes of violence among pregnant HCW.

The current study revealed that the majority of the sample’s age ranged from 25 to more than 30 years. Concerning the level of education and job status, the present study revealed that more than two-thirds of pregnant female HCWs have diploma degree. A similar study conducted by Ayrancy (2005) who reported that nurses aged between 30 and 39 years were more vulnerable to be abused.

Regarding previous history of violence exposure, approximately two-thirds of the sample was exposed to violence during pregnancy, and nearly half of the sample was multiparous women. This was in line with Moustafa and Gewaifel (2013), who found that more than two-thirds of the sample was exposed to violence previously. This was supported by Ewis and Arafa (2014) who reported that most female nurses were exposed to violence more than once.

Regarding the prevalence of exposure to workplace violence, more than two-thirds of the studied pregnant HCWs were exposed to workplace violence. The present results agreed with Moustafa and Gewaifel (2013) who reported that most female HCWs (72.6%) experienced workplace violence. A similar study was conducted by Samir et al. (2012) who revealed that most nurses (86.1%) had been exposed to workplace violence during the past 6 months. Moreover, Ewis and Arafa (2014) found that most female nurses were exposed to violence more than once. However, it contradicted with Abbas et al. (2010) who studied the workplace violence against nurses in Ismailia Governorate, Egypt, and determined its prevalence to be about 27%.

The current study revealed that most pregnant HCWs were nurses. Moreover, the studied pregnant HCWs worked for different hospital departments, such as surgery, ICU, internal medicine emergency department, and outpatient unit. Among the pregnant HCWs who experienced exposure to violence, the highest frequency was observed in emergency department and ICU, followed by other departments. A similar study was conducted by Moustafa and Gewaifel (2013) who emphasized that the studied female HCWs were nurses and workers from different hospital departments such as surgery, internal medicine, radiotherapy, outpatient units, and emergency department. Most nurses (42.9%) in the all studied departments except radiotherapy experienced exposure to violence, with the highest frequency observed in emergency department (85.2%) followed by other departments (78.0–72.3%). The differences were statistically significant (P<0.0001).

In the present study, nearly half of the pregnant HCWs had duration of work from 5 to 10 years. Moreover, more than two-thirds of the pregnant HCWs exposed to violence were in the afternoon shift. Regarding joining an extra job, most pregnant HCWs did not have an extra job. This disagreed with Moustafa and Gewaifel (2013) who reported that no significant differences were observed between female HCWs of both groups regarding duration of employment, joining an extra job, duration of working hours, or frequency and duration of breaks during shift. In addition, Samir et al. (2012) showed that nurses with less than 3 years of work experience were more likely to be exposed to violence than nurses with longer work experience.

Regarding the type of workplace violence, verbal violence was the most common form of violence encountered among pregnant HCWs followed by psychological, physical, and finally sexual violence. In the same line of this finding, Moustafa and Gewaifel (2013) estimated verbal violence was the most common form of violence encountered among female HCWs followed by physical and least one was sexual violence. This is also in congruence with Al-Omari (2015) who reported that 67.8% were verbally attacked and 52.8% of the participants were physically attacked in the last 12 months. Furthermore, Al Bashtawy (2013) estimated that more than three-quarters of the females (75.8%) were exposed to at least one type of violence. The incidents of verbal violence were approximately five-fold than that of the physical violence. Additionally, Ewis and Arafa (2014) found verbal and psychological aggression incidents were the most common types of violence nurses were exposed to.

The current study revealed that most pregnant HCWs who were exposed to violence reported that they were exposed to such incidents more than once, mostly by patients and their relatives. Nearly equal percentages of violence were caused by supervisors, physicians, and colleagues. Violence was committed nearly by both males and females. Results were similar to Abbas et al. (2010) and Samir et al. (2012) who found in previous Egyptian studies, patients and their relatives were the main perpetrators for most of the assaults. Aligned with the current findings, Farrell et al. (2006) indicated that patients or their visitors are the most likely perpetrators of verbal and physical abuse. Similarly, Hegney et al. (2010) found that patients were the major source of workplace violence, with nurses in the aged care and public sectors at highest risk as compared with the private setting. Another study done by Farrell and Shafiei (2012) showed that patients and their visitors were identified as the main perpetrators of violence, at approximately 85 and 38%, respectively, with more than half of the perpetrators (54%) being males who were aged more than 50 years. Nurses reported that patients were the most distressing to cope with at 56%, followed by their visitors. Moreover, Al Bashtawy (2013) studied workplace violence against nurses in emergency departments in Jordan and estimated that patients were the primary perpetrators. Additionally, Fawole and Dagunduro (2014) stated that ‘the main perpetrator of violent acts were clients.’

Findings of the current study state the most HCWs who were exposed to violence were evident during the day shift as compared with the night shift. Moreover, the main causes for exposure to violence were being a female, having excess work load, and/or absence of security guards. These findings are in agreement with Ayrancy (2005) who reported that most violence occurs during the morning shift between 8 a.m. and 5 p.m. This result comes in disagreement with Lin and Liu (2005) who addressed that most violence occurs during the evening shift. In the same line with the current results, Ewis and Arafa (2014) confirmed that the main causes perceived by female HCWs for being exposed to violence were being a female (91.1%), having excess work load (67.9%), and/or absence of security guards (48.2%). Moreover, Bessa et al. (2014) reported that exposure of female HCWs to aggression and violence related to pregnancy, the excess of work load, and absences of security guards.

Regarding the reporting of violence incidents to hospital authority by pregnant HCWs exposed to violence, approximately half of the pregnant HCWs reported the violence incidents to hospital authority. Yet, no action was taken by hospital authority regarding majority of those reported incidents, and the causes of not reporting violence incidents included the concept of lack of a reporting policy following by lack of faith in the reporting system and fear of retaliation. These findings are in accordance with Ewis and Arafa (2014) who stated that violence incidents were reported by approximately half of the nurses who were exposed to external and internal violence. Of the reported external and internal violence, only one-third of the incidents reached the hospital administration. Similarly, May and Grubbs (2002) highlighted that only 29% of abuse is reported and pursued by nurses. This disagreed with Brewer et al. (2013), who showed that approximately 70% of those nurses who had experienced violence indicated they did not report it. Moreover, Samir et al. (2012) reported that no action was taken by the hospital authority regarding more than half of the reported incidents (61.2%), which constituted much frustration to female HCWs and raised questions about the worth of such reporting. This asserted by Snyder et al. (2007) who stressed that the underreporting of violence might lead to inefficient attention to strategies for preventing aggressive behavior; the reasons for such behavior not being reported frequently have not been well examined. Moreover, El-Gilany et al. (2010) noted that Middle Eastern women would be quite hesitant to admit to sexual harassment. On the same line, Moustafa and Gewaifel (2013) recommended that the majority of sample in their study reported the accident of violence but the hospital did not take any action in most of these events. The majority of The female HCWs reported that, no need to report, while the others not report due to fear from the perpetrator and feeling shame.

Regarding maternal complications and birth outcomes related to violence. Nearly half of the pregnant HCWs who experienced physical violence during pregnancy delivered by cesarean. Moreover, the complications of first and second stages of labor such as disorders of progression of labor stages I and II as well as fetal distress were reported. However, one-third of pregnant HCWs who experienced physical violence during pregnancy experienced premature rupture of membranes. According to adverse birth outcomes, pregnant HCWs had LBW and preterm birth. In the same line of this finding was the study by Faramarzi et al. (2005) which reported that the violence against pregnant HCWs was associated with adverse fetal and maternal conditions such as cesarean delivery, having abnormal progression of labor, premature rupture of membranes, LBW, preterm birth, and hospitalization before delivery. This result coincided with Copper et al. (1993) who stressed that accompaniment of emotional or sexual abuse with physical abuse increases the risk of adverse birth outcome and complications of labor and delivery, except for fetal distress. Moreover, maternal stress has been associated with spontaneous preterm birth at less than 35 weeks of gestation after adjustment for maternal demographic and behavioral characteristics. Moreover, Altarac and Strobino (2002) emphasized that there was a positive association between physical violence and LBW.

In the present study, there was a significant correlation between age and verbal violence. Moreover, there was a significant correlation between level of education and verbal, physical, and psychological violence. However, there was no significant negative correlation between monthly income of the family and all types of violence. According to the history of previous exposure to violence, there was a significant correlation between history of previous exposure to violence with verbal and physical violence. Finally, there was a significant correlation between parity and verbal and sexual violence. In congruence with this finding, Campbell and Boyd (2003) found a significantly higher prevalence of abuse among young/adolescent women during pregnancy than older ones. Moreover, there was a significant correlation between level of education and verbal, physical, and psychological violence, as well as between history of previous exposure to violence and verbal and physical violence. Additionally, there was a significant correlation between parity and sexual violence. Furthermore, Faramarzi et al. (2005) stated that there was no association between women’s duration of marriage or parity and physical violence. Moreover, Bessa et al. (2014) clarified that there was an association between aggression against pregnant female and her socioeconomic conditions.


  Conclusion Top


Based on the result of the study, the following conclusion emerged:
  1. The majority of sample’s age ranged from 25 years to more than 30 years, and more than two-thirds of the sample had a diploma degree.
  2. Female HCWs reported they faced verbal, psychological, physical, and sexual violence. The majority of them were verbally attacked.
  3. Pregnant HCWs faces many maternal and fetal complications because of violence such as abortion, disorders in progression of labor, cesarean delivery, fetal distress, and PROM. The most prominent form of this complications are fetal distress, LBW and preterm birth.
  4. There is a significant correlation between different types of violence and selected sociodemographic characteristics of female.


Recommendation

Based on the finding of the study, the following recommendations are suggested:
  1. Give more attention to pregnant health care worker groups who working in units such as the emergency department and outpatient clinics to avoid the violence incidents..
  2. Training programs for female HCWs about communication skills, and anger management is essential for violence prevention.
  3. Improve security of hospital through increasing the number of security officer in duty.
  4. The administration should form multidisciplinary committees to identify the risk factors and to develop strategies and guidelines for prevention of workplace violence with a clear and publicized system for reporting.
  5. Further research is needed to study strategies that should be adopted to control violence against HCWs. Moreover, comprehensive understanding of patients and visitors satisfaction will help in reduction of violence at hospitals.
[37]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

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Abstract
Introduction
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