The study described in this article examined the prevalence and determinants of IPV against mothers in order to contribute to the understanding of various social determinants of poor maternal and child health in Dowa district. The prevalence of controlling behavior (74.7%) found in this study was significantly higher than the prevalence of controlling IPV in the general population of women (24%) in Malawi found in previous studies (4). There are several possible explanations for the higher prevalence rate in our study. First, the nationally representative studies of IPV sampled women between 15 to 49 years, including women who had never married and those who were divorced or widowed (4), while our sample was more homogeneous, consisting of married women from the rural areas of one district of Malawi. In addition, since we asked about women’s relationship with their current spouse, it is possible that they will have been better able to recall specific incidents and behaviors. Further, our study was administered by female community health workers who have served in the area in the range of nine to twenty years providing primary health care services, such as family planning, antenatal, and postnatal services.
Therefore, it is possible that mothers would be more open with these community health workers, with whom many had developed personal relationships over time.
The prevalence of psychological IPV in our study was 38.5%, slightly higher than the findings of the nationally representative study of IPV against women, which found a psychological IPV prevalence of 30% (4). However, our findings were lower than those in the systematic review of studies of IPV in Ethiopia by (43), where 51.7% of women were found to have experienced psychological abuse. On the other hand, a study conducted among pregnant women in Rwanda found that 20.6% of participants had been victims of psychological abuse (44). Although the prevalence of psychological IPV in Dowa is within the range of many studies in SSA, it will be important to continue to explore regional and methodological differences to better understand these variations in prevalence among studies.
Our study found that 43.7% of mothers experienced physical violence by their current husband. This finding is slightly higher than the average prevalence of physical IPV found among the general population of women in SSA (45). However, studies in Guinea, Tanzania, and Gabon measured prevalence as 54%, 53%, and 46% respectively, higher than our findings (46,47). The most common forms of physical IPV against mothers in our study were slapping (32%) and pushing (28%). This is in line with another study in SSA where women reported being slapped (23%) and punched (11.2%) by their partners (2).
In our study, the prevalence of sexual IPV (73.2%) was significantly higher than the average prevalence of sexual IPV found in other studies of SSA (13.3%). The prevalence in our study was also significantly higher compared to studies conducted in Ghana (30%), Uganda (27%), and the Democratic Republic of Congo (26%), which are considered high in the SSA region (1).
The difference between our results and those of other studies may be related to sample selection. We specifically selected mothers who were in conjugal relationships and thus assumed to be sexually active. Culturally in Malawi, once a woman is married, she is generally expected to be submissive to her husband, particularly with regard to sex (48). Therefore, the high prevalence of sexual abuse in our study may reflect cultural beliefs that support sexual aggression by men and submission by women. It is interesting, however, that the women reported that their partners’ behavior was in violation of their wishes and welfare, an indication that all wives do not fully accept these cultural norms, a finding which deserves further exploration.
In this study, we found that women with partners who had extra marital sexual affairs were at greater risk for experiencing controlling, psychological, and physical violence than women who reported that their partners did not had extra marital affairs. This finding is consistent with the literature in SSA that found that marital infidelity by men was a significant trigger of IPV against women (49,50). Studies have shown that when women confront their partners after discovering their infidelity, some partners respond aggressively, which can escalate into emotional or physical violence (51).
This study supports previous research in SSA that suggests that alcohol consumption by male partners increases the odds of women experiencing IPV (52,53). Recent studies have shown that, biologically, alcohol diminishes the judgment and perception of the drinker, and thus partners who are under the influence of alcohol are more likely to lose self-control and engage in violent behavior (52).
This study also found that mothers who were spending 30 minutes or more drawing water had a greater chance of experiencing controlling, physical, and sexual IPV. This finding is in line with a qualitative study conducted in Bangladesh where women who fetched water from distant wells were more likely to experience IPV (54). In Malawi, mothers are expected to fulfill multiple household roles such as preparing food and taking care of children (55,56). Since fetching water from distant wells takes time away from other tasks, the IPV may be interpreted within the village context as a male partner’s right to reprimand his wife for not fulfilling her obligations. The issue of cultural norms with regard to IPV is one that deserves further attention (57).
Finally, we found that mothers who were married to tobacco smokers had a higher risk of experiencing controlling IPV than mothers who were not married to smokers. Our findings are consistent with the results of a study in Bangladesh that found tobacco smoking among men linked to perpetration of IPV (58). Similarly, in two nationally representative studies conducted in the United States, tobacco smoking was a significant mediating factor for men’s perpetration of IPV (59,60). One potential explanation for the observed link between IPV against women and tobacco smoking by partners can be drawn from biology literature. Research has found that the nicotine in tobacco can undermine efforts to regulate smokers’ emotions such as anger, hostility, impulsivity, and anxiety (61). Therefore, partners who were under the influence of nicotine could be more likely to show aggressive behavior than partners that were not under the influence of nicotine. Following the ecological model, there may well be additional cultural and social factors influencing the relationship between smoking and IPV (62). Regardless, further research is needed to understand the relationship between IPV, and smoking found in our study.
Conclusion and recommendations
This study has identified a high prevalence of IPV against mothers of children under five years of age in Dowa district, Malawi. In particular, at least three-quarters of the mothers in our sample reported that they had experienced controlling behavior and sexual violence from their current husband. In our study, most of the risk factors of IPV against mothers were found to be related to their husbands’ health risk behaviors. These included alcohol consumption, tobacco smoking, polygamy, and infidelity. Of interest is that women who spent more time fetching water were more likely to experience violence perpetrated by husbands.
There are several recommendations that emerged from our study. First, we recommend that community programs aimed at reducing IPV against mothers in Dowa district not only provide needed services to mothers but take the larger context of traditional gender roles into account. In particular, the programs should also consider taking a prevention approach by developing interventions that address husbands’ risk factors. In fact, we hold that the primary focus should be on transformative community approaches that can motivate husbands to change their social risk behaviors, particularly infidelity, polygamy, alcohol consumption, and tobacco smoking.
We also recommend that international, national, and district public health policy should prioritize potable water development projects in the study area. Such projects will not only improve access to safe water for families with young children, but our study indicates that it may also reduce the likelihood of IPV against mothers. We have found that time spent by mothers fetching water outside the home may interferes with other important responsibilities, such as childcare, and believed this time away from other responsibilities triggered IPV. Caution should be taken from this recommendation, as we are not encouraging partners in this study area from secluding mothers from their social networks on pretense of enforcing social norms. Such act is a violation of women’s right to freedom of movement and is punishable by law (63,64).
Strengths and Limitations
This is the first local study to collect data on the prevalence and determinants of IPV against mothers of children under five years of age in rural areas of Dowa district in Malawi. A primary strength of the study is the use of the well-established WHO multi-country questionnaire previously used and validated in Malawi. Thus, the results of this study can be compared to those of other studies that use the same instrument. However, this study also had limitations. Since this is a cross-sectional study, we cannot establish a causal relationship between IPV against mothers and the risk factors associated with IPV. Further, despite our culturally relevant mixed-methods approach, we believe it likely that mothers under-reported their experiences of IPV for several reasons. First, as a retrospective study, mothers were asked to recall situations and behaviors that they had experienced in the past, and it is possible that recall bias could influence results, particularly the memory of incidents of IPV. Second, despite increased awareness regarding the detrimental effects of IPV against women in Dowa district, including laws in place intended to protect those experiencing it, IPV remains a sensitive issue. Due to legal repercussions for perpetrators, some respondents may have been afraid to disclose that they were abused in order not to bring harm to their husbands or to lose their husband’s income and other support roles if they are convicted of IPV and imprisoned or fined. Although a higher percentage of mothers in Dowa district reported experiencing IPV in our study than previous studies in Malawi and SSA, we believe that IPV against mothers in the district continues to be under-reported by mothers for larger cultural, social, and economic reasons. As a crucial factor in the well-being of women and children in Dowa district, our study indicates that IPV should be addressed at several societal levels. In addition to direct protective services to mothers who are at risk, the risk behaviors engaged in by husbands identified by this study should be addressed through social programming. Finally, there should be coordination between IPV prevention and public health policy, since our study suggests that potable water projects not only improve the health of the public but may also reduce the risk of IPV for mothers with young children.