Intimate partner violence (IPV) is well recognized as a human rights violation and a serious global health issue. IPV is physical, sexual, or psychological harm caused by a spouse or an intimate partner (National Institute of Justice, 2007). Physical IPV (PIPV) is defined as the intentional physical harm done to a partner. Sexual IPV (SIPV) is forcing a partner to have intercourse or perform other sexual activities against her or his will, and emotional IPV (EIPV) is the traumatization of a partner by threats, insults, or emotional and/or physical control of the person. Violence against women is rooted in societal norms and beliefs that consider women subordinate to men (Heise et al., 1999). Although both men and women are prone to IPV, women are significantly more likely to experience various forms of IPV and are susceptible to more severe health consequences than men (Coker et al., 2000; Tjaden & Thoennes, 2000).
In 1993, the United Nations General Assembly declared the elimination of violence against women was urgently needed to promote “equality, security, liberty, integrity, and dignity of all human beings” (United Nations, 1993). Despite international efforts to eliminate violence against women, twenty-seven years after the UN’s declaration, the IPV prevalence among women has barely declined: 33.33% of women experienced IPV in 1985 compared to a 30% prevalence in 2017 (Heise et al., 1999; World Health Organization, 2013).
Health Consequences of IPV
IPV has short and long-term detrimental effects on women’s physical, mental, sexual, and reproductive health (Campbell, 2002; Coker et al., 2000; Plichta, 2004). Physical health problems associated with IPV include injuries, gastrointestinal disorders, hypertension, chronic pain, seizures, and fainting. IPV is also the underlying cause of 40-60% of female murder cases in North America, and this proportion is expected to be larger in low-income countries (Campbell, 2002). Mental health consequences of IPV include depression, post-traumatic stress disorders, suicide, insomnia, anxiety, social dysfunction, eating disorders, and substance abuse (Campbell, 2002). To cope with stress and anxiety resulting from IPV, survivors often abuse drugs and alcohol. A South African study found that women who have experienced IPV are 3.1 times more likely to suffer from depression and 3 times more likely to exhibit drinking problems (Wong et al., 2008).
IPV is also associated with an increased risk of reproductive health problems such as unintended pregnancy, sexually transmitted diseases, gynecological disorders, and adverse birth outcomes (Campbell, 2002; Coker et al., 2000; Plichta, 2004). IPV-associated gynecological problems include vaginal bleeding, vaginal infection, reduced sexual desire, genital irritation, painful intercourse, urinary tract infections, and pelvic pain. Preterm delivery, low birth weight, fetal distress, antepartum hemorrhage, and preeclampsia are adverse perinatal outcomes associated with IPV. Consequently, IPV increases healthcare costs and reduces the quality of life of IPV survivors (Campbell, 2002).
Even though South-Asia fares better than Sub-Saharan Africa in terms of resources, food security, and literacy, women’s and children’s overall nutritional status in the region is poorer than in Sub-Saharan Africa (Nubé, 2009; Ramalingaswami et al., 1997). Known as the South Asian Enigma, this contradictory phenomenon is associated with women’s low social status and the wider gender inequality in this region.
Risk Factors of IPV
Minority status, low income, cohabitation, low literacy, high socioeconomic gap between partners, childhood experience of violence, and low autonomy increase women’s likelihood of experiencing IPV (Campbell, 2002; Tjaden & Thoennes, 2000). Male partners who engage in IPV commonly have a history of being arrested, substance abuse, low education, and unemployment (Campbell, 2002).
Risk Factors of Undernutrition Among Women
The known risk factors of undernutrition among women are pregnancy, young age, rural residence, smoking, gender disparity, low literacy, poverty, unemployment, low empowerment, and food insecurity (Bhandari et al., 2016; Hasnat Milton et al., 2010; Kamal et al., 2015; Letamo & Navaneetham, 2014; Malapit et al., 2015; Sethuraman et al., 2006; Singh et al., 2014).
IPV survivors are prone to psychological stress, depression, smoking and drinking problems, and discriminatory food distribution, factors that are well-known to be associated with nutritional status. Loss of appetite is a major symptom of depression and is highly correlated with being underweight (Mayo Clinic, 2017; Steer et al., 1999; Stunkard et al., 1990). Psychological stress, one of the consequences of IPV, increases oxidative stress and diminishes the body tissues’ potential to detoxify, leading to prematurely degeneration (Filomeni & Ciriolo, 2006; Salim, 2014). The symptoms of oxidative stress are associated with low body mass index (Dhakal et al., 2015). Withholding of food, one of the tactics used to abuse women would also directly impact IPV survivors’ nutritional status. Together these study findings suggest that IPV could cause undernutrition.
A few studies have previously analyzed the relationship between violence against women and their nutritional status. A study in Bangladesh found that survivors of PIPV are 1.22 times (95% CI 1.02-1.46), survivors of SIPV are 1.1 times (95% CI 0.74-1.63), and survivors of both PIPV and SIPV are 1.24 times (95% CI 1.04-1.58) more likely to be underweight than women who have not experienced IPV (Rahman et al., 2013). This study adjusted for the confounding effect of age, education, decision-making autonomy, occupation, religion, residence, number of household members, use of contraceptives, and height.
Another study in India found that women who have experienced physical domestic violence are 1.27 times (95% CI 1.02- 1.57) more likely to be severely anemic and 1.2 times (95% CI 1.06-1.35) more likely to be severely underweight (Ackerson & Subramanian, 2008). This study adjusted for twelve variables: residence, age, religion, caste, education, employment, living standard, recent birth, breastfeeding practices, and the number of children, decision-making autonomy, and recent illnesses.
A recent study in Nepal did not find a significant association between being underweight and any type of IPV (Adhikari et al., 2020). However, the study found that controlling behaviors increased women’s odds of being anemic by 31% (95% CI = 1.11–1.54). Women’s characteristics- age, education, household size, ethnicity, wealth status, and place of residency- were accounted for in the study’s analyses.
Food security and household wealth are well-known determinants of nutrition, and menstruation can cause anemia through blood loss or increase body weight through the process of edema (Tacani et al., 2015). Rahman et al., Ackerson et al., and Adhikari et al. did not adjust their analyses for food security or menstruation, and Rahman et al. did not adjust their analyses for household wealth too, so their findings could have been confounded. Also, the previous studies have either analyzed the three IPV types separately or failed to analyze all three IPV types, so a specific IPV type may have easily masked the relationship between other IPV types and nutrition. The previous studies have also failed to adjust their analyses for whether IPV survivors sought help to cope with IPV incidences, which would offset IPV’s effect on health outcomes. Addressing the shortcomings in previous studies, this study aimed to explore the association between intimate partner violence and undernutrition among married Nepalese women of reproductive age.