Contents

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Kebebush Worku¹ and Godana Arero^2*

Citation:

Kebebush Worku and Godana Arero. Appraisal of Intimate Partner Violence and associated factors among Pregnant Women in Nagele, East Borena, Oromia Regional State, Ethiopia, Special Journal of Public Health, Nutrition, and Dietetics. 2021, 2(1): 1-17

 Highpoints

• Intimate partner violence is a public health priority that needs urgent intervention
• Advance our knowledge on Intimate partner violence to mitigate the challenge
• Empowering women economically, socially, and politically are a new systematical approach to mitigate problem especially in developing countries

Abstract:

Background:

Intimate partner violence especially during pregnancy is an important public health and human rights issue associated with fatal and non-fatal adverse health outcomes for the pregnant woman and her baby. The paucity of data, seeming urgency, and significance of this topic warrants the attention of all stakeholders of health and relationship matters

Objective:

This study aims to determine the magnitude of intimate partner violence among pregnant mothers and associated factors Since there is inadequate data and intimate partner violence is common in this study area, we needed to study this topic.

Materials and Methods:

A facility-based cross-sectional study was carried out from Oct15/2020 –Dec15/2020. Face-to-face interviews were conducted using a pre-tested structured questionnaire. The collected data were entered into Epi info version 7.2.1.0 and then exported into Statical package for social science version 20 for analysis. Descriptive statistics were conducted. Bivariate analysis was done to select candidate variables for multivariate analysis. Finally, variables that had significant associations with intimate violence during pregnancy were identified based on p-value<0.05 and AOR with 95% CI.

Result:

About 44.3% (95% CI 44.2-44.4) of pregnant women had faced at least one form of intimate partner violence during the current pregnancy. Psychological violence 29.1%, Sexual violence 24.4%, physical violence 23.9% were forms of violence the respondents was encountered. Respondents who were primary educated  (AOR 2.99, 95%CI 1.23-7.25), secondary educated (AOR 2.36,95%CI 1.047-5.34), respondents in the age group of 26-34years (AOR 0.20 95%CI 0.065-0.64) and age group of >=35years (AOR 0.26, 95%CI 0.09-0.77).

Respondents with a history of miscarriage, abortion and/ stillbirth (AOR 0.5,95%CI 0.32-0.78), respondents who accepted their partner had the right to beat them(AOR 1.83, 95% CI 1.82-2.82), respondents whose partners were in the age group of 40-49 years(AOR 2.22,95%CI 1.10-4.47), tertiary educated (AOR 0.38, 95%CI 0.20-0.71), had a history of fighting with other men (AOR 1.77 95%CI 1.14- 2.75) were factors significantly associated with IPV during pregnancy.

Conclusion:

The prevalence of intimate violence in the Negele Borena town selected public health facility is among the highest. Policymakers need to consider screening for IPV in the antenatal care service as one component. It is also better to include IPV screening as one component of the community health extension package

Keywords:

Intimate partner violence, pregnancy, Negele Borena, Oromia,

Addresses:

(1) Nagele Borana School of Public health, Nursing School, Oromia regional state, Ethiopia. (2) Adama Comprehensive Specialized Hospital Medical College, Department of Public Health, Oromia Regional State, Ethiopia

Article history:

Received September 18, 2021: Accepted: November 3^rd, 2021:  Published:  November 30th, 2021

 Distribution and usage license:

This open-access article is distributed by the terms and conditions of the Creative Commons Attribution 4.0 International License seen in this link (http://creativecommons.org/licenses/by/4.0/ ). You are free to use, distribute, and reproduce this article in any medium, provided you give correct credit to the original author(s) and the source, including the provision of a link to the Creative Commons license website. Pls show any modification’s

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Introduction 

According to the world health organization (2) intimate partner violence (IPV) is defined as “any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship”. An intimate partner is a current or former partner, whom the woman has been married, cohabited, or dated.

The terms “wife abuse”, “domestic violence” and “violence against women,”  are interchangeably used to refer to the extent of sexually, psychologically, and physically coercive acts used against adult and adolescent women by current or former male intimate partners. Although it is not common globally about less than one in ten women are violent to their partner. Violence against women may occur at any stage of women’s lives, including during pregnancy (3-6).

Violence against women is largely recognized as a major human right abuse, and a significant public health problem with multiple adverse physical, mental, sexual, and reproductive health effects. Intimate partner violence can occur before pregnancy, during pregnancy, and in the postpartum period.

Because of the changes in the social, economic physical, and emotional, needs of women during pregnancy, conception may be a time of unique vulnerability for women to become victims of IPV. Intimate partner violence during pregnancy is increasingly being recognized as an important risk factor for adverse health outcomes for both mother and newborn(6-8).

The risk factors for Intimate Partner Violence during pregnancy are usually not different from that of IPV in general, the only difference is that pregnancy is a time that may need increased rela­tionship commitment and increase the resources needed. Some risk factors are likely to be more important during pregnancy one potential risk factor significantly associated with intimate partner violence during pregnancy is having an unwanted or unplanned pregnancy (2, 6, 8).

Globally, one-third of women who have been in a relationship have experienced physical and/or sexual violence by their intimate partner in their lifetime and the prevalence is highest in African, Eastern Mediterranean, and South-East Asia regions where approximately 37% of ever-partnered women reported having experienced physical and/or sexual intimate partner violence at some point in their lives.

Whereas the prevalence of intimate partner violence during violence varies between1% to 28% worldwide (9-11). The magnitude of intimate partner violence during pregnancy in Africa ranges between 2% to 57%. The magnitude of intimate partner violence during pregnancy in Ethiopia is estimated to be 4%-59% (12-15).

Objective:

This study aims to determine the magnitude of intimate partner violence among pregnant mothers and associated factors Since there is inadequate data and intimate partner violence is common in this study area, we needed to study this topic.

Materials and Methods:

An Institutional based cross-sectional convenient sampling study was carried out from Oct 15 – Dec 15/2020. All pregnant women who visited Negelle Borena hospital and health center for antenatal care (16) were the source population. Sampled pregnant mothers who got   ANC in Negele Borena Hospital and health center and fulfill the selection criteria was the study population. Mothers who were pregnant and Visit the health center for ANC service only were included in the study; because the focus of the study was on pregnant mothers.

Sampling procedure

The sample size for each health facility was determined by proportion to population size by reviewing the previous annual ANC service report of the two facilities. So six months of ANC service achievements of Negelle Borena Hospital and health center of the year 2011/2019 were 1980 and 891 respectively. The sampling interval (K) for each health facility was determined by dividing the average expected ANC during the study period by the sample size for each health facility.

Thus, for hospital K=4 and health center K= 2. Study participants were selected by using systematic sampling. The first mother was selected by the lottery method; by rolling four and two papers with their registration number of pregnant women for hospital and health center respectively(17). Then every kth mother was selected and interviewed till the Sample size was fulfilled. The sampling frame was fixed based on the antennal registration list. In case the women in the list were absent the next consecutive women were interviewed.

Data Collection Procedure for Intimate Partner Violence study

 A validated instrument, based on the standard of WHO multicounty study on women’s health and domestic violence against women was used to collect data from each of the Study participants. This questionnaire had four items for psychological violence, six items for physical violence, and three additional items for sexual violence (8).

 WHO standardized questionnaire was adapted and then translated to Afan Oromo (local language) and back to English to maintain the consistency of the tool by a language expert. Two female midwives for data collection and one experienced Bsc nurse for supervision were recruited. A face-to-face interviewer-administered questionnaire was used to collect data from all pregnant women who consented to be part of the study.

 Exclusion criteria for the Intimate Partner Violence survey

Those women who come for the first time during data collection were excluded because their list was not available to fix the sampling frame

Ethical approval.

The Institutional Review Board (IRB) of Adama Hospital Medical College has approved the research for scientific and ethical integrity. A letter of permission was obtained from the Negelle district administration and health offices. Before conducting the interviews, information was given to the participants, and participants were assured of voluntary participation, confidentiality, anonymity, and freedom to withdraw from the study at any time.

The nature and importance of the study were explained and written consent was obtained from the participants. The interview with the pregnant women was conducted privately in a separate room. In this case, the interview may trigger emotional response appropriate counseling and where to go for help was told. The WHO ethical and safety recommendation protocol for research on domestic violence against women was followed as a guide (10).

Data Quality Assurance

Data collectors and the supervisor were trained for one day on techniques of data collection and supervision. The principal investigator and supervisor were made day-to-day on-site supervision during the whole period of data collection as the WHO standard of researching violence against women (2).

And data was checked in each questionnaire daily for completeness and consistency. The questionnaire was pre-tested to check the response, language clarity, and appropriateness of the questionnaire, while the pretest was done outside the study area with a 5% of sample Size of 20 women. Based on the finding from the pre-test, modification of the questionnaire was done, and the arrangement of questions was revised.

Data Processing and Analysis

Data were first checked manually for completeness, Coded, then entered into Epi-Info version 7.2.1.0 and exported to SPSS version 20 for further analysis. Exploratory data analysis was done to check missing values and outliers. Descriptive statistics were conducted to summarize the data. Then results would be presented in text, tables, graphs, and charts. Bivariate analysis was done to select candidate variables for multivariate analysis.

Variables that had p values up to 0.25 were considered for the multivariable logistic regression analysis to control the effects of confounding variables. A collinearity test was carried out to see the correlation between independent variables using the standard error A Hosmer– Lemeshow and Omnibus tests were conducted to test model goodness of fit(18). Finally, variables that had significant associations with intimate partner violence during pregnancy were identified based on AOR with 95% CI and a p-value of 0.05.

Result

A total of 406 pregnant women participated in the study, making the response rate 99.3%. Three of the Questitionere were not turned back. The socio-demographic character of women and obstetrics associated factors are described in table 2. The median age of the respondents was 25years with  6 interquartile range/6 IQR. The majority (48.8%) and (60.8%) of the respondents were Muslim religion followers and Oromo ethnicity respectively.

More than nine in every ten (93.6%) were married. Regardless of their occupation more than two in every five (44.1%) of them were housewives followed by 18% of them being a merchant. The vast majority (40.9%) of them were primary educated and about less than one in three (28.3%) of them were illiterate. About three in every four (74.9%) of them were urban dwellers (table1).

Reproductive and Women Related Characteristics

According to respondents report half (50%) of them contribute income for their living. Nearly two in every three (56.7%) of them witnessed their father batter their mother. More than one in every three (40.9%) of them accept wife-beating if there are justifiable reasons.

Concerning respondents’ reproductive-related factors; nearly two in every three (61.6%) of them didn’t want the current pregnancy. More than one in every three (35.2%) of the respondents had a previous history of artificial abortion, spontaneous abortion (miscarriage), and stillbirth history. According to the respondent’s report, the number of children they had; nearly four in every three (73.4%) of the respondents had one to four children on the range and more than two-thirds (70.7%) of the respondents were six or above six months pregnant during the interview. See table3 below.

Table  1 . Socio-demography characteristics and socio-economic factors of pregnant women in Negelle Borena town selected public health facility 2020(n=406)

Key   Other^,= wakifta, catholic^,   Other ⁼  Sidamo, walayita, gurge^, Other^s  = students, farmer

Table 2. Reproductive and women related Factors of IPVDP in Negelle Borena town selected public health facility 2020(n=406)

 Socio-cultural and Family-Related Factors of Respondents

According to respondents’ reports, nearly two in every three (60.6%) of their marriage ceremonies had dowry payments. And two in every three (66.3%) decision on the household issue was made jointly with their husbands. Regardless of the number of family members nearly half (49. %) of them had 4-6 family numbers. With one word count, 58 of the respondent’s partners had other wives, and as well as 57 of the respondents’ marital sequences are second or above. Refer table3

Table 3. Socio-cultural and Family factors of pregnant Women in Negelle Borena Town Selected public Health Facility 2020(n=406)

Socio-demographic Characteristic, Socio-economic and Behavioral Factors of respondents’ Partners

According to respondents’ report, the median age of their partners was 31years with an interquartile range of 8 years. The majority (28.8%) of the respondent’s partners were a merchant. More than one-third (36.2%) of them were primary educated. More than half (52.2%) of the partner’s income was in>= 2500 Ethiopian birr. Concerning respondent’s partner behavioral factors; more than half (52.7%), more than half (53.7%), and 18 % of them drank alcohol, chew khat, and smoke cigarettes respectively. More than one in every three (39.9 %) of the partners had a history of violence with other men.

Forms of intimate Partner Violence among Pregnant Women

More than two in every five 180(44.3% 95% CI 44.2-44.4) of pregnant women had faced at least one form of intimate partner violence during the current pregnancy. From the three (3) forms of violence emotional /psychological violence was the leading 118(29.1%); from this emotional violence majority (28.1%) of the victim was insulted or made to feel bad about themselves followed and some (8.9%) of them were belittled or humiliated in front of other people.

 Sexual violence was the second common 99(24.4%) form of intimate partner violence during the current pregnancy. From this majority (23.2%) of them had sexual intercourse without their interest because of the fair of their partner. About 6.9%, 6.4% of them were forced to have sexual intercourse without their interest and to do something sexual that found her degrading or humiliating by their partner respectively during the current pregnancy. Less than one in every three 97(23.9) of the respondents were the victim of at least one form of physical violence during their current pregnancy. The majority (19.2%) of them were slapped by their partner. About 2.2% of them were choked or burned.

 Overlap of different Form of Intimate Partners Violence

There was an overlap of the different forms of intimate partner violence among respondents. About five percent (5.6%) of them were victims of all three forms of violence (physical, sexual and psychological violence. Around ten percent (10.3%) of them were physical and sexual, thirteen (13.8%) of them were physical and psychological, the remaining fourteen percent (14.2%) were sexual and psychological violence respectively violence victims (Fig.1).

Figure  1. Overlap of different forms of intimate partner violence among pregnant women in Negelle Borena Town selected public health facility 2020

 Factors associated with IVP among Pregnant Women

Bivariate logistic regression was used to identify factors associated with IPV. Accordingly; many Sociodemographic characteristics of the respondents and their partners, their partners’ behavioral factors, reproductive and pregnancy-related factors, and family associated factors were assessed for the presence or absence of association with IPV. From variables entered in Bivariate fifteen were identified as a candidate for multivariate, based on the criteria specified in the method part.

 At multivariate from fifteen candidates seven of them were identified as significantly associated with IPV. Of those seven factors, half of them have allied to respondents and her partner Sociodemographic factors look below table5. Respondent’s educational status was one of the factors significantly associated with IPV. A respondent who was primary educated were three times (AOR 2.99, 95%CI 1.23-7.25), secondary educated more than two times(AOR 2.36,95%CI 1.047-5.34) more likely encountered IPV during current pregnancy respectively compared to illiterate( uneducated) pregnant women.

Age of respondents was also significantly associated and those respondents in the age group of 26-34years were about 80% times (AOR 0.20 95%CI 0.065-0.64) and age group of >=35years about 70% time (AOR 0.26, 95%CI 0.09-0.77) less likely encountered IPV during current pregnancy compared to the age group of 16-25years. Respondents were also asked about their reproductive and women-related factors; respondents with a history of miscarriage, abortion.

Stillbirths were 50% times less likely to report IPV compared to respondents without a history of miscarriage, abortion, and or stillbirth(AOR 0.5,95%CI 0.32-0.78). Accepting or justifying as the husband had the right to beat his wife is also significantly associated with IPV. And respondents who accepted their partner had the right to beat them were about two times more likely to face IPV compared to those who didn’t accept (AOR 1.83, 95% CI 1.82-2.82).

Respondents were asked about their partners’ socio-demographic characteristics and behavioral factors. Respondents whose partners were in the age group of 40-49 years were encountered IPV about two times(AOR 2.22,95%CI 1.10-4.47)  compared to respondents whose partners were in the age group of 20-29yers. Concerning education status; respondents whose Partners were tertiary (diploma and above) educated 62% times (AOR 0.38, 95%CI 0.20-0.71) were less likely violent to the respondents compared to illiterate respondent’s partners.

Partners’ behavior like fighting with other men or aggressive behaviors were significantly associated with IPV. Respondents whose partners had a history of fighting with other men were encountered IPV about two times (AOR 1.77 95%CI 1.14- 2.75) more likely compared to respondents whose partner had not fought history with other men

Table 4. Bivariate and Multivariate analysis results of intimate partner violence associated factors in Negelle Borena selected public health facility 2020

Key COR – Crude odds Ratio, AOR – Adjusted Odds Ratio, CI: confidence interval.* P- Value<0.05, 1=reference

Discussions

In this cross-sectional study, the prevalence of intimate partner violence among pregnant women was 44.3% (95% CI 44.2-44.4)(fig3). This finding is in agreement with findings from Portugal (43.4)(19), a systematic review of  Africa (2%-57%)(15), and also found in our countries such as in Abay champagne (44.5%)(20), Debre Markos(41.1%)(13) and Tigre region (40.8%)(21). It is higher than study in Vietnam(37%)(22), Rwanda(10.2%)(23) and Uganda (27.8%)(51), in Ethiopia in the southeast part of the counters (25.8%)(24), Tigray region (20.6%)(25) and of a district in Tigray region (37.%)(26).

This higher variation could be a result of the sample size difference. For example in Uganda, the total sample size was 180. This could result in lower prevalence. Another possible cause of such discrepancy could be using only physical intimate partner violence alone. For example, in the Tigray region, only physical intimate partner aspects were used but in our case physical, sexual and psychological aspect were assessed. This could result in higher prevalence. The high prevalence of IPV may lead to poor pregnancy outcomes and maternal Psychological and physical health problems.

However this finding was lower than finding from Kenya putoko (66.9%)(16), finding from different parts of Ethiopia; Gonder (58.7%)(27), Bale zone (59.0%)(14). The higher prevalence in finding from Bale zone (59%) could be due to using economical and controlling aspects in addition to the usual physical, sexual, psychological. In this study psychological violence was frequent; followed by sexual and physical intimate partner violence.

Nearly one in every three (29.1%) of the respondents were the victim of psychological violence in the form of insult or made her feel bad about herself. This finding is in line with the finding from Namibia(28) but lowers the finding from Gonder town(29) and Abay chamone(30). Physical violence was the less frequent type of violence which accounts for about one in every (23.8%).

The finding that psychological violence was the most prevalent abusive act in this study, probably because pregnancy could offer protection against physical violence for many women and that the decrease in physical violence during the pregnancy period may parallel an increase in psychological violence, as evidenced by the patterns of longitudinal violence prevalence about pregnancy onset in studies from Brazil (31) and Bangladesh (32).

Moreover, in this study, the use of the culturally sensitive WHO Violence Against women questionnaire is considered to increase detection of the emotionally abusive acts of insulting, intimidating, and threatening, which might not be culturally considered as acts of violence in many traditional societies.

Respondent’s educational status (Table1) was one of the factors that significantly associated with IPV. Respondents who were primary and secondary educated were about three and two times more likely to encounter IPV during the current pregnancy. This finding is consistent with finding from Brazil(31), a study in Hind Mumbai(44), a systematic review in Africa(13), Gonder(29). This is due to those primary and secondary educated women were more complain/report violence than uneducated or illiterates are more tolerant of violence (33)

Respondents’ age (Table1) was significantly associated with IPV during the current pregnancy. Respondents in the age group of 26 – 35 years and age group of >=35years about 80% time were about 70% times less likely to encounter IPV during current pregnancy compared to the age group of 16-25years.t This is in line with finding ever were (10) and in Ethiopia(14). This according to Fernandez’s idea who described as the age of a woman increases she often grows in social status as she becomes not only a wife but also a mother and a socially influential member of her community(34). Thus, older women are less likely to report current experiences of IPV than younger.

 In this study (Table3) women’s acceptance or support as husband has the right to beat his wife was significantly associated with IPV. Respondents who accept violence were about 2 times more likely to encounter IPV. This finding is congruent with findings from WHO multi-country study on women’s health and domestic violence, findings northern part of the country shire town(10), Ofla district in Tigray region(26).

The possible justification for this unawareness of basic human rights and other legal rights of women. It is this state of ignorance that ensure their acceptance and consequently, the perpetuation of harmful traditional practices affecting their wellbeing or it can be due to poor and weak implementation of various women-oriented laws is also a factor we need to take into consideration as one of the causes of violence against women (61).

Respondent’s reproductive and pregnancy histories (Table3) Were significantly associated with IPV during the current pregnancy. Accordingly, respondents with a history of pregnancy loss /miscarriage, abortion, or/and stillbirth /were 50% times less likely to encounter IPV during the current pregnancy. This finding is inconsistent with another finding (14, 35). This could be due to different studies showing that unwanted pregnancy is associated is a more likely hood of IPV during pregnancy (14, 15, 26, 29).

As this unwanted pregnancy is lost /miscarriage, abortion or/and stillbirth; this can result in less likely of IPV. But such type of association is more liable for reverse causality than whether pregnancy loss results in IPV or IPV lead to pregnancy loss. This is beyond such a cross-section study and it needs further study.

Respondent’s partner’s educational status (Table1) was one of the factors that were significantly associated with IPV during current pregnancy; Respondent’s whose partner was higher educated/diploma and above 61% times less likely to encounter IPV. This finding is in agreement with the finding of Elsewhere (10, 28, 36) and finding in Ethiopia(37).possible justification is educated partners did have awareness about basic human and women rights this and consequence it’s of violation or it can be due to understanding the consequence of violence during pregnancy both on the mother and unborn baby. Finding from Abay chamone in the Oromia region contradicted this(20)

 Respondent’s partner age (Table1) is also significantly associated with IPV. Respondents whose partners were in the age group of 40- 49years were more than two times more likely to encounter IPV Compared with their younger age groups. This finding is in line with (14, 38). The age discrepancy between women and their partners could be the possible reason for the increased odds of violence among the oldest intimate partners. In our study, there was a big difference between the age of pregnant women and their intimate partners.

In this study (Table1), the mean age of the respondents was 25±4.6 and partners was 32±5 more than fifty percent of the respondents were in the age group of 16-25 years. Finding in Nigeria showed that an age difference of between 5-9years increases the likelihood of encountering IPV by 1.35 times(39). The age difference between the partners might affect communication and understanding that lead to a violation.

Respondent’s partner’s history of violence with other men or aggressive behavior (Table1)was also significantly associated with IPV during the current pregnancy. Respondents whose partners had a history of violence with other men were 77% more likely to encounter IPV during the current pregnancy. This is congruent with finds from Kenya (10, 15, 40)and Ethiopia (14). The possible explanation violence is learned behavior (41)

Conclusion

The prevalence of intimate violence intimate partner violence in the Negelle Borena town selected public health facility is among the highest compared to other areas. More than two in every five(44.3%)  women were experienced at least one act of IPV. Psychological and sexual violence were the most frequent type of IPV. The primary and secondary educated, age group of 26-35years, acceptance of violence or women beating, miscarriage, abortion /or stillbirth were respondents relate factors that were associated with IPV. Respondent’s partner tertiary educated, age of  40-49years, history of violence with other men were partners associated factors with IPV.

Recommendation

Creating community awareness to change beliefs that are culturally embedded in collaboration with the indigenous leadership, community leader, and other key stakeholders is mandatory. Policymakers need to consider screening for IPV in the antenatal care service as one component. It is also better to include IPV screening as one component of the community health extension package. Further studies that show the effect of intimate partner violence on the pregnancy outcome need to be conducted. Better to work on women’s education and empowerment.

Ethics approval and consent to participate:

The Ethical Committee of Institutional Review Board (IRB) for Research at Comprehensive Specialized Hospital of Adama Medical College approved the research project under the tenets of the Helsinki Declaration and the Oromia Regional State Ethical guideline for Medical Research. The ethical approval code is OR.CSSAMC.REC.2015.235. Furthermore, informed consent was obtained from the study participants and all concerned bodies.

Consent for publication: “Not applicable”

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.’

Competing interests: NA

Funding: NA

Authors’ contributions:

I did plan, develop a research proposal, collected data, and took the overall activities of the paper from the planning phase to write up results.

Acknowledgments:

I would like to acknowledge Adama Hospital Medical College Institutional Review Board ( IRB), all concerned administrative and study participants.

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