WHO South-East Asia Journal of Public Health
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 Table of Contents  
ORIGINAL RESEARCH
Year : 2012  |  Volume : 1  |  Issue : 2  |  Page : 133-143

Abuse against women in pregnancy: a population-based study from Eastern India


1 Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar-751 023, Orissa; Indian Council of Medical Research, New Delhi-110 029, India
2 Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar-751 023, Orissa, India

Date of Web Publication24-May-2017

Correspondence Address:
Bontha V Babu
Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar-751 023, Orissa; Indian Council of Medical Research, New Delhi-110 029
India
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DOI: 10.4103/2224-3151.206926

PMID: 28612789

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  Abstract 


Background: Violence against women is widely recognized as an important public health problem. However, the magnitude of the problem among pregnant women is not well known in several parts of India. Hence, the prevalence and characteristics associated with various forms of domestic violence against women in pregnancy were studied in Eastern India.
Methods: A population-based cross-sectional sample survey covering married women with a history of at least one full-term pregnancy (n 1525) was carried out in the Orissa, West Bengal and Jharkhand states of India. Interviews were conducted using a pre-piloted structured questionnaire to inquire about physical, psychological and sexual domestic violence. Data on socioeconomic characteristics and behaviours were also collected. The association of independent variables with domestic violence were examined by using logistic regression models.
Results: The prevalence of physical, psychological and sexual domestic violence during a recent pregnancy was found to be 7.1%, 30.6% and 10.4% respectively, and the lifetime prevalence during all pregnancies was 8.3%, 33.4% and 12.6% respectively. Urban living, higher maternal age and husbands’ alcoholism were the factors associated with domestic violence in pregnancy. Women belonging to lower social groups were less likely to have physical domestic violence. Factors such as higher prevalence of undesirable behaviours like denying adequate rest and diet, demand for more sex, not providing antenatal care and pressure for male child were also associated with domestic violence in pregnancy.
Conclusions: Considerable proportions of women experience some type of domestic violence during pregnancy. Health-care providers should be able to recognize and respond to pregnant women’s victimization and refer them for appropriate support and care.

Keywords: Violence, pregnancy, retrospective, cross-sectional, survey, India.


How to cite this article:
Babu BV, Kar SK. Abuse against women in pregnancy: a population-based study from Eastern India. WHO South-East Asia J Public Health 2012;1:133-43

How to cite this URL:
Babu BV, Kar SK. Abuse against women in pregnancy: a population-based study from Eastern India. WHO South-East Asia J Public Health [serial online] 2012 [cited 2019 Oct 17];1:133-43. Available from: http://www.who-seajph.org/text.asp?2012/1/2/133/206926




  Introduction Top


Violence against women is widely recognized as an important public health problem. A substantial number of women across several countries have reported abuse by intimate partner at some point in their lives.[1],[2],[3] Estimates of domestic violence prevalence vary widely from 18% to 70% in India. Differences in study methodology may account for such large variations. It is also realized that the magnitude of the problem has not been studied very well in several parts of India.[4] Prevalence of domestic violence in pregnancy, which is a serious concern in both developing and developed countries, is reported to be 33%.[5] The occurrence of domestic violence across women’s life-course is not inevitable but it can be a normalized behaviour in certain social circumstances.[6]

There is some support to the argument that prevalence of domestic violence decreases during pregnancy.[7] It seems that domestic violence is not initiated during pregnancy. However, whether pregnancy is a risk factor or a protective factor for women against domestic violence is inconclusive.[8] In several countries including India, pregnant women retain the privileged public position. Cultural norms may play an important role in affecting the degree to which women are protected from domestic violence at family level. Regardless of these issues, several pregnant women do report a history of domestic violence. They should be identified as high-risk group for developing preventive interventions in view of severe health consequences.[6],[9],[10] These consequences include a general loss of interest on the part of the mother in her or her baby’s health, both during the pregnancy and after the child is born.[11] In addition, women subjected to several abusive behaviours during pregnancy may lack emotional support of their partners during pregnancy. Many women have no access to health care during pregnancy and this proportion is high among women who experience domestic violence.[12],[13] Pregnant women who experience domestic violence have been found to have higher risks of obstetric and other complications to mother and foetus/child that warrant antenatal care.[6] The desire for male child is rampant in Indian communities[14] and exerting pressure on women for bearing a male child is very common. It is established that violence and abuse against pregnant women affects not only the health and well-being of the mother, but also that of the foetus and the child.[6],[10]

There is paucity of data on domestic violence during pregnancy in India. A population-based study undertaken across the country reported the prevalence of physical domestic violence to be 18%.[15] In addition, some clinic-based studies revealed that 22% to 48% of women report physical domestic violence during pregnancy.[16],[17],[18],[19] These studies have reported the prevalence of psychological and sexual domestic violence to be 29% and 6% respectively.[19] We hypothesized that domestic violence is a wide-spread phenomenon, however, its prevalence may vary across Indian states. These variations may occur within the population due to differences in socioeconomic characteristics such as habitation (rural or urban residence), age, religion and caste affiliation, education, occupation and income. Hence, this study was conducted to determine the prevalence and associated characteristics of women with various forms of domestic violence during pregnancy.


  Methods Top


A population-based study was undertaken in three eastern states of India. The population of the selected states, i.e. Orissa, West Bengal, and Jharkhand, was 31.7 million, 80.2 million and 26.9 million, respectively in the year 2001.[20] This cross-sectional study was carried out in 2004-2005. Quantitative data were collected through interviews using a structured questionnaire. The questionnaire contained items on socioeconomic data and domestic violence experience. To assess domestic violence exposure, women were asked several questions on various behaviours related to violence. Questions were posed to get women’s experience to a specific act of violence during their pregnancy. These behaviours and corresponding questions have been identified, based on previous studies in other settings. A multiphase process was used to develop these questionnaires to ensure that they were culturally and linguistically appropriate. Later the questionnaires were piloted to check appropriateness, clarity and flow of questions, but villages where pilots were conducted, were not included in the study. The other details of the questionnaire and the interviews are available elsewhere.[4] Interviews were conducted by women investigators after obtaining consent from women respondents.

The sample size was calculated based on the estimate of domestic violence prevalence from the sampled states.[20] The multistage sampling strategy was used. This is described in detail elsewhere.[4] Briefly, from each state, four districts were selected from different corners of the state. Out of these four districts, two each were allocated to draw rural and urban samples. From each district chosen for a rural sample, two blocks (administrative units in the district) were randomly selected. From each block, two villages were randomly selected. From each district allocated for an urban sample, an urban area (a city or a town) was selected and in this area, eight pockets comprising people belonging to different socioeconomic strata (high-income groups, middle-income groups, low-income groups and slums) were identified. A married woman up to the age of 50 years was sampled from each selected household. Initially, 1753 women were contacted; however, 35 women refused to participate, yielding a refusal rate of 2%. Of 1718 women, 1525 women who were chosen for the study had at least one full-term pregnancy. Only women with full-term pregnancy were included in the study to examine the association between domestic violence and pregnancy outcome. Complete data were available on all 1525 women included in the analysis.

Study variables

Independent variables

Data were collected on a number of characteristics of women that were expected to have association with domestic violence. The community-level variables included in the study were the state of residence (Orissa, West Bengal or Jharkhand), area of residence (rural or urban), religion (Hindu, Muslim, Christian or any other religion) and social group (scheduled tribe, scheduled caste, backward caste or general caste). The other independent variables were age and education, which were categorized into illiterate (those who can neither read nor write), functional literate (those who can read or write, but did not have formal schooling), school education (1-10 years of schooling), and college or higher education (those having more than 10 years of education). The occupation of the participant was recorded and categorized into housewives, salaried jobs (those in permanent or temporary jobs with fixed monthly salary), farming and small business (those engaged in agriculture-related activity and small businesses) and labourer (daily-waged skilled and unskilled labourers). The monthly income of the family was calculated during data analysis, based on the information collected on income of all members as well as from common sources of the family. The income details were collected in Indian rupees. One rupee was equivalent to 0.02 United States dollar. The information on parity was also recorded. The husband’s habit of drinking alcohol was also noted.

Outcome variables

The three principle domestic violence outcome variables considered in our analysis were: (i) physical domestic violence; (ii) psychological domestic violence; and (iii) sexual domestic violence. These variables were identified from the responses to a set of questions that were asked for each of the outcome variables. If a woman (as a victim) gave a positive response to any of the questions in a set, it was considered as presence of domestic violence for that category. These questions are described in detail elsewhere.[4] In addition, experiences of women for other behaviours namely change in sexual activity, availability of rest and diet, seeking of antenatal care and exposure to demand for male child by the family were also investigated. For change in sexual activity, the respondent was asked about the frequency of sexual activity during pregnancy. For availability of rest and diet, she was asked whether adequate food and rest were given during pregnancy. For these two questions, the respondent was given three options - as usual, decreased or increased during pregnancy. For seeking antenatal care, respondents were asked whether or not they visited any health facility during pregnancy for check-up. Respondents were specifically probed to know whether the woman was pressurized by her husband or other family members for delivering a male child.

Statistical analysis

The association of independent variables with different types of domestic violence were examined by using multivariate procedures. Binary domestic violence variables (experienced domestic violence or did not experience domestic violence) were modelled with multivariate logistic regression as a function of each independent variable. The independent variables were categorized into different groups as described earlier. Multiple logistic regression models were run by backward step-wise elimination procedure. The fit of the logistic regression models was checked by applying the Hosmer-Lemeshow Goodness of Fit tests. A p value of less than 0.05 was considered as the minimum level for statistical significance.


  Results Top


The prevalence of physical, psychological and sexual domestic violence during the recent pregnancy was found to be 7.1% (95% confidence interval (CI): 5.9%-8.4%), 30.6% (95% CI: 28.3%-32.9%) and 10.4% (95% CI: 8.9%-12.0%) [Table 1]. The lifetime prevalence of physical domestic violence during pregnancy was 8.3% (95% CI: 7.5%-9.2%), psychological domestic violence was 33.4% (95% CI: 31.9%-34.9%) and sexual domestic violence was 12.6% (95% CI: 11.5%-13.6%). The variability in domestic violence during pregnancy was very small across the states.
Table 1: Prevalence of domestic violence per 100 women during pregnancy in Eastern India

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The association of women’s characteristics with three forms of domestic violence during pregnancy was presented in terms of adjusted odds ratios (AORs) [Table 2]. With regard to physical domestic violence, urban residence, older age, salaried job and husband’s alcoholism emerged as the risk factors, whereas women’s affiliation to lower social group, higher levels of education and family income were protective against physical domestic violence. Religion was not included in the model.
Table 2: Association of socioeconomic variables of women with the prevalence of domestic violence in Eastern India

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Women who lived in urban areas, were older in age, belonged to backward castes and scheduled tribes, were multiparous and those whose husbands were alcoholics, were found to be more likely to experience psychological domestic violence. However, some variables, i.e. belonging to scheduled castes and having higher education, emerged as significant protective factors against psychological domestic violence.

The regression analysis for sexual domestic violence revealed that five of the nine variables had significant association. Urban residence, higher age of women, multiparity and husband’s alcoholism were found to be the risk factors. And women with higher levels of education were found to be less likely to experience sexual domestic violence during pregnancy.

[Table 3] presents the prevalence of abusive behaviours against women by their partners. It is expected that there is decreased demand for sex by the husband when his wife is pregnant. About 85% (95% CI: 83.1%-87.5%) women who have not experienced any sort of domestic violence reported that the frequency of sexual activity decreased during pregnancy, whereas only 52% (95% CI: 47.7%-56.5%) women who had experienced domestic violence reported decreased frequency of sexual activity in pregnancy. Those who were exposed to sexual abuse had low level of sexual activity in pregnancy (23.3%; 95% CI: 16.7%-29.9%). Overall, 67.2% women reported that frequency of sexual activity decreased during pregnancy, about 25% women said that there was no change, and 7.4% said that there was no sexual intercourse during pregnancy. A very small proportion (0.9%) of women said that there was increase in the frequency of sexual activity during pregnancy.
Table 3: Prevalence of selected behaviours against women during recent pregnancy, by type of domestic violence in Eastern India (data in percentage)

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With regard to allowing women to take adequate rest and diet, about 19% women reported that diet and rest increased during pregnancy, and the same proportion (19%) of women reported that diet and rest decreased, while 62.6% women said that there was no change in the provision of diet and rest. However, a higher number of women who had faced domestic violence during their pregnancy said that there was decrease in the adequate amount of rest and diet (26.7%; 95% CI: 22.8%-30.6%), compared to women who had not experienced any domestic violence (15.1%; 95% CI: 12.9%-17.3%). Overall 20% women did not receive antenatal care. This proportion was higher (29%; 95% CI: 25.0%-33.0%) among women who experienced domestic violence than those who had not experienced domestic violence during pregnancy (15.6%; 95% CI: 13.4%-17.8%).

About 18% women expressed that they faced pressure from family for having a male child. The pressure for having a male child was higher (25%; 95% CI: 21.1%-28.7%) among those women who had experienced domestic violence, compared with those who had not experienced domestic violence (15%; 95% CI: 12.8%-17.2%).


  Discussion Top


This population-based study revealed that a considerable proportion of women had experienced some type of domestic violence during their pregnancy. These findings are similar to those of some hospital-based studies conducted in India.[16],[17],[18],[19] The prevalence of domestic violence among ever married women in this region was found to be 56%.[4] The prevalence of domestic violence during pregnancy was lower than that of domestic violence during the lifetime (physical domestic violence -7.1% vs 16.1%; psychological domestic violence -7.1% vs 16.1%; and sexual domestic violence -10.4% vs. 25.4% respectively). Considerable variation in the prevalence of lifetime and during-pregnancy domestic violence has been reported. With regard to the perpetrators of violence, usually husbands are the perpetrators, followed by very few cases of perpetration by husbands’ parents and kins.[4]

Pregnant women were also victimised by abusive behaviours and by lack of emotional support. These behaviours were faced more frequently by women who experienced domestic violence. Usually, the men who perpetrate violence tend to hold conventional gender role attitudes, expecting women to take sole responsibility for household chores. Also, the inability to perform routine household tasks due to physical exhaustion and reduced mobility due to pregnancy frequently resulted in violence.[21] Women who experienced domestic violence reported lower utilization of antenatal care. Association between domestic violence and delayed and failed antenatal care-seeking was reported by previous studies also.[12],[13] Similarly, exerting pressure for male child was noticed more frequently among women who faced domestic violence. It is to be noted that this type of behaviour is a form of psychological domestic violence women experience. These abusive behaviours are also a risk factor for domestic violence during pregnancy. These behaviours had a positive association with all the three forms of domestic violence.

Living in urban areas was found to be a risk factor than living in rural areas. Other studies from developing nations support this finding.[22],[23] The urban social environment can be more stressful and alienating than rural areas. These conditions may influence spousal relations.[23] Women from the higher age groups were at a higher risk of all forms of domestic violence during pregnancy[12],[24]. Multiparity is usually correlated with higher maternal age. However, some studies have found that younger pregnant women are more likely to have been exposed to domestic violence than older pregnant women.[13],[25],[26] Alcohol consumption is positively associated with domestic violence during pregnancy and also with lifetime domestic violence in several communities.[27],[28],[29] In India, alcoholism is usually a cause of spousal conflict, as women questions husband’s habit of alcohol consumption. They try to stop him from taking alcohol and squandering money on it. Domestic violence is a consequence of this type of conflict, as men take it as challenge to their authority. This phenomenon goes on in several Indian households on a regular basis.

Higher levels of education and family income were found to be protective factors against risk of domestic violence during pregnancy. Educational attainment has repeatedly been found to reduce the likelihood of domestic violence even in developed communities.[30] Women with education are typically more autonomous and possess the resources and skills necessary to better recognize and terminate a potentially abusive relationship.

Though this study has identified some risk factors and protective factors with regard to domestic violence during pregnancy, it is important not to assume that any group or individual is especially at a low risk. In addition, the limitation of the study is the cross-sectional design itself, which does not allow for establishing a cause-and-effect relationship. Hence, the associations observed during regression analyses could be the function of some prior cause. However, study results provide vital information to develop policies and interventions for preventing domestic violence in pregnancy. Women should have access to information on the health hazards of domestic violence during pregnancy and sources of help.

A higher prevalence of domestic violence in pregnancy has public health implications. Health-care providers should have a role in preventing domestic violence during pregnancy and its health consequences. Hence, health-care providers should be trained to recognize and respond to violence during pregnancy and refer women for appropriate support and care, if required. Further research is needed on the feasibility and benefits of universal screening for domestic violence in pregnancy, particularly for encouraging the utilization of antenatal care services to prevent the health consequences of domestic violence.


  Acknowledgements Top


This study received financial and technical support from the Indian Council of Medical Research (ICMR), New Delhi, India.



 
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    Tables

  [Table 1], [Table 2], [Table 3]


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