The World Health Organization and various other professional medical organizations 1 have universally recognized wife battering as a major public health problem of significant importance in concert with the United Nation (UN) Declaration on the Elimination of Violence against women. 2 Research on the magnitude of lifetime marital abuse and its associated risk factors has resulted in a growing body of evidence that has raised public awareness regarding women's hidden burden of spousal abuse in developing countries. Between 10% and 69% of women reported being physically assaulted by an intimate partner, as illustrated by 48 population-based surveys conducted in developed and developing countries. 3
Factors such as household wealth, education of husband and wife, age, parity, duration of marriage, consumption of alcohol or drugs, HIV status, family history of abuse, and unplanned pregnancy have been shown to be associated with increased risk of physical abuse in developing countries. 4-6 Living with an abusive partner has an adverse impact on reproductive health outcomes like gynaecological disorders, unwanted pregnancy, unsafe abortions, pregnancy complications, and sexually transmitted infections including HIV. 3
However, the public health impact is particularly tragic when such events occur during pregnancy, as the health consequences are not limited to the pregnant woman but also affect her unborn child i.e., (abortion, stillbirth, maternal death, placental abruption, premature rupture of membranes, pre-term birth, and low birth weight). 4, 7-9
According to a recent review in the United States, the prevalence of domestic violence during pregnancy has been estimated between 0.9% to 20.1%,7 comparatively similar to rates reported from developing countries, (4% to 25%). 8-13 Determinants of violence during pregnancy, such as socioeconomic status, maternal age, parity, education of wife, unplanned pregnancy, and consumption of alcohol or drugs, are similar to those outside of pregnancy. 9-11,4
Pakistani obstetricians do not routinely screen pregnant women for any history of domestic violence unless there is strong clinical suspicion from injuries or depression. 15 Consequently, identifying domestic violence victims during antenatal care will sensitize Pakistani obstetricians to the enormous burden of violence in women's lives including during pregnancy and its potential role in pregnancy and newborn complications. This study was conducted to highlight the magnitude of wife battering during pregnancy among recently delivered women in a large public hospital in Karachi. The objectives of the paper were to assess the magnitude and determinants of domestic abuse in the marital lifetime and during pregnancy and attitude regarding domestic violence screening.
Subjects and Methods
A cross-sectional survey was conducted among women in the postnatal wards of a large public tertiary hospital in Karachi,during June 2002 to September 2002.
Our eligibility criteria included all recently delivered women (within three days post-delivery) irrespective of whether the pregnancy outcome was a live or still birth, and whether the delivery was normal vaginal, assisted, or Caesarean section. Women who were admitted for an abortion or with pregnancy complications and later discharged undelivered were excluded. Women occupying every alternate bed in the postnatal wards were assessed for eligibility. The subsequent occupied bed was selected if the woman in the identified bed was not eligible. (Less than 1% of women refused to participate in the study). The selected women were administered the questionnaire outside the visiting hours by the interviewer after obtaining verbal consent.
The pre-coded structured questionnaire was developed in collaboration with the local investigators, pre-tested and revised; translated into Urdu and back-translated into English. It elicited information on demographics, care-seeking behaviours for abuse related injuries, and attitudes to domestic violence screening during antenatal care clinics. Prevalence and severity were measured by a modified Conflict Tactics Scale that has been used extensively to measure physical spousal violence.16-18 The final tool included 14 items, of which 11 enquired about physical violence, two about verbal abuse, and one about sexual coercion. For each item, women were asked whether they had experienced the event during the index pregnancy, during any previous pregnancy, and another time during marital life excluding pregnancy. Each interview lasted on an average for 40 minutes.
Physical abuse was defined as objects thrown, pushed, grabbed or shoved, hair pulled, slapped or hit, kicked or bitten, choked, tried to drown, used knife, gun or other weapon by their husbands. Verbal abuse was defined as cursed, yelled, insulted, humiliated or threatened with knife, gun or other weapon by their husbands. Sexual coercion was being forced to have sexual intercourse against her will.
Prevalence estimates were calculated to reflect the relative frequency of sexual coercion, verbal and physical abuse for marital lifetime and during the previous (index) pregnancy. Standard descriptive analysis was performed. To investigate associations between socio-demographic variables and physical abuse status (abused versus never abused), bivariate and multivariate logistic regression analysis were conducted; odds ratios and 95% confidence intervals were calculated. Dichotomous dependent variable was defined as 0 = never been physically abused and 1= one or more episodes of physical abuse during marital lifetime and index pregnancy. All analyses were carried out using the Statistical Package for the Social Sciences (Version 11).
Interviews were completed on 300 women; most interviews were conducted within two days post-delivery. Women, on average, were 6.6 years younger than theirspouses; nearly half of the study sample was 25 years and the mean duration of marriage was 6.7 (±5.8) years. Consanguineous marriages were common (49%) with most marriages being among first cousins (22% maternal; 20% paternal). Slightly less than half of the women (48%) had not attended school, whereas most of their husbands (60%) had received some formal education. Although most husbands were employed (88%), women were rarely employed (8%).
The index pregnancy was the first pregnancy for nearly a quarter of the study women; for many women (37%) this was either their second or third pregnancy. Nearly all of the women (96%) attended at least one antenatal clinic for their index pregnancy. A substantial number of women (40%) were admitted for a pregnancy complication. Common pregnancy complications included decreased fetal movement (20%), antepartum haemorrhage (13%), pregnancy induced hypertension (18%), obstructed labor (9%), pre-term labor (4%), and postpartum haemorrhage (2%). Caesarean sections (44%) and normal vaginal (44%) were the main mode of delivery, whereas assisted vaginal delivery (breech and episiotomy) constituted the remaining 12%.
Domestic violence of any form was less frequently reported during pregnancy as compared to marital lifetime. For example, 44% of women reported ever experiencing any form of physical abuse during their marital lifetime, declining to 23% for the index pregnancy. Nearly all women who reported being physically abused during pregnancy (68/69 women) had a history of physical abuse. Verbal abuse and threats were common; 80% of women reported verbal abuse in their marital life whereas fewer such events occurred during pregnancy (66%). Generally, sexual coercion was less frequently reported as compared to physical or verbal abuse. Among the 132 ever physically abused women, 36% were also coerced to have sex and all 132 were verbally abused. Slapping, hitting, pushing, grabbing, shoving and pulling hair were the most commonyears). Women with no education or primary level education were at a significantly higher risk of physical violence, compared to women with secondary level education. Women married to distant relatives had significantly higher risk of violence (OR=3.6; 95% CI=1.2-11.2). Parity was a strong predictor of physical abuse. Women with four or more live births were nearly four times likely to experience physical abuse (OR=3.9; 95% CI=2.0-7.5). The statistically significant risk factors in the multivariate logistic regression analysis were wife's education, consanguinity, and duration of marriage. Women's age, spousal age difference and parity lost their significance ( Table 1 ).
Potential risk factors for physical abuse during the index pregnancy were similar to those reported for lifetime marital physical abuse, though the magnitude of the odds ratio was higher. Women with no formal education were two and a half times more likely to be physically abused during pregnancy (OR=2.6; 95% CI=1.2-5.6) as compared to women with a high school education, after controlling for all other variables. Women who were married for five to nine years (OR=3.8; 95% CI=1.3-11.2) or ten or more years (OR=3.7; 95% CI=1.0-13.9) were at higher risk of being abused than women who were married for less than five years ( Table 2 ).
A quarter of women (23%) reported physical abuse during their recent pregnancy suggesting a serious social and health problem that is particularly challenging for Pakistani obstetricians. The point prevalence estimates for physical abuse during pregnancy and marital lifetime reported from our study fall within the range quoted from developing 3,13 and developed countries. 3,7 In this study, the rates of lifetime marital physical abuse at 44% was nearly double that during the recent pregnancy. The widespread belief that pregnancy either initiates or increases the risk of violence was not substantiated in our study, similar to findings from other studies in developed7 and developing13 countries.
The results of this study also highlighted the burden of verbal and sexual coercion on married women living in a conservative patriarchal and patrilocal family structure like Pakistan. A majority of women experienced verbal abuse during their marital life or during their preceding pregnancy; significantly higher than reported from China 9 or the United States. 7 Physical assault is not an isolated event in a woman's marital life but rather part of a perpetual pattern of spousal abusive behavior. Results of our study as well as those conducted elsewhere 19,20 highlight the inter-relationship between verbal abuse, sexual coercion and physical abuse. Furthermore, our findings substantiate results of other studies14,21 that identify past abuse as a significant predictor of abuse during pregnancy.
Factors provoking physical abuse identified in our study are similar to those reported elsewhere. 5 The fact that nearly 14% of the respondents specifically mentioned using contraception without spousal permission highlights the inter-spousal conflict associated with contraceptive use as has also been reported from India. 6
In this study, strong significant associations were found between abuse (lifetime marital or during last pregnancy) and duration of marriage, education and consanguineous marriages. Significant relationships between abuse and age, spousal age difference, husband's education and parity lost their significance at the multivariate stage perhaps emphasizing the co-linearity between these time-dependent factors that was best explained by duration of marriage. On the other hand, the retention of duration of marriage might also signify the unique explanatory role of marriage duration over and above the time element.
Pre-marital family relationship appears to play a significant protective role in an abusive relationship. Women whose spouses were distantly related were nearly four times as likely to be in an abusive relationship as compared to women married to their first cousins. Maintaining spousal and family harmony is perhaps another reason for the continued high prevalence of first cousin marriages in Pakistan in addition to maintaining wealth within the family.
Assessments of domestic violence, either lifetime or during pregnancy, generally highlight the need for the involvement of health services4,6,12,22 as an intervention strategy to break the chain of family violence. Sharing information about physical abuse is rare due to perceptions of shame, fear of blame, or reluctance to be disloyal to spouse or marital family. Few women profess to seek medical or health care for injuries sustained consequent to physical abuse. Our study results also corroborate these findings. However, our results also strategically highlight that women are amenable to screening during an antenatal visit.
The results of our study should be interpreted in the light of methodological constraints. First and foremost is the sensitive nature of the topic and its proneness to response bias that may lead to under-reporting of the true extent of the abuse. Methodological limitations regarding the definitions of abuse used, the uniformity maintained when inquiring about abuse, language barriers and privacy concerns are additional constraints. Second, information about violence was self-reported, which may have led to recall bias. Third, the point prevalence for physical abuseduring pregnancy in our study may be over-estimated compared to other studies. This perhaps is affected by the timing of the interview. Most studies have collected data during prenatal care, thereby restricting the reference period to that prior to the interview, whereas our study included the entire gestation period. Alternatively, the exclusion criteria of women admitted for an abortion or pregnancy complication and later discharged undelivered fails to capture cases of violence during pregnancy that may have led to abortions or pregnancy complications, thus underestimating the total burden of violence during pregnancy.
Despite these study limitations, these findings should alert Pakistani health professionals to the enormous burden of physical abuse especially during pregnancy, which places the health of both mother and foetus in jeopardy. Pakistani health care professionals can play a major role in ensuring that women are routinely screened for domestic violence by including a few simple questions during routine antenatal care for identification of abused women.
We gratefully acknowledge the financial support of the John D. and Catherine T. Mac Arthur Foundation and the Robert H. Ebert Program for Critical Issues in Reproductive Health.
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