Does intimate partner violence influence the utilization of maternal health services?

Intimate partner violence IPV is public health problem globally and most common in developing countries that affects more than one fourth of women of reproductive age WRA. It is more critical during pregnancy. IPV not only affects physical and mental well-being but also leads in birth outcomes with negative consequences. We use secondary data from Nepal Demographic and Health Survey 2016 to assess the association between IPV, and maternal service utilization: ANC visits and institutional delivery. Altogether 1374 WRA were randomly selected. Background characteristics of WRA and IPV were the independent variables, and ANC visits and institutional delivery were the dependent variables. Data show that 26 percent of WRA had faced at least one form of IPV, 68 percent had visited health facilities at least four times for ANC check-up during pregnancy, and the rate of delivery was 61 percent. There were association among IPV with ANC visits and institutional delivery (p<0.001). Age group, educational level, ethnicity, number of child, residence setting, and wealth of were significantly associated with ANC visits and delivery (p<0.001). Data show that participants who faced at least one form of violence from husband were less likely to receive four or more ANC visits compared to no experience of violence from husband (aOR = 0.74, CI [0.56 – 0.98], p<0.05) similarly participants who had experiences of at least one form of violence were less likely to received delivery services at health facilities (aOR = 0.80, CI [0.60 – 0.90], p<0.05). Participants having age more than 34 years were less likely to have four or more ANC visits (aOR = 0.58, CI [0.37 – 0.91], p<0.05) compared to age less than 25 years. Similarly, participants having age between 25 to 34 years tended less likely to receive natal service during delivery form health facilities compared to the age less than 25 years (aOR = 0.86, CI [0.52 – 0.89], p<0.01). Educational status seemed significant predictor for both ANC visits and institutional delivery. Participants having primary; and secondary or higher education were more likely to receive ANC visits four or more time (aOR = 1.62, CI [1.16 – 2.26], p<0.01; aOR = 3.03, CI [2.17 – 4.22], p<0.001) and more likely to receive delivery services form health facilities respectively compared to those who had no education respectively (aOR = 1.68, CI [1.20 – 2.35], p<0.01; aOR = 3.10, CI [2.24 – 4.29], p<0.001). Participants times


Abstract Background
Intimate partner violence IPV is public health problem globally and most common in developing countries that affects more than one fourth of women of reproductive age WRA. It is more critical during pregnancy. IPV not only affects physical and mental wellbeing but also leads in birth outcomes with negative consequences.

Methods
We use secondary data from Nepal Demographic and Health Survey 2016 to assess the association between IPV, and maternal service utilization: ANC visits and institutional delivery. Altogether 1374 WRA were randomly selected. Background characteristics of WRA and IPV were the independent variables, and ANC visits and institutional delivery were the dependent variables.

Results
Data show that 26 percent of WRA had faced at least one form of IPV, 68 percent had visited health facilities at least four times for ANC check-up during pregnancy, and the rate of institutional delivery was 61 percent. There were association among IPV with ANC visits and institutional delivery (p<0.001). Age group, educational level, ethnicity, number of child, residence setting, and wealth status of WRA were significantly associated with ANC visits and institutional delivery (p<0.001).
Conclusion IPV, educational level, and wealth status of WRA were significant predictors for maternal health service utilization. Policy maker should incorporate these significant predictors during planning and intervention as well. Background 3 Violence whether from intimate partner or from others plays significant impact in public health. But intimate partner violence [IPV] is more critical, that is most common and affecting women disproportionately in Nepal. It is in different forms: physical, mental, psychological or mixed (1). IPV during pregnancy is global health issue and most common in low and middle income countries which creates serious forms of consequences for woman's and child health. IPV not only creates physical problems or injuries but also leads to mental disorder, homicide and even suicide too (2). Various evidence show that IPV is strongly associated with mental disorder in women (3).
Women are at more risk of being exposed to IPV during pregnancy (4). Physical consequences such as a low birth weight, premature birth, birth with disabilities, miscarriage, perinatal mortality are some examples of IPV. Some studies claim that IPV is the predisposing factor for delinquent, hyperactivity, aggressiveness, anti-social behaviours, anxiety, depression as well as somatic symptoms to the children if their mother faced any form of violence during pregnancy (2). IPV also leads to unintended pregnancy. Nearly 15 percent of the total pregnancy is reported as unintended due to IPV (5). Another study shows that more than one third (37%) of the participants reported that they had faced any type of IPV during their lifetime (6,7). It is not only the issue developing countries, but also persists in developed countries. Chisholm et al. (2017) state that suicide and homicide are still the major causes of pregnancy related mortality in many localities of USA. A study from Uganda shows that women having disabilities were more vulnerable to IPV compared to the women without disabilities (8). IPV not only persists in the community but also in the university's students too (9).
Various evidences show the miraculous fact that nearly one third of the women aged more than 15 years have had experience of IPV during their lifetime globally but nearly two third in East Asia (10). IPV during pregnancy leads negative consequences not only the mother but also affects the offspring women's health, and economy (11). It is claimed that the cost of IPV is five percent of the total gross domestic product [GDP] (12).
WHO defines IPV as "any behaviour within an intimate relationship that causes physical damage, psychological or sexual abuse to a woman in the relationship, including physical assault, psychological abuse, forced intercourse and other forms of sexual coercion and of controlling behaviours" (10). Similarly, IPV is defined as "physical, psychological and/or sexual violence that occurs between intimate partners (including cohabiting or divorced intimate partners, independent of gender)" (13). It is universal phenomenon and an intentional manifestation of physical force, sexual and emotional abuse, use of any power to harm against the women form intimate partner (14).
Sustainable development goal number five incorporates achieve gender equality and empower all women and girls and goal number 5.1 and 5.2 have mentioned to end and eliminate all kind of violence and discrimination against women and girls (15), in the same way the Constitution of Nepal has also declared to eliminate all kind of discrimination and violence against women and child (16).
IPV significantly influences the public health. IPV destroys the life in some instances though it can be preventable (1). IPV not only affects the mother but also the child and family as well. Some major component to be healthy, such as breast feeding, good parenting and or family harmony are affected by IPV. Studies show that there was association between IPV and breast feeding that ultimately affected the child health (14).
Furthermore, IPV against pregnant women were more likely to be depressive symptoms, anxiety, a low level of attachment with infant and chances of poor breast feeding compared to non-expose to IPV (4). It leads to adverse pregnancy as well as birth outcomes that ultimately affects the gross domestic product and national economy as well (17).
Very few researches are conducted on the field of IPV and its consequences for women's health as well as utilization of maternal health services which are provided at free of cost from government health facilities. So there is a lack of evidence based information whether IPV influences maternal health services utilization or not. This paper aims to find out the association among background characteristics of participants, IPV; and utilization of maternal services specially ANC visits and institutional delivery. We analysed 'four or more visits for antenatal care [ANC]', and 'delivery at health facility' as dependent variables with socio-demographic, and IPV with background characteristics as independent variables such as age group, educational status, ethnicity, number of children, religion, women's autonomy for household decision, residence setting, employment status, and wealth status. The dependent variables were categorized into two attributes for each i.e. (i) less than four ANC visits; and equal or more than four ANC visits; and (ii) delivery at home; and health facilities for the variables: ANC visits and place of delivery respectively. We merged or manipulated some attributes of the variables due to poor responses to make meaningful the bivariate and multivariate analyses. We extracted raw data from NDHS and systematically filtered the data as per the nature of objective.
The study protocol was reviewed and ethical approval was approved from Nepal Health Research Council and the ICF Institutional Review Board. The consent was taken prior to interview from the participants. The questionnaire was the tool for data collection which was translated into Nepali, Maithili and Bhojpuri from English as it required. Data were collected by using tablet computers to facilitate the computer assisted personal interviewing.
Since the survey was designed to represent the national population of 15-49 years.

Background characteristics of the participants
Of the participants, nine out of ten were from the age less than 35 years. Among the participants, 49 percent from the age of 25 to 34 years, 41 percent from less than 25 years and rest of them were from more than 34 years. Data show that more than two third (68%) were literate which was just over the literacy rate than the population and housing census 2011 which was recorded as 57 percent of female (19). More than one third (34%) were from Adibasis/Janajatis, 28 percent were from Brahmin/Chhetri and rest of them were from Dalit and others.
Nearly one third of the participants had none/one child, 32 percent of the participants had two children and 15 and 17 percent had three and four or more children respectively. Of the participants, 86 percent were Hindu, whereas six, five, and three percent were from Islam, Buddhist and Kirat/Christian respectively which was as similar as the population and housing census 2011 (19). One third of the participants expressed that they had no role in household's decision-making process whereas one third expressed moderate autonomy in household decision. Most of the participants (54%) were from urban areas and 53 percent were engaged in any kind of employment.
Forty-three percent of the participants were from poor economic background; 21 percent were from middle wealth status whereas 37 percent were from rich wealth status. Nearly  Experiences of violence and utilization of maternal health service Data show that experience of violence plays significant role in maternal service utilization.
There was negative association between experience of violence and utilization of maternal health services. Seventy-one percent of the participants who did not faced physical violence during pregnancy had visited health facilities for ANC check-up more than four times whereas just 57 percent of the participants, who had faced physical violence, visited for ANC check-up equal or more than four times during pregnancy which was statistically significant (p<0.001). Similarly, only 57 percent of mothers who faced emotional violence had equal or more than four time ANC visits compared to 70 percent who did not have faced emotional violence (p<0.001). In the same way, only 55 percent of the participant, who had faced sexual violence, had four or more ANC visits compared to 69 percent did visited four or more ANC visits during pregnancy. Majority of the participants (72%), who did not have any kind of violence from husband, had visited health facilities four or more time for ANC compared to 58 percent who had faced at least one violence from husband (p<0.001).
Data show that institutional delivery was influenced by any type of violence. Less than half (49%) of the participant, who faced physical violence, utilized delivery services from health facilities compared to 65 percent who did not faced physical violence (p<0.001).
Nearly the same result observed from any type of violence and delivery at health facilities. Sixty-four and 52 percent of deliveries were conducted in health facilities who did not have any kind of violence and who had at least one violence from intimate partner respectively (p<0.001).
Socio-demographic or background characteristics also influenced the number of ANC visits and institutional delivery. Data show that lower the age, higher the ANC visits, and higher the institutional delivery. Seventy-three percent of the participants, having the age less than 25 years, visited health facilities equal or more than four times for ANC compared to 67 and 54 percent by age group of 25 to 34 years, and more than 34 years respectively (p<0.001). Data show the education and ANC visits were positively and significantly associated that higher the education and higher the utilization of maternal health services (p<0.001). Eighty-three percent of the respondents, who had secondary education, visited health facilities for ANC more than four times. But less than half (49%) of the respondents, who had no formal education, visited to health facilities for ANC more than four times (p<0.001). Brahmin and Chhetri had utilized the maternal health services [four or more ANC visits] than the other ethnicity/caste (p<0.001).
The negative relationship was observed between number of child and more than four ANC visits. Higher the number of child and lower the maternal service utilization (p<0.001).
Eighty-two percent of the respondents who had none/one child visited the health facilities for antenatal services compared to 37 percent of those who had four or more children.
Three fourth of the participants, who followed the Buddhist religion, received more the four ANC services compared to 67 and 54 percent of Hindus and Islam respectively (p<0.05). Data show that higher women's autonomy in household decision and higher the ANC visits.
Three fourth of the participants who resided in urban areas had visited more than three times of ANC visits compared to rural areas which accounts for 61 percent (p<0.001).
Employment status of the women also associated with the utilization of ANC services.
Seventy-one percent of the participants, who engaged in any kind of occupation, visited health facilities more than three times for maternal health services (p<0.05) compared to the participants (65%) who had no job. Wealth index was also associated factor for maternal health service utilization. Eighty percent of the participants who were rich visited health facilities for ANC equal or more than four times compared to middle (65% of the participants) and poor (59% of the participants) (p<0.001).   Participants' residence plays key role in utilization of maternal services. Data show that 70 percent of the participants residing urban areas received natal services at health facilities compared to 51 percent of participants form rural residence (p<0.001). Two-third of the participants who did not currently working received delivery services from health facilities and 57 percent of participants who were currently working received the delivery services from health facilities (p<0.01). Wealth status of the participants seemed positive association with delivery services utilization. Eighty percent of participants, who were rich, received deliver services from health facilities followed by middle (64%) and poor (44 %) respectively (p<0.001).

Main findings
Results show that more than one fourth of the women, who had last birth within the past five-year preceding the NDHS 2016, had faced at least one violence from their husband.
Nearly one third of them did not have at least fourth ANC visits and more than one third had experience of delivery at home. Data show that higher the violence leads lower the rate of maternal health service utilization. Similarly, higher the age of women leads lower utilization of maternal health services. Whereas higher education status leads higher utilization of ANC and natal care. Data show that women having more child have lower utilization of maternal health services. Urban women have more utilization rate of maternal health services compared to those who live in rural areas. Interestingly, employed women have more utilization of ANC services but lower utilization of delivery services from health facilities. Economically rich women have more utilization of maternal health services than middle class and poor women. Multivariate analyses show that young than elder, educated than illiterate, Brahmin and Chhetri than other caste, women form urban than rural areas, rich than poor were more likely to utilize the maternal health services available at free of cost at government and other health facilities.
Various studies support the results. One fourth of the participants had faced at least one violence from husband in Nepal but nearly three fourth of the pregnant women had faced at least one form of IPV during their current pregnancy in Iran (4) which is three folds compared to Nepal but more than one third from US have had an experience of IPV which is similar to Nepal in terms of IPV rate (17). Interestingly, not only women but also the gay, bisexual and other men having sex with men [GBMSM] also violated by intimate partner. A study at London shows that GBMSM also victimized by IPV (20). Besides these, child also influenced by IPV. Eighteen percent of children had faced IPV in United States that leads homelessness, involvement in criminal activities, unemployed and chronic health conditions (21).
A study from Dhanusha shows that 29 percent of the pregnant mother had faced at least one types of IPV during their pregnancy (22). Similarly, another study by Laelago, Belachew, and Tamrat (2017) observed that about 23 percent of the women had faced IPV during their pregnancy at Ethiopia. So it can be concluded that nearly one fourth of the mother are facing IPV during their pregnancy. In the same ways the study also supports the results that IPV during pregnancy was associated with the low utilization of maternal health services (22). A study form Wuhan, China shows that IPV was associated with prenatal depression that leads to adverse birth outcomes (24).
Some controversial statements were observed that elder women were more vulnerable for IPV and their later life can be complex (25) but the study shows that younger women were more vulnerable than elder. So, type and magnitude IPV and its effects may be different in socio-geographical context. A study from Ethiopia shows that low birth weight and preterm birth were associated with IPV (23,26). So, IPV not only influences the mother but also affects birth outcomes too. Exposure to any form of violence leads to a barrier of maternal health service utilization (27).
Employment is a predictor for IPV during pregnancy. A study conducted at New York City shows that 79 percent of the respondents were victimized by IPV. In the same way, higher education leads to lower IPV which supports the study (28). The study also supports that younger age and poor financial status were associated with IPV during pregnancy as observed by Doi et al. (2019). Another study shows that poverty, lack of education and food security lead to IPV during and after pregnancy (29,30). Appropriate interventions can minimize and control the IPV as various experiments became successful in many countries (31).
A systematic review and meta-analysis [SRMA] shows that IPV reduces utilization of maternal health services by 25 and 20 percent in ANC visits and delivery services by skilled health worker respectively (32). Similarly, another SRMA from Ethiopia shows that women's and partners' educational status, partners' alcohol use were significant predictor for IPV (33). A study conducted at Nawalparasi, Chitwan and Kapilvastu shows nearly the same results that so called 'low caste', women's employment, income, inadequate marital discussion were associated with IPV (34) but another study shows that IPV was not associated with modern contraceptive uses (35). All these studies support the study and can be concluded that IPV is significantly associated with maternal health services utilization.

Conclusions
Data and evidences show that IPV was the significant predictor for the utilization of health services during pregnancy. Therefore, clinical, educational, legal as well as motivational interventions should be planned and implemented to overcome the violence by intimate partner. Intervention programmes should focus the women who belonging in facing violence form their intimate partner, women having age more than 25 years, no education, Janajatis, Dalit and other caste, rural and poor women since they are more vulnerable compared to others. the survey; ## = place of delivery for the most recent live birth in the five-year preceding the survey; NS = not significant; *** = significant at p<0.001; ** = p<0.01; and * = p<0.05