The mediation effect of contraceptive use and women’s autonomy on the relationship between intimate partner violence and unintended pregnancy in Ethiopia

Intimate partner violence (IPV) includes acts of physical aggression, psychological abuse, sexual coercion and controlling behaviours within an intimate relationship [1]. IPV affects one in every three women globally [2]. It has several effects on women’s physical, mental, and reproductive health [3‐5]. The reproductive health consequences of IPV include sexually transmitted infections [6‐8], obstetric complications such as haemorrhage, abortion, hypertensive disorders, and foetal complications [3, 9], and reduced utilization of maternal health services [4, 10].

Studies have revealed that women’s experiences of different forms of IPV are significantly associated with a higher rate of unintended pregnancy [11‐17], defined as pregnancies that are either unwanted or mistimed. Other studies have also demonstrated that IPV is associated with reduced uptake of contraception [18‐23]. Women who report abuse are also more likely to have partners that make decisions for them about contraception and whether and when to have a baby [24‐27]. This implies that women experiencing IPV have reduced ability to use contraception and make decisions regarding their fertility, both of which could negatively affect their ability to enact their reproductive intentions.

There is evidence that unintended pregnancy is mainly the result of inadequate contraception practice such as incorrect/non-use of contraception, discontinuation of contraceptives, and contraceptive failure [28‐31]. Researchers also identified that low women’s autonomy is a significant predictor of unintended pregnancy [32‐34]. Women’s autonomy relates to women’s power and ability to control over resources, making their own decisions, improve and maintain their health, and seek necessary information for their reproductive choices [32]. There is recognition of the importance of the interplay between IPV with contraception use, IPV with women’s autonomy, IPV with unintended pregnancy, contraception use with unintended pregnancy, and women’s autonomy with unintended pregnancy. However, there is limited evidence on the pathways by which the four experiences are inter-related i.e. how IPV affects unintended pregnancy through contraception use and women’s autonomy is less known. Furthermore, some researchers [11, 14, 35] who investigated the relationship between IPV and unintended pregnancy have treated the contraception use variable as a confounder; they explain that IPV might affect unintended pregnancy by affecting women’s contraception use. However, we argue that in the interplay between these three experiences, contraception use should be considered as a mediator rather than a confounder. In mediation, a third variable (the mediator) partly conveys the causal relationship between the exposure and outcome (Exposure → Mediator → Outcome). In contrast, with confounding a third variable (the confounder) causally affects both the exposure and the outcome. Adjustment for confounders is necessary to estimate unbiased causal effects, but confounders do not convey the causal relationship among the exposure and outcome [36].

The current study is from Ethiopia, which is generally characterized by high gender inequality, high fertility (total fertility rate of 4.6 children per woman) [37], low contraception use (only 36% of women use modern contraception) [37], high rates of unintended pregnancy (25%) [37], and one of the highest national rates of IPV (ranging from 20 to 78% in different areas of the country) [38]. In the current analysis, we hypothesized that women’s lifetime experience of IPV would be associated with contraception use and women’s autonomy in a sample of married Ethiopian women. While IPV may affect unintended pregnancy, it is likely that this effect would be mediated by contraception use and women’s autonomy that are influenced by IPV and affect unintended pregnancy.

Most available literature on IPV and its negative effects preclude defining partner controlling behaviour as a form of IPV, and consider IPV as a composite measure of physical, sexual, and emotional abuse. However, there is evidence that partner controlling behaviour is a reflection of power dynamics in an intimate relationship and indicates imminent risk of other forms of abuse [27, 39]. Studies have also revealed that partners’ control influences women’s decision-making power [27], health service access and utilization [27, 40], and fertility control [15, 41, 42]. Therefore, we have adopted the World Health Organization (WHO) definition of IPV (1 p89) and included partner control as a form of IPV in our analysis.

The hypotheses tested in this study were:

The current study investigated unintended pregnancy in relation to different forms of IPV in Ethiopia and the role contraceptive use and women’s autonomy plays in these relationships. We computed a series of multiple mediation logistic analyses to examine the interplay between the IPV types, contraceptive use, women’s autonomy, and unintended pregnancy. Women’s autonomy, but not contraceptive use, had a significant partial mediation role in the relationship of unintended pregnancy with some forms of IPV and unintended pregnancy. Given that unintended pregnancies are common in Ethiopia and women have less power in intimate relationships, this study provides insights into the need to develop and initiate culturally appropriate women’s empowerment interventions in maternal health programs to mitigate some of the negative reproductive health impacts of IPV.

Women’s experience of IPV (physical, sexual, and/or emotional) was associated with unintended pregnancy, which is in line with previous research that investigated the association between combined forms of IPV with unintended pregnancy [11‐13, 35, 50]. Though our study was cross-sectional, which limits our ability to draw conclusions regarding causality, the effect of IPV on unintended pregnancy was both direct and indirect. The direct effect could be through coerced pregnancy (coercion by husband to become pregnant) or coerced unprotected sex (coercion by partner to have sex against her will) [41, 42]. This study further revealed that IPV might influence unintended pregnancy indirectly by reducing women’s autonomy. This could be because abusive partners might dominate women economically and emotionally that may cause women’s inability to make decisions freely [32].

In this study, contraception use did not show any mediation role in the relationship between IPV and unintended pregnancy. A similar finding from the U.S also revealed that the significant association between IPV and unintended pregnancy, where abused women were twice as likely as non-abused women to have had an unintended pregnancy, was not mediated by condom use. In this study, condom use had a positive association with unintended pregnancy and IPV had a negative association with condom use but both associations were not significant [51]. While some previous evidence has shown that IPV is associated with contraception use [18‐20], in this study the association between IPV and contraception use was not significant. In Ethiopia, contraceptive use is generally low; for example, in this sample, only 24% of women were using contraception. Women in an abusive relationship share similar other socio-cultural and religious factors that hinders Ethiopian women from contraception access and use such as religious objection, community disapproval, rumours and perceived side effects among others [37]. As a result, there may be other immediate factors influencing women’s contraception use.

This study revealed that emotional IPV was negatively associated with women’s autonomy and women’s autonomy, in turn, was negatively associated with unintended pregnancy. However, there was no direct association between emotional IPV and unintended pregnancy after adjusting for women’s autonomy. This implies that the association between emotional IPV and unintended pregnancy was explained by the role of decision-making autonomy as mediator. Women who experienced emotional abuse could have reduced control over their reproductive choices and, potentially, reduced access to resources to achieve this. There is also evidence that emotional IPV is often accompanied by other forms of IPV [2] and the synergistic effect of these co-occurrences might lead to the strong association between emotional IPV and low women’s autonomy.

In this study, multiple partner controlling behaviour was significantly associated with unintended pregnancy, low contraceptive use, and low women’s autonomy. Simultaneously, women’s autonomy was associated with unintended pregnancy suggesting that not only partner control and unintended pregnancy were associated, but also partner control may influence unintended pregnancy by reducing women’s autonomy. Partner controlling behaviour is a reflection of power dynamics in an intimate relationship and husbands’ attempt to closely control and monitor their wives’ behaviour may affect women’s autonomy, contraceptive access and use, and fertility control [15, 27, 40‐42]. Our finding demonstrated that the higher the number of partner controlling behaviours, the more severely a woman was being controlled; therefore, her autonomy in decision-making is lower, and her ability to control her fertility is more likely to be compromised compared with women not subjected to controlling behaviours. In Ethiopia, where patriarchal views are common, controlling behaviour is considered an acceptable behaviour for husbands in interactions with their wives [52, 53]. For this reason, women who have not experienced any partner control and those who experienced single partner control might not differ significantly in terms of the impact of partner control on their reproductive intentions.

The current study showed that physical IPV was associated with women’s autonomy, but not with contraceptive use nor unintended pregnancy. It is reasonable to think that women for fear of physical abuse might not have overall freedom and might therefore refrain from making their own decisions. The lack of a significant association between physical abuse and unintended pregnancy is supported by some previous research [35, 44] but contradicts findings from other studies [11, 50, 54]. In contrast, sexual IPV was significantly associated with unintended pregnancy but sexual IPV did not show a significant association with contraceptive use and women’s autonomy. This implies that the association between sexual IPV and unintended pregnancy was direct and could be because of forced unprotected sex despite risk of pregnancy during the ‘unsafe period of conception’ [41].

In this study, a lack of autonomy was strongly associated with high odds of unintended pregnancy in all the models. The more women have autonomy, the more likely they are to have access to and control over resources, access to health care, and the ability to decide on fertility (how many children to have and when to have the children) [32] thereby protecting them from unintended pregnancy. Contrary to the general perception, the association between contraception use and unintended pregnancy was not significant. The majority of women in the sample (76%) were not utilizing contraception and we assume that this high non-use may have affected the results. Moreover, further is required to understand what types of contraception were used, how effective these contraceptives were, and how consistently women have been using contraception. Lastly, while we hypothesized that there might be a relationship between the two mediators, that is, when women are autonomous, they are more likely to use contraception, our study did not show any significant association between these two variables. In this study, we have measured women’s overall autonomy in household matters and this might not necessarily reflect their autonomy in contraceptive choices.

As there is no prior study that has examined the role of IPV on unintended pregnancy and how women’s autonomy and contraception use plays a role in this relationship, the findings could contribute to design interventions for women in abusive relationships in Ethiopia that help mitigate the detrimental reproductive health effects of IPV. However, the findings should be considered in light of some limitations. Data for the current analysis were drawn solely from a cross-sectional study so causal inferences could not be made. Women with unintended pregnancies or low autonomy in decision-making may enter into violent relationships. Therefore, future prospective studies are needed to examine the temporal order of the IPV-unintended pregnancy association and potential mediators in this relationship. The partial mediation maintains that women’s autonomy accounts for some, but not all, of the relationship between some forms of IPV and unintended pregnancy. This implies that the assumed pathways are not entirely established. Another limitation is that although potential confounding variables were included, there could still be some residual confounding effects. Reports of IPV may also be underestimated due to social desirability bias. However, the study has strictly followed WHO strategies for domestic violence research which should minimize such under-reporting [55].

This study has indicated that sexual IPV, emotional IPV, IPV (physical, sexual, and/or emotional), and multiple controlling behaviours were associated with unintended pregnancy. The associations of emotional IPV, IPV (physical, sexual, and/or emotional), and multiple controlling behaviours with unintended pregnancy were partially mediated by women’s autonomy where women’s autonomy mediated about 35, 35, and 43% of the total effect of these relationships, respectively. However, there was no mediation effect of contraception use in the relationships between these forms of IPV and unintended pregnancy. Reproductive health programs and strategies designed to improve fertility choices among women in Ethiopia should address both intra- and interpersonal factors in order to create conditions under which women are empowered to involve in making decisions about their own fertility. Interventions with women’s partners that reduce the incidence of IPV are also necessary. In the meantime, focussed interventions on improving victimized women’s decision-making power may help mitigate the effect of IPV on unintended pregnancy and other reproductive health problems.