Background
Rates of violence against women are reported to be highest in Africa compared to other continents [
1]. In South Africa, the national mortality rate attributed to intimate partner violence (IPV) was found to be double that of the United States [
2]. A World Health Organisation multi-country study on IPV found that between 15 and 71% of women reported lifetime physical or sexual violence by a partner [
3]. This is an important public health concern.
Domestic violence (DV) is defined as any physical, sexual, psychological or economic abuse that takes place between people who are sharing, or have recently shared a residence [
4]. While this usually takes place between intimate partners [
5], in the context of a low-resource setting, where extended family members reside within the same household, DV is not limited to intimate partners. Globally, rates of DV seem to be higher in rural than urban areas, with most cases not being reported to police or healthcare providers. Thus, data reported in epidemiologic studies are likely to underestimate the prevalence [
6].
A national study conducted in the USA, with data from over 34,000 participants, showed that DV is associated with physical illness including injury, chronic pain, asthma and sexually transmitted infections [
7]. In an economic evaluation of the cost of IPV to the Australian health system, it accounted for 8% of the overall burden of disease for women of child-bearing age, contributing more than either raised blood-pressure, obesity or tobacco use. The association with poor mental health was one of the greatest contributors to this burden [
8]. Globally, high levels of symptoms of perinatal depression, anxiety, and Post-traumatic Stress Disorder (PTSD) are significantly associated with having experienced DV [
8‐
10]. Greater severity of traumatic experience and sexual violence are each associated with greater levels of depressive symptoms [
11].
A Nigerian study reported that co-wives and step-sons perpetrate 24 and 17% of DV respectively [
12]. In Bangledesh and Uganda, acid throwing is a commonly reported method of violence against women, usually perpetrated by family members other than partners [
13]. In a South African study, Hoque et al. (2009) found that 12% of DV that occurred during pregnancy, was perpetrated by a family member other than a partner [
14]. An earlier South African study indicated that 24% of DV during pregnancy was perpetrated by an in-law [
15].
Violence during pregnancy has negative implications for both the mother and the child. In its most severe form, violence against pregnant women has been reported as a contributing cause of maternal deaths [
16]. Violence during pregnancy has been associated with inadequate uptake of antenatal care, with abused women being more likely to delay seeking pregnancy care and to attend fewer antenatal visits [
17]. Detrimental perinatal physical health outcomes for both mother and child have been reported. These include: low birth weight, foetal death by placental abruption, antepartum haemorrhage, foetal fracture, rupture of the uterus and premature labour [
11] A strong association between suicidal ideation and IPV in pregnant women has been reported in low-income settings [
18].
Many of the risk factors for violence during pregnancy have also been identified in studies of IPV and DV against women in general. However, global literature indicates that both unintended and unwanted pregnancies are each associated with experiencing violence during pregnancy [
19]. A Canadian study showed that women with unintended pregnancies are three times more likely to experience IPV than those with intended pregnancies [
20]. From global literature, other risk factors pertaining specifically to the antenatal period include: low socio-economic status, being young or adolescent, being unmarried, becoming separated or divorced during pregnancy, belonging to an ethnic minority, alcohol misuse by either the woman or her partner and low educational status [
19,
21]. Further factors associated with IPV in Southern Africa, have been identified as: having a younger male partner, problem drinking by the partner, partner control of woman’s reproductive health, and risky sexual practices [
22]. In Africa, studies on Human Immunodeficiency Virus (HIV) diagnosis and status as risk factors for IPV are inconclusive [
21]. However, sexual risk factors have been positively associated with experience of IPV. These included transactional sex, having more than five lifetime sexual partners and having multiple sexual partners [
21]. Further, this review shows that one of most significant predictors of violence during pregnancy is a history of abuse (defined as experiencing abuse before the age of 15, abuse in the past 12 months and abuse at any point over one’s lifetime) [
21]. However, the pattern of abuse may be influenced by pregnancy itself. A global review study indicated that between 13 and 71% of women who are abused during pregnancy reported an increase in the frequency and/or severity of violence during this time [
19].
In South Africa, high levels of violence occur within a context of multiple contributing social dynamics. These include prominent patriarchal norms where masculinity is associated with defence of honour, harshness and risk taking [
23]. Poverty and gender inequalities contribute to the structural determinants of violence [
24].
The aim of this study is to determine the associations between mental illness, demographic, psychosocial and economic factors with experience of IPV among pregnant women in Hanover Park, Cape Town. We also aimed to explore the contextual factors associated with violence in the homes of those women who received mental health counselling.
Results
Facility-based survey results
During the data collection period, 2228 women booked for antenatal care at the facility. 562 eligible women were approached to participate, of which 55 (9%) declined. Reasons cited were predominantly logistical: they did not have the time or child care arrangements to engage with the interviewer. A further 140 women did not complete the full survey, due to time-constraints or feeling tired, and these data were excluded from the survey database. In total, three hundred and seventy-six (376) women (67% of those approached) contributed survey data.
While 26% were experiencing their first pregnancy, 30% were in their second, and 45% had had multiple pregnancies. Only 6% of the sample were single, with 4% in casual relationships and the majority (51%) in stable but unmarried relationships. The remaining 39% were married. Sixty percent of the sample had attained an education level of grade 10 or more. Over half of the sample (58%) were unemployed at the time of the study. Based on their asset index, 2% belonged to the poorest socio-economic status index while 25% belonged to the least poor category. Indicated by the RFA questionnaire, approximately a quarter of the sample (24%) reported experiencing some form of abuse (emotional, physical or sexual) in the past.
From the CTS2 tool, the prevalence of IPV was 15% (n = 58) of the 376 sample population. Of those reporting IPV, 81% (47/58) of women reported emotional and verbal abuse (endorsement of question 7), 76% (44/58) reported physical abuse (endorsements of questions 1–5) and 26% (15/58) reported sexual abuse (endorsement of question 6). Furthermore, 46% of individuals that screened positive for IPV had experienced multiple forms of abuse. Forty-nine percent of the women that experienced this violence were between 18 and 24 years of age. Over half (62%) had education levels of Grade 10 and lower. The majority were in the second trimester of their pregnancy. Of those that experienced IPV, 58% were not currently employed. Food insecurity was noted for 62% of these women. Out of the total number of women currently abused by a partner, 66% were in a stable relationship but not married, 50% had experienced a form of past abuse, and 40% were not pleased with their current pregnancy. Of the sample experiencing IPV, 40% were diagnosed with MDE, 36% with an anxiety disorder and 31% were assessed with suicidal thoughts or behaviours. Twenty-nine percent of these women used alcohol and other drugs and 24% had a self-reported history of mental health problems.
Results of the Cronbach’s α tests show that the CTS2 tool (Cronbach’s α0.85), the MSPSS tool (Cronbach’s α 0.89), and the HFSSM tool (Cronbach’s α 0.83) exhibited good internal consistency and reliability when used on the study sample. Results of the multicollinearity test indicated that the variance inflation factors among the predictor variables were below 10 points and the regression coefficients exhibited stability with a condition number below 10 points. This shows that there is no multicollinearity inherent in the model.
Bivariate analyses generated significant variables that were incorporated into the multivariable model. See Table
1.
Table 1
Characteristics for survey participants and bivariate associations between IPV and demographic and psychosocial factors
Age: 18–24 years | 146 (39) | 28 (49) | 118 (37) |
25 29 years | 114 (30) | 21 (36) | 93 (29) |
> 29 years | 116 (31) | 9 (15) | 107 (34)* |
Parity: Nulliparous | 122 (32) | 23 (40) | 99 (31) |
Primiparous | 128 (34) | 19 (33) | 109 (34) |
Secundiparous | 83 (22) | 9 (15) | 74 (23) |
Multiparous | 43 (11) | 7 (12) | 36 (12) |
Gravida: Primigravida | 96 (26) | 18 (32) | 78 (24) |
Secundigravida | 114 (30) | 20 (34) | 94 (30) |
Multigravida | 166 (45) | 20 (34) | 146 (46) |
Gestation: 1st trimester | 96(32) | 14 (32) | 82 (32) |
2nd trimester | 175 (58) | 27 (61) | 148 (58) |
3rd trimester | 29 (10) | 3 (7) | 26 (10) |
Education level (≥Grade 10) | 225 (60) | 36 (62) | 189 (59) |
Working currently | 159 (42) | 16 (28) | 143 (45)* |
Socio Economic Status: Least poor | 94 (25) | 16 (28) | 78 (25) |
Poor | 94 (25) | 15 (26) | 79 (25) |
Very poor | 96 (26) | 11 (19) | 85 (27) |
Poorest | 91 (24) | 16 (28) | 75 (24) |
Food insecure | 158 (42) | 36 (62) | 122 (38)** |
Relationship type: Married | 146 (39) | 14 (24) | 132 (42) |
Stable partner | 192 (51) | 38 (66) | 154 (49) |
Casual partner | 16 (4) | 2 (3) | 14 (4) |
Single | 22 (6) | 4 (7) | 16 (5) |
Perceived support from family | 23 (5) | 21.86 (SD 5.23)a | 22.66 (SD 5.04)a |
Perceived support from friends | 20 (7) | 18.34 (SD 6.80)a | 20.30 (SD 6.70)a |
Perceived support from “special person” | 24 (4) | 22.62a (SD 4.87)a | 24.33a (SD 3.68)a |
Past abuseb | 89(24) | 29 (50) | 60 (19)** |
Not pleased with pregnancy | 81 (22) | 23 (40) | 58 (18)** |
Major Depressive Episode (MDE) | 81 (22) | 23 (40) | 58 (18)** |
Any anxiety disorder | 86 (23) | 21 (36) | 65 (20)* |
Suicidal Ideation or Behaviour (SIB) | 69 (18) | 18 (31) | 51 (16)* |
Alcohol and other drug use (AoD) | 65 (17) | 17 (29) | 48 (15)* |
History of mental health problems | 57 (15) | 14 (24) | 43 (14)* |
Demographic and economic factors associated with IPV were also explored. Significant findings showed that women older than 29 were less likely to report an experience of IPV than younger women (aOR 0.25, 95% CI 0.09–0.65). Pregnant women who were food insecure were more likely to report an experience of IPV than those that were food secure (aOR 1.96, 95% CI 1.01–3.76). Pregnant women in a stable relationship but not married were twice as likely to report experiencing IPV than those who were married (aOR 2.48, 95% CI 1.17–5.27). As perceptions of social support from a “special person” increased, pregnant women were less likely to report an experience of IPV relative to those who experienced a lower perception of social support (aOR 0.91, 95% CI 0.82–0.99). Pregnant women that reported experience of any form of abuse in the past were four times more likely to report an experience of current IPV relative to women with no history of abuse (aOR 4.81, 95% CI 2.28–10.12). Women who were not pleased with their pregnancy were also twice as likely to report an experience of IPV compared to women who were pleased with their pregnancy (aOR 2.54, 95% CI 1.28–2.04). See Table
2.
Table 2
Unadjusted an adjusted multivariable associations between IPV and risk factors
Parity: Nulliparous | 1 | |
Primiparous | 0.75(0.38–1.46) | |
Secundiparous | 0.52(0.22–1.59) | |
Multiparous | 0.83 (0.33–2.11) | |
Gravida: Primigravida | 1 | |
Secundigravida | 0.92(0.45–1.86) | |
Multigravida | 0.59(0.29–1.18) | |
Gestation: 1st trimester | 1 | |
2nd trimester | 1.08(0.53–2.15) | |
3rd trimester | 0.67(0.18–2.53) | |
Age: 18–24 years | 1 | 1 |
25 29 years | 0.95 (0.50–1.78) | 0.99 (0.48–2.05) |
> 29 years | 0.35 (0.16–0.78)* | 0.25 (0.09–0.65)* |
Education level (≥Grade 10) | 1.11 (0.62–1.98) | |
Working currently | 0.46 (0.25–0.86)* | 0.26 (0.15–1.66) |
Socio Economic Status: Least poor | 1 | 1 |
Poor | 0.92 (0.42–2.00) | 1.11 (0.46–2.68) |
Very poor | 0.63 (0.27–1.44) | 0.81 (0.32–2.06) |
Poorest | 1.04 (0.48–2.22) | 1.05 (0.44–2.49) |
Food insecure | 2.62 (1.47–4.67)** | 1.96 (1.01–3.76)* |
Relationship type: Married | 1 | 1 |
Stable partner | 2.23 (1.20–4.48)* | 2.48 (1.17–5.27)* |
Casual partner | 1.34 (0.27–6.54) | 0.99 (0.17–5.76) |
Single | 2.35 (0.69–8.03) | 1.72 (0.42–7.08) |
Perceived support from family | 0.97 (0.92–1.02) | 1.06 (0.98–1.45) |
Perceived support from friends | 0.96 (0.92–0.99)* | 1.00 (0.95–1.05) |
Perceived support from “special person” | 0.89 (0.86–0.97)** | 0.91 (0.82–0.99)* |
Past abusea | 4.30 (2.39–7.72)** | 4.81 (2.28–10.12)** |
Not pleased with pregnancy | 2.94 (1.61–5.35)** | 2.54 (1.28–2.04)** |
MINI assessed mental health problem | 2.7 (1.51–4.80)** | 1.33 (1.25–2.69)* |
History of mental health problems | 2.03 (1.02–4.02)* | 1.93 (1.20–2.17)* |
Results also indicated that IPV was associated with MINI-defined mental health problems. These included MDE, any anxiety disorder, suicidal ideation or behaviour (SIB) and alcohol and substance use disorders (AOD). We grouped these assessed mental health problems into one variable because of the inherent correlation between the different types of assessed conditions and their impact on the adjusted logistic regression. Women with an assessed mental health problem were more likely to have reported experiencing IPV relative to those with no assessed mental health problem (aOR 1.33, 95% CI 1.25–2.69). Women who had a self-reported history of mental health problems were also more likely to report an experience of IPV than those with no history of mental health problems (aOR 1.93, 95% CI 1.20–2.17). See Table
2.
Qualitative results
From the case notes of the qualitative study sample (n = 95), 31 women were noted to have been experiencing domestic violence in the current pregnancy, 55% (17/31) by someone in the household who was not an intimate partner. Perpetrators included fathers, stepfathers, uncles, brothers, grandmothers and brothers in-law. Six of these 17 women were simultaneously in a current relationship with an abusive partner. Sexual abuse was reported by 23% (7/31), 48% (15/31) reported verbal / emotional abuse and 74% (23/31) reported physical abuse. Further, 38% (12/31) reported a history of abuse.
Although the focus of the study using the quantitative data was to explore the predictors and associated risk factors for domestic violence, the client case notes provided additional information. The client notes raised themes that were not apparent from the quantitative data. This is summarised in Table
3. The main themes that emerged were: alcohol and substance abuse by members of the family were a contributing factor to violence; past abuse affected current behaviours and violence was seen as “normal behaviour” for many of the participants. The case note examples in Table
3 below add detail to the themes. A cross cutting sub-theme to emerge was the wide diversity and forms of abuse, many of them physical and escalating. They included: not providing food, social isolation, swearing, shouting, smacking, beating with fists, hitting with objects, stabbing, and forced sex.
Table 3
Case note themes and examples
Alcohol and substance abuse by members of the household as a contributing factor to violence | 19 | A: “Her stepfather started drinking excessively and would beat the [participant’s] mother in front of the children. Current boyfriend drinks excessively.” |
B: “Husband is drinking excessively. Stays away for long periods of time without telling her of his whereabouts. He borrows money from other people to obtain alcohol. He came home drunk after being away the whole day. She was so angry she smacked him. This started a fight.” |
Past abuse affecting current behaviours | 12 | C: “Witnessed [participant’s] mother’s ex-husband beating her mother. Gets flashbacks. She pictures the husband beating her mother and becomes extremely angry.” |
D: “Abused as a child, raped, sodomized/abused by ex-husband.” |
Violence is “normal behaviour” | 16 | E: “He hit her against her head and hit her with a fist against her stomach. This is how they normally handle conflict. It doesn’t seem strange/abnormal that they are so violent with each other.” |
F: “She and her husband often get into physical fights with each other. An argument inevitably leads to fighting.” |
Discussion
In our sample of pregnant women, 15% were experiencing IPV and this was associated with food insecurity, unemployment, unmarried, but stable relationship status, past experience of abuse and discontent with the current pregnancy. Current mental health diagnosis and a self-reported history of mental illness were also significantly associated with IPV. Domestic violence within the household was not limited to intimate partners and, domestic violence in this context was often perceived as ‘normal’ behaviour by the participants.
The prevalence of IPV in this study was 15% using the CTS2 tool, which is considerably lower than the finding from a survey of pregnant women attending a public sector South African antenatal service. That study reported 38% had experienced abuse from a partner at some point in their lives, with 35% reporting domestic violence during the current pregnancy [
15]. It is possible that women who experience mental health problems or domestic violence may be more likely to decline participation in a study of this nature. However, this does not explain the discrepancy in the findings of the two studies [
15]. The authors of the Mbokota study, both health professionals, indicated that they used directed interviews to investigate the presence of domestic abuse. It is possible that this method was perceived by participants as a more confidential space than a survey questionnaire administered by a research assistant, and thus increased disclosure. Other literature supports increased detection via face-to-face screening [
52] and further increased identification of DV when this was done by a health professional [
53]. The prevalence in our study is the same as the overall prevalence yielded by a meta-analysis review on IPV during pregnancy in Africa [
21]. However, while the case study sample size was very small, the prevalence of DV was higher than that reported by the survey sample: 32% as opposed to 15%. Several factors could contribute to this difference. The case study notes were from women who had received counselling for mental health problems and would therefore have been a high risk group. The association between mental illness and IPV has been reported in South Africa [
54‐
56], as well as in global studies [
8‐
10]. Further, women may have been more open to disclosure of DV during counselling than in a survey. Other studies have demonstrated that asking open-ended questions about DV are more likely to elicit disclosure [
57,
58]. In addition, women from our case note sample reported violence within the household, of which, 55% was perpetrated by a non-intimate partner. Another South African study reported high levels of domestic violence during pregnancy, with 24% of the abuse being perpetrated by the mother-in-law of the pregnant woman [
15]. This underscores the need to screen for domestic violence as perpetrated by other members of the household, and not only by intimate partners.
We found that women who were unemployed were more likely to have reported experiencing violence from their partners. While the settings are not the same, these findings contrast with a study conducted in Ugandan that found no difference in the experience of abuse between women who were unemployed and those who were employed in either the formal or informal sectors [
50]. Further, we found that food insecurity was associated with IPV. Shamu et al. assert that, in Africa, the feminization of poverty means that many poor women rely on their partners for household maintenance and access to pregnancy care. Men who are perpetrators of physical violence exploit this economic vulnerability by abusing their partners [
21]. This economic exploitation is a further abuse, in and of itself [
4,
59].
We identified intimate relationship status and perceived support as significant factors associated with abuse. Women in stable but unmarried relationships were more likely to have reported experiencing intimate partner violence than those who were married. This is supported by findings from a United States (US) based study on low-income pregnant women [
60]. Further, our findings concur with evidence from low and middle income countries that a lack of perceived support from a significant other, is significantly associated with IPV [
19,
61]. Interventions targeting domestic violence may be enhanced by linking the survivors of violence to supportive networks and by assisting them in identifying and maximising any existing supportive relationships. We showed a significant association between those women who were not pleased about the current pregnancy and IPV. This is supported by findings in a review that consolidated findings from global literature [
19] and has been found in a US study among pregnant women in a community setting [
20]. We postulate that an unwanted pregnancy reflects dysfunction in interpersonal relationships and or compromised socio-economic status, both of which are themselves factors associated with domestic violence. Further qualitative investigation may elucidate the complexity of these interactions.
Current mental health problems were significantly associated with IPV in the bivariate analyses in this study. This association is supported by studies in both high and low-income settings [
8‐
10,
18,
62] and by a systematic review and metanalysis [
63] . Further, a South African, clinic-based study by Mbokota et al. indicated that 78% of the sample who experienced domestic violence during pregnancy experienced psychological problems [
15], this is supported by our multivariable analyses, which indicated that women who reported experiencing violence were 2.4 times more likely to experience a mental health problem. However, the Mbokota study [
15] failed to indicate how psychological problems were assessed and did not present diagnostic data for specific disorders. Chen et al. provide a systematic review on sexual abuse (only) for any women in any setting, with diagnostic psychiatric data. They found significant associations between a history of sexual abuse and diagnoses of depression, anxiety, eating and sleeping disorders and Post-traumatic Stress Disorder (PTSD). However, few of these studies were from low-income settings [
64]. A community-based, South African study on pregnant women, linked depressive symptoms, obtained from screening data, with IPV and alcohol abuse [
65]. The association of IPV with the use of alcohol and other drugs, either by the pregnant woman or by members of her household, is supported by other research from the US with urban, minority women [
66,
67]. Our study adds to the literature from low-income settings by demonstrating associations with current mental health problems as assessed by diagnostic interview. Additionally, our finding that a history of mental health problems is significantly associated with IPV is widely supported by others’ evidence [
8‐
10,
18,
62]. Although many of these studies, like ours, were not designed to demonstrate causal relationships, the evidence suggests that mental ill-health and violence against women exist in a vicious cycle, maintained by inequitable gender norms, low relationship power, poverty and the societal acceptability of violence [
11]. This is supported by work conducted on social determinants of mental ill-health [
68]. Machisa et al. described the structural pathways to IPV for a sample of South African women where binge drinking, depression, PTSD and lower relationship power mediated the relationship of prior childhood abuse and recent IPV [
11]. Not excluding other factors, we hypothesise that the experiences typical of common mental disorders, i.e. low self-esteem, social withdrawal and a sense of helplessness [
69,
70] may confer particular vulnerabilities to violence for pregnant women with these mental health problems. Mental ill-health, possibly through the same mood and cognitive features described above, also compromises women’s access to social and emotional resources [
71,
72] which further maintains their vulnerability to victimisation. The co-existence of mental ill-health and violence against pregnant women has implications for the design of interventions for women who experience domestic violence.
In a review of studies on IPV from African countries, a history of experiencing abuse (abuse before the age of 15, abuse in the past 12 months and abuse in lifetime), is strongly associated with IPV during pregnancy [
21]. While our qualitative sample size was low, and should not be considered as representative, the findings support this association, with examples of currently abused women reporting having been abused during childhood or by previous partners. For example, “Abused as a child, raped, sodomized/abused by ex-husband”.
The qualitative data from this study provide examples of how domestic violence was considered normative in this sample. This is reflected in the examples: “He hit her against her head and hit her with a fist against her stomach. This is how they normally handle conflict. It doesn’t seem strange/abnormal that they are so violent with each other.” and “She and her husband often get into physical fights with each other. An argument inevitably leads to fighting.” Several studies from low income settings have produced findings indicating the influence IPV has on social norms. Women who experienced family violence as a child are more likely to perpetrate violence [
73], and find wife beating acceptable [
74‐
77]. A WHO World Report on Violence and Health indicates that social norms and values play a powerful role in how violence is perceived, condoned, inhibited and responded to [
78].
Benjamin (2014) draws on the concept of dysfunctional community syndrome, where violence takes many different forms and occurs increasingly over generations and at increased intensity, to describe the setting in Hanover Park [
79]. Benjamin and Crawford-Browne (2011) refer to observed patterns of behaviours in clients from Hanover Park who attended counselling over a number of years, and were exposed to continuous trauma due to their violent environment. These clients had an inability to regulate emotion which was demonstrated by heightened or flattened affect in response, high levels of aggression, a reduced capacity for empathy and an inability to regulate impulsivity. There was also the tendency to minimise the impact of trauma [
80]. The behaviours they describe seem to indicate how acceptable violence is in this environment, and is reflected in the examples provided in the qualitative descriptions of our study.
In the context of normalised violence, gender-based power disparities and poverty typical within the South African settings such as this [
23], it is thus not surprising that domestic violence is perpetrated both by intimate partners as well as by other members of the household. Our finding that 55% of the case study sample had experienced domestic violence by a member of the household who was not an intimate partner concurs with other studies that have disaggregated the perpetrators of domestic violence in samples with pregnant women [
12,
14,
15].
This demonstrates the need for intervention design to take account of motivations for violence and to deconstruct relationships of power and coercion. Further, our study reinforces the imperative to change societal norms regarding the acceptability of violence, and the need for preventive work and well as programmes that separately target men, women and children.