DOI: https://doi.org/10.21203/rs.3.rs-1754355/v1
Intimate partner violence (IPV) continues to be a challenge in the 21st century. IPV is social problem stipulated with many sectors and affecting at multiple levels. The aim of the study was to determine magnitude and associated factors of intimate partner violence during pregnancy at selected hospitals in Addis Ababa.
Multicenter cross sectional study conducted. Four hundred twenty pregnant women attending Antenatal care selected from the hospitals in proportion to their client load from April 2021- May 2021. Data collected using modified standard questionnaire for IPV. Data analyzed using SPSS version 25. Descriptive statistics and multivariate binary logistic regression computed. Statistical testes were considered significant when P < 0.05.
The magnitude of intimate partner violence in pregnancy was 48.6%. Women with no formal education (AOR = 7.73, CI = 2.18, 27.38), lack of occupation in women (AOR = 2.82, CI = 1.39, 5.69), intimate partners with primary education (AOR = 3.62, CI = 1.36, 9.66), intimate partner alcohol consumption (AOR = 4.45, CI = 2.34, 8.47), lack of financial freedom(AOR = 10.58,CI = 5.03, 22.24) and unplanned pregnancy (AOR = 6.78, CI = 3.76, 12.23) were factors associated with intimate partner violence towards pregnant women.
Almost one in two women studied were victims of some form of intimate partner violence during pregnancy. Lower educational status, intimate partner alcohol consumption, lack of economic freedom as well as unemployment and unplanned pregnancy were associated with
Intimate partner violence refers to various forms of assault by intimate partner that include physical, sexual and emotional abuse. These have been referred as domestic violence in some countries, which is more broad form of violence at household level. Intimate partner violence (IPV) occurs in all settings and among all socioeconomic, religious and cultural groups[1].
Around the globe, different studies found IPV during pregnancy at substantial levels. A wide ranging prevalence report from 1% in urban Japan to 28% in provincial Peru was reported in WHO study[2]. Intimate partner violence is prevalent ranging from 2–13.5% according to a study review in different countries. [3]. An even higher IPV prevalence up to 40% was reported in some African countries [4]. Studies done on IPV during pregnancy has implicated adverse outcomes such as miscarriage, late entry into prenatal care, stillbirth, premature labor and birth, fetal injury and low-birth-weight or small-for-gestational-age infants [1, 3, 4]. Other consequences are also apparent on pregnant women as it is demonstrated in non-pregnant women. This includes injury and physical health impairment, mental health impairment and suicide, impaired sexual life and reproductive health, homicide, negative social and health consequences on children[1].
IPV has been studied and the ecological model widely employed to understand the leading factors. Violence is expressed a consequence of complex interaction of many factors operating at multiple levels in a society. These factors have been reflected in different studies with contextual variation.(e.g. between rural and urban settings)[1]. Though studies have been done to better understand IPV from burden to factors to burden in population there is still more exploration needed in our understanding of IPV in different population.
The studies done in Ethiopia in some districts show significant burden of the problem. In 2018, a meta-analysis that included eight studies reported a pooled prevalence of 26.1% with highest prevalence in Oromia followed by Amhara region[6]. Other individual studies have reported varying prevalence reports. In 2014, a cross sectional study in Hossana, reported IPV during pregnancy of 23% [9]while in the same year a cross sectional study in west Shewa, Oromia found IPV during pregnancy to be 64%[8]. Another cross sectional study in 2018 in Debre Markos, Amhara region reported prevalence of 41.1%[7] and in the same year almost similar finding(46.4%) was reported from cross sectional study in east gojjam[10]. The aim of this study was to assess the magnitude and factors associated with IPV among pregnant women attending ANC at SPHMMC and affiliate hospitals. This will help in objective understanding of the burden of IPV in the urban Ethiopia.
Study area
The study was conducted in St. Paul millennium hospital medical college and affiliate hospitals in Addis Ababa, Ethiopia. The hospital has one of the largest maternity center in the country. It provides ANC service with an average of 1500 mothers per month. SPHMMC has affiliates with three hospitals in Addis Ababa for obstetrics and gynecology services. These hospitals are RDDMH (Ras Desta Damtew Memorial Hospital), Abebech Gobena mothers and children Hospital (AGMCH) and Minilik II referral hospital. Their monthly client flow at ANC averages to 500,750,550 clients respectively.
Study design
Multicenter prospective analytic Cross sectional study was conducted. All pregnant women above 28 weeks of gestation (Estimated fetal weight (EFW) above 1KG if unknown date) attending ANC in the study hospitals, included in the study after fulfilling the inclusion criteria, and randomly selected.
Inclusion and Exclusion criteria
Inclusion criteria
Exclusion criteria
Sample size determination and sampling procedure
Sample size was calculated using single population formula, where z is the normal standard deviation set at 1.96, with a confidence level specified at 95% and a tolerable margin of error (d) at 5%, considering 10% nonresponse rate and prevalence of violence (p) 46.1% from a previous similar study in Debre Markos, Ethiopia. The total sample size after considering 10% non-response rate is 420. Based on pre-determined sample size, probability proportional to size (PPS) sampling employed to allocate number of participants in each of the respective hospitals.
Data collection tools and procedures
The standard WHO multicountry study questionnaire for assessing women’s health and violence was used for data collection as modified to fit local setting in previous studies. The questionnaire had four items for psychological violence, five items for physical violence, and three items for sexual violence, and the response to each item was either “Yes” or “No.” Participants who respond “Yes” to one or more items of violence during recent pregnancy were incident cases of intimate partner violence victimization [2]. The adopted questionnaire was assessed among 5% of the total sample size before the actual data collection. Data collected by ten midwives (all females, which enable better rapport with better disclosure from study participants). The principal investigator supervised the data collection procedures. Training given for two days regarding interviewing techniques, the purpose of the study, the importance of privacy, discipline and approach to the interviewees, and confidentiality of the respondents. The investigator assessed collected data weekly for consistency, completeness and double entry of data.
Data processing and analysis
Data entry achieved using Epi-info version 7.1. The raw data then exported into SPSS version 25 for analysis. Descriptive statistical analyses computed to describe the characteristics of participants/partners. Then, information presented using tables and figures. Bivariate analysis carried out to see the association of each independent variable with the outcome variable (IPV). Variables with p value <0.2 in the bivariate analysis transferred in to multivariate analysis model. Odds ratios with 95% CI reported to show the relation pattern among variables. Variables with p values less than 0.05 were taken to be significantly associated.
Study variables
Dependent variable:
Independent variables
Socio-demographic and socio-economic characteristics, intimate partner related factors, family related factors, pregnancy and reproductive history of the participants are predictors included for assessment of any association.
Data quality control
Training was given to data collectors on the purpose of the study and data collection process. Revision of the collected data and checking for the completeness before data entry was done. Pretest among (5%) of the sample prior to the actual data collection carried out to test the accuracy of the questionnaire to collect the intended data.
Operational definition
Intimate partner violence (IPV): A study participants who responds at least one YES response for the Likert Scale (sometimes, usually, and always) among thirteen items (five item for Psychological/emotional, five for physical, and three items for sexual) qualifies the respondent as victim for IPV[2].
Psychological or emotional violence: at least one YES response for the Likert Scale (sometimes, usually, and always) among five items for psychological violence qualifies the respondent for being faced with psychological/ emotional violence[2].
Physical violence (beating): at least one YES response for the Likert Scale (sometimes, usually, and always) among five items for physical violence qualifies the respondent for being faced with physical violence[2].
Sexual Violence: at least one YES response for the Likert Scale (sometimes, usually and always) among three items for sexual violence qualifies the respondent for being faced with sexual violence[2].
Four hundred twenty pregnant women were involved in this study, yielding a response rate of 100%. About 273 (65%) pregnant women were between 25–34 years, and the mean age was 28.84 years (SD ± 4.31). The majority of pregnant women (258; 61.4%) were Orthodox Christian, 121 (28.80%) were Muslim and 39(9.3%) were Protestant. The majority of respondents (402(95.7%) were married and 12(2.9%) were divorced.
The majority of respondents had primary level 121(28.8%) and secondary level 134(31.9) education (Table 1). Among the 420 study participants 252 (60%) had no formal occupation and the majority are homemakers. More than half 245(58.3%) of the respondents do not have their own income and their main income source is their husband (partner).
| Characteristics | Frequency | Percent | |
|---|---|---|---|
| Age | 15–24 25–34 > 34 Total | 104 273 43 420 | 24.8 65.0 10.2 100.0 |
| Religion | Orthodox Muslim Protestant Other Total | 258 121 39 2 420 | 61.4 28.8 9.3 0.5 100.0 |
| Marital status | Singleton Married Divorced Separated Total | 5 402 12 1 420 | 1.2 95.7 2.9 0.2 100.0 |
| Educational status | Illiterate Primary level(Grade 1–6) Secondary level(Grade 7–12) Above secondary level Total | 73 121 134 92 420 | 17.4 28.8 31.9 21.9 100.0 |
| Occupation | Unemployed Employed(Gov, NGO, Selfemployed) Student Total | 252 162 6 420 | 60.0 38.6 1.4 100.0 |
| Income | 0 < 2500 > 2500 Total | 245 38 137 420 | 60.0 38.6 1.4 100.0 |
| Income source | My self My husband My family(parents, brother, sister, other family) NGO aid None Total | 161 249 5 3 2 420 | 38.3 59.3 1.2 0.7 0.5 100.0 |
| Economic freedom | Yes No Total | 304 116 420 | 72.4 27.6 100.0 |
Two hundred twenty two 52.9%) of the intimate partners were between 20–34 and 178(42.4%) were between 35–44 years. About seventy present of intimate partners had secondary level 142 (33.8%) and higher 155 (36.9%) educational status. Almost all intimate partners of respondents 408(97.1%) were reported to have some form of occupation with 314(74.5%) earning more than 2500 ETB. The mean monthly income among their partners was 4587.09 ETB (Table 2).
Alcohol drinking and Khat use habit is not predominant among the respondents and majority of the respondents have never consumed alcohol 386 (91.9%) or khat 416(99.0%) during index pregnancy. One hundred thirty four (31.9%) of the intimate partners of respondents have been reported to use alcohol at different frequency and about 64(15.2%) use khat. Among the partners 34(8.1%) were found to have smoking habits.
| Characteristic | Frequency | Percentage | |
|---|---|---|---|
| Alcohol use | User Non user Unwilling to answer Total | 33 386 1 420 | 7.9 91.9 0.2 100.0 |
| Khat use | User Non user Unwilling to answer Total | 3 416 1 420 | 0.7 99.0 0.2 100.0 |
| Partner Alcohol use | User Non user Unwilling to answer Total | 134 285 1 420 | 31.9 67.9 0.2 100.0 |
| Partner Khat use | User Non user Unwilling to answer Total | 64 351 5 420 | 15.2 83.6 1.2 100.0 |
| Smoking | Yes No Total | 34 386 420 | 8.1 91.9 100.0 |
The mean gravidity and parity of respondents were 2.9 (SD ± 1.89) and 1.8 (SD ± 1.60) respectively. Among the respondents, 136 (32.4%) were reported to be nulliparous and 46(11%) of the respondents had history of abortion. From the total respondents 166 (39.5%) stated the pregnancy was unplanned while almost all pregnancies were stated to be wanted.
The prevalence of IPV during the current pregnancy was 48.6% (Table 3). Among the study hospitals, the prevalence of IPV was highest in Yek-12 MH 53(49.5%) in and lowest in RDDMH 28(47.5%) in Hospital (Table 4).
Among those reported with IPV, psychological violence 197 (46.9%) was the most common type and physical violence 97(23.1%) was the lowest following sexual type of violence 161(38.3%). This kind of pattern was seen in each hospital. Among the psychological violence humiliation and insult were the most common. Unwillful sexual activities were the most reported and forced sexual intercourse was the least in this group of violence. Among those who reported physical violence, being, slapped was the most common and the use of weapons (knife, Gun) was the least.
| Characteristic | Frequency | Percentage | |
|---|---|---|---|
| Psychological violence | No Yes Total | 223 197 420 | 53.1 46.9 100.0 |
| Physical violence | No Yes Total | 323 97 420 | 76.9 23.1 100.0 |
| Sexual violence | No Yes Total | 259 161 420 | 61.7 38.3 100.0 |
| IPV | No Yes Total | 216 204 420 | 51.4 48.6 100.0 |
| Characteristic | SPHMMC | AGMCH | RDDMH | MIIH | |
|---|---|---|---|---|---|
| Number (%) | Number (%) | Number (%) | Number (%) | ||
| Psychological violence | No Yes | 99(53.2) 87(46.8) | 58(54.2) 49(45.8) | 31(52.5) 28(47.5) | 35(51.5) 33(48.5) |
| Physical violence | No Yes | 145(78) 41(22) | 79(73.8) 28(26.2) | 49(83.1) 10(16.9) | 50(73.5) 18(26.5) |
| Sexual violence | No Yes | 115(61.8) 71(38.2) | 62(57.9) 45(42.1) | 39(66.1) 20(33.9) | 43(63.2) 25(36.8) |
| IPV | No Yes | 96(51.6) 90(48.4) | 54(50.5) 53(49.5) | 31(52.5) 28(47.5) | 35(51.5) 33(48.5) |
The study showed women’s age, women’s educational status, women’s occupation status, women’s Income and income source, Women’s financial freedom, intimate partner’s education, intimate partner’s alcohol consumption, intimate partners’ khat consumption, Smoking habit, and whether pregnancy was unplanned to be associated with IPV in the current pregnancy in the binary regression analysis. In the multivariable analysis, women’s educational level, women’s financial freedom, intimate partners’ educational level and intimate partner’s alcohol consumption, unplanned pregnancy were significantly associated with IPV during the current pregnancy. The model was found fit with Hosmer-Lemeshow goodness of fit test (p = 0.541). Women with no formal education were 7.73 times more likely to face IPPV during pregnancy (AOR = 7.73, CI = 2.18, 27.40) than those with primary school education or greater (AOR = 3.50, 95% CI = 1.18, 10.35) (Table 5).
Partners with Primary level education were 3.62 times more likely to result IPV to their wives compared to those who have higher education. (AOR = 3.62, CI = 1.36, 9.66) Pregnant women who have some form of occupation were 2.8 times less likely to experience IPPV. (AOR = 2.80, CI = 1.40, 5.69) In addition, women with financial freedom are more than l0 times less likely to face IPV during their pregnancy (AOR = 10.58, CI = 5.03.22.24). Pregnant women whose partner consumes alcohol are more than four times likely to experience IPV (AOR = 4.45, CI = 2.34, 8.47).
At last, those women who are having unplanned pregnancy were more than six times likely to experience IPV (AOR = 6.78, CI = 3.76, 12.23).
| Variables | No | Yes | COR(95%CI) | AOR(95%CI) |
|---|---|---|---|---|
| Number (%) | Number %) | |||
| Age <25 years 25–34 years ≥ 35 years | 56(53.8) 143(52.4) 17(39.5) | 48(46.2) 130(47.6) 26(60.5) | 1 1.06(0.67,167) 1.78(0.87,3.68) | |
| Educational status No formal education Primary Secondary Higher | 13(17.8) 43(35.5) 84(62.7) 76(82.6) | 60(82.2) 78(64.5) 50(37.3) 16(17.4) | 21.92(9.79,49.10) 8.62(4.48,16.59) 2.83(1.49,5.38) 1 | 7.73(2.18,27.38)** 3.50(1.18,10.35)* 1.47(0.57,3.83) 1 |
| Educational status No formal education Partner Primary Secondary Higher | 6(27.3) 25(24.8) 78(54.9) 107(69.0) | 16(72.7) 76(75.2) 64(45.1) 48(31.0) | 5.94(2.19,16.13) 6.78(3.85,11.93) 1.83(1.14,2.94) 1 | 1.02(0.21,4.97) 3.62(1.36,9.66)* 1.21(0.57,2.57) 1 |
| Occupation Unemployed Employed | 110(42.6) 106(65.4) | 148(57.4) 56(34.6) | 2.55(1.70,3.83) 1 | 2.82(1.39,5.69)** 1 |
| Income 0 <2500 ≥ 2500 | 106(43.3) 18(47.4) 92(67.2) | 139(56.7) 20(52.6) 45(32.8) | 2.68(1.73,4.15) 2.27(1.10,4.71) 1 | |
| Income partner 0 <2500 ≥ 2500 | 3(25.0) 37(38.9) 176(56.2) | 9(75) 58(61.1) 137(43.8) | 3.85(1.02,14.51) 2.01(1.26,3.22) 1 | |
| Income source Myself My Husband/Other | 104(64.6) 112(43.2) | 57(35.4) 147(56.8) | 1 2.40(1.60,3.59) | |
| Financial freedom Yes No | 198(65.1) 18(15.5) | 106(34.9) 98(84.5) | 1 10.17(5.84,17.72) | 1 10.58(5.03,22.24)** |
| Alcohol use partner User Non-user | 35(26.1) 181(63.5) | 99(73.9) 104(36.5) | 4.92(3.12,7.76) 1 | 4.45(2.34,8.47)** 1 |
| Chat/khat use User Non-user | 10(15.6) 206(58.7) | 54(84.4) 145(41.3) | 7.67(3.78,15.56) 1 | |
| Smoking Yes No | 2(5.9) 214(55.4) | 32(94.1) 172(44.6) | 19.91(4.70,84.24) 1 | |
| Pregnancy planning Yes No | 185(72.8) 31(18.7) | 69(27.2) 135(81.3) | 1 11.68(7.24,18.84) | 1 6.78(3.76,12.23)** |
| *P value < 0.05, **P value < 0.005 | ||||
Among 420 pregnant women included in the study from the four study hospitals, the prevalence of IPV during the index pregnancy was 204(48.6%). The proportion of different types of IPV showed similar pattern in the study hospitals.
These findings are similar to the study conducted among pregnant women in Debre Markos town, North West Ethiopia with prevalence of 41.1% [7] in east gojjam Ethiopia (46.4%) [23]. In addition, the findings are similar to the report on IPV among pregnant women in St. Paul hospital (49.1%) [26]. A systemic review of Africa studies on IPV against pregnant women reported the overall prevalence of intimate partner violence during pregnancy ranged from 2.3% to 57.1% [29]. Furthermore, the prevalence of IPV in this study was lower than the lifetime prevalence of IPV in Ethiopia (60.6%), and low and lower-middle income countries (55.8%) [24, 25]. This can be due to similar methodology employed in a similar urban setting. Yet there are reports of lower prevalence in a metanalysis of 8 studies done in Ethiopia that resulted pooled prevalence of 26.1%(CI:20,32.3) [6].This finding is in contrary to the systematic review of about 15 community based studies on prevalence of IPV among women with a prevalence report more than 50% up to 78% [28]. The variance in the prevalence of IPV among pregnant women in different studies could be due to the uncontrolled variance in the environment created during data collection from participants.
The findings of this study during current pregnancy with respect to psychological, physical,
and sexual violence is higher compared to the study conducted in Bale zone, Southeast Ethiopia. That is psychological (33.0%), physical (20.0%) and sexual (36.3%) [22]. In addition, the study in Debre Markos has lower proportion of the different types of violence even if there is comparable prevalence of IPV in general [7] . Systematic review of African studies on IPV during pregnancy reported similar prevalence rates of 23% to 40% for physical, 3% to 27% for sexual and 25% to 49% for emotional intimate partner violence during pregnancy [28]. In the index pregnancy the findings showed that 97(23.1%) physical violence. Similarly, the WHO multi-country study on women’s health and domestic violence against women found the prevalence of physical intimate partner violence in pregnancy to range between 1% in Japan city to 28% in Peru Province, with the majority of sites ranging between 4% and 12% [11]. This could be due to the variance in the utilization of data collection tool and factors related to participants’ environment such as culture, social norm.
Low level of women’s education was highly associated with IPV and the relation is strongest in those with no formal education. This finding is in coherence with studies done elsewhere in the world. [13] This can due to the advantage of having education in the better awareness about their rights and ability to maintain balanced relation with their partner.
Although, in this study the response rate in the uneducated group is low and the association is difficult to ascertain. Partners with primary level education were 3.6 times more likely to use violence against their intimate partners during recent pregnancy (AOR = 3.62, CI: 1.36, 9.66). This is coherent with studies conducted in Hossana, Ethiopia [9], which revealed partner who attended tertiary education is protective against intimate partner violence during pregnancy. This can be explained by the fact education allows better understanding of women’s rights and legal implications as well as the ability to refrain from unhealthy norms of the society.
Those pregnant women who have no employment or occupation were almost three times at risk to be a victim of IPV than pregnant women with some form of occupation (government, NGO, other) (AOR = 2.82, CI= (1.39, 5.69). Occupational status reported to have no significant association with intimate partner violence in the study in Debre Markos, Ethiopia [7]. The importance of occupation in this study in Addis Ababa might be due to the link that having a job has with having decision-making ability in the household and ability to demand respect from the society as well as the intimate partner.
According to this study finding, pregnant women who do not have financial freedom are more than 10 times likely to experience IPV compared to those who have financial freedom(AOR = 10.58, CI = (5.03, 22.24). Similar finding was reported in a study done in Uganda [27]. Husband making decision alone in household matters had a seven times (COR = 6.7, 95%CI, 2.3, 23.3) increased likelihood of IPV perpetration compared to shared decision-making [23]. These was also substantiated in another study in Ethiopia [25]. The association of occupation and financial freedom with IPV explains that financially capable women are likely to have lower tolerance for IPV as they can make their living on their own.
In this study, pregnant women whose partners drink alcohol were 4.45 times (AOR = 4.45 CI= (2.34, 8.47) more likely to experience IPV during pregnancy by their husbands/partners compared with those pregnant women whose partners rarely drink alcohol (less than or equal to one times per month). These findings are supported by studies conducted in Arua, Uganda [27], and in Ethiopia [21]. This is well explained with the established stimulatory effect of alcohol and escalating effect towards aggressive behaviors.
There is strong association between IPV prevalence and unplanned pregnancy in this study. Such pregnancies are likely result of unstable relationship or family condition. It can also be result of IPV by itself. Such association was also reported else were in Ethiopia. [26]. This is probably due to fear of taking the responsibility to care for both the mother and the newly coming child. In addition, the unplanned pregnancy might be result of sexual violence.
Abebech Gobena Mothers and children Hospital
Antenatal care
Central statistics agency
Ethiopian demographic health survey
Intimate partner violence
Institutional review board
Menilik II Referral Hospital
Premature rupture of membrane
Ras Desta Damtew Memorial Hospital
Saint Paul Hospital Millennium Medical College
Statistical package for social science
simple random sampling
World health organization
Acknowledgements
The authors are grateful to St. Paul Hospital Millennium Medical College and affiliate hospitals for their cooperation and support. Also grateful for data collectors and supervisors for their responsible data collection and support, and all the study participants, particularly those pregnant women who disclosed their painful violence experiences.
Funding
The Federal democratic republic of Ethiopia Ministry of Health in support of the postgraduate thesis project funded the study.
Author’s information
Department of Obstetrics and gynecology, School of medicine, St. Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
Israel Mamo Arkisso (MD, OBGYN)
School of public health, St. Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
Kinfe Haile (BSc, MPH)
Department of Obstetrics and gynecology, School of medicine, St. Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
Hassen Hussein (MD, Assistant professor of OBGYN, Reproductive Endocrinologist)
Authors' contributions
IM was involved in conception and design of the study, acquisition of data, analysis of data, interpretation of data, revising the paper, and writing of the manuscript. KH and HH were involved in advising during proposal development, data analysis, and revising the paper. All authors read and approved the final manuscript.
Ethics declaration
Ethical clearance obtained from St. Paul Millennium medical college Institutional Health Research Ethics Review Committee (IHRERC). Written informed consent obtained from all participants and/or their guardians for study participation. All methods were performed in accordance with the relevant guideline and regulations.
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
The authors declare that they have no competing interests.