Factors associated with intimate partner physical violence among women attending antenatal care in Shire Endaselassie town, Tigray, northern Ethiopia: a cross-sectional study, July 2015

Intimate partner physical violence against pregnant women is common globally and in sub-Saharan Africa. Violence during pregnancy has serious negative health consequences for both mother and fetus. This study assessed prevalence of physical violence during pregnancy and associated factors among women attending antenatal care in Shire Endaselassie town, Tigray, northern Ethiopia.

A written survey was collected at three public health facilities to obtain information related to intimate partner physical violence for 422 pregnant women. In addition, 22 women were interviewed. The data collectors and supervisors were trained on relevant methods. Analysis was conducted to identify factors associated with intimate partner physical violence in pregnancy. Interview data were categorized into themes and compared with the survey results.

About one-fifth of women experienced physical violence in pregnancy. Early marriage, rural dwelling, intimate partner alcohol consumption, and educational status were associated with a higher prevalence of physical violence during pregnancy. Urgent attention is essential at all levels to alleviate the problem of physical violence and its risk factors.

The World Health Organization (WHO) defines intimate partner violence as one of the most common forms of violence against women and includes physical, sexual, emotional abuse and controlling behaviors by an intimate partner [1]. Intimate partner physical violence (IPPV) is more common than some health conditions routinely screened for in antenatal care [2].

Worldwide, about 35.00% of women experienced physical violence committed by their intimate partners [1]. Intimate partner physical violence is highest in sub-Saharan Africa, where 38.83% of women were abused by their intimate partners [3]; the prevalence in Nigeria, Rwanda and Tanzania was 22.90%, 19.30% and 18.00% respectively [4‐6]. In Ethiopia, intimate partner violence was reported as high as 64.70% [7] and 76.50% [8]. A study in Abay Chomen district, Western Ethiopia revealed 44.50% women experienced intimate partner violence in a recent pregnancy [9]. This higher prevalence may be due to women’s disadvantaged position in the country’s patriarchal society [9]. The Ethiopian Demographic Health Survey (EDHS) report in 2011 demonstrated that physical violence against women was common, in both urban and rural areas. In addition, according to the EDHS report, 68% of women agree that wife beating is justified [10].

Intimate partner violence during pregnancy has been associated with fatal and non-fatal adverse health outcomes due to the trauma and stress of abuse [11]. There is particular concern if the abdomen is targeted during pregnancy due to the risk of injury to the fetus [11]. Violence in pregnancy adds to the many challenges such as unintended pregnancies, pregnancy-related distress, inadequate prenatal care, induced and spontaneous abortion, gestational weight gain, intrauterine restriction, hypertension, pre-eclampsia, third trimester bleeding, sexually transmitted infections (STIs) and risks of death [9, 12‐15]. Neonatal and postnatal death are increased twofold and threefold respectively, among women suffering physical violence by their husband [4, 12, 13].

In Ethiopia, studies among non-pregnant women, indicate physical violence against women is common [16, 17]. Though physical violence during pregnancy has significant health risks to the mother and her fetus, there is limited information about the prevalence and risk factors of intimate partner physical violence during pregnancy. Therefore, this study assessed the prevalence and factors associated with intimate partner physical violence during pregnancy in northern Ethiopia.

The prevalence of IPPV during pregnancy in this study was 20.60%. This is consistent with studies in other African countries, Nigeria, Rwanda and Tanzania, which showed a prevalence of 22.90%, 19.30% and 18% respectively [4‐6]. Furthermore, these findings are supported by a study conducted in India, which states that the prevalence of IPPV during pregnancy was 23% [22]. However, it is lower than the community based study in Western Ethiopia among married pregnant women, which reported the prevalence of IPPV is 29.2% [9]. This difference might be due to difference in study designs, as the study conducted western Ethiopia was community based study [9] whereas this study was health facility based which may miss those women who were not coming to health facilities. The difference in IPPV rates between regions might be due to differences in community perceptions towards IPPV. The high prevalence of IPPV may lead to poor pregnancy outcome and maternal psychological and physical health problems [23].

Twenty women (22.98%) who faced PV during pregnancy, were kicked in their abdomen. This is in line with a multi-country study which shows between one quarter and one half of the pregnant victims were kicked in the abdomen [16]. Furthermore, a study in Bangladesh showed a 37% of urban and 25% of rural pregnant women were kicked in their abdomen while they were pregnant [24]. It is also supported by the qualitative data where some of the pregnant women stated that perpetrators were kicking them in the abdomen, which is life threatening for the mother and the fetus.

About one quarter of the pregnant women in this study believed that men have the right to beat their wives during pregnancy. A study conducted in western Ethiopia, reports a similar finding that women were expected to be tolerant [8]. This result was also supported by the qualitative data. Some women from the women affairs office claimed that many hide violence and they did not inform the police or any other legal body. That might be due to socio-cultural dynamics which encourage women to be tolerant.

Women who were married at less than 18 years were 4.42 times more likely to experience violence by their intimate partners during pregnancy. Similarly, the Demographic Health Surveys in Kenya, Bangladesh, Bolivia, Rwanda, and Zimbabwe showed that women who married at younger ages were more likely to experience PV [25]. The 2011 EDHS revealed that domestic violence in Ethiopia was justified if the husband was not satisfied by his wife’s cooking, due to arguments, if she went out without permission, if he perceived her to neglect the children, or the refusal of sexual advances [10].

In this study, women who had no formal education were 3.40 times more likely to experience IPPV during pregnancy than those with a high school education or greater. Studies in Tanzania and Rwanda also showed pregnant women with no formal education were more likely to experience violence by their intimate partners [4, 6]. This is also consistent with a study in Nigeria which showed pregnant women with no formal education were at 2.43 times increased risk of IPPV compared to those who have formal education [26]. Likewise, a study done in Iran showed that pregnant women who have no formal education were more likely to experience PV [27]. This may be due to the fact that pregnant women with no formal education have less access to information towards women empowerment or they may have more acceptances for PV than educated women [28].

Pregnant women whose intimate partners had no formal education were 2.78 times more likely to abuse their wives than those who had a high school education or greater. In contrast, a study done in Nigeria stated that intimate partners who had no formal education had a lower prevalence of PV [26]. This may reflect socio-cultural differences such as high acceptance of wife beating in Ethiopia. A study done in Bangladesh showed that pregnant women whose intimate partners had more than 10 years of schooling had a lower odds of experiencing PV by their intimate partners during pregnancy [24]. This might be due to the fact that partners with no formal education were more likely to have traditional perceptions regarding gender equality [24]. One pregnant woman supported this idea by saying most of the intimate partners who beat their wives are uneducated and account traditional belief of wife beating as a norm.

In this study, rural dwellers were 2.23 times more likely to experience PV by their intimate partners as compared to those living in urban areas. This is supported by a study conducted in Bangladesh which found that pregnant women from rural areas were more likely to experience PV than those from urban settings [24]. One pregnant woman stated that most of the perpetrators are in the rural area where victims are not aware of their equality right with their intimate partners and are more influenced by traditional influences.

Pregnant women, whose intimate partners consumed alcohol, were 3.80 times more likely to experience IPPV. This finding is consistent with those from Kenya, Zambia and Bolivia on IPPV which reported alcohol consumers abused their wives more frequently [25]. Other studies from Brazil [29] and Turkey [30] also revealed alcohol consumers were more likely to violate their wives. Some victims of PV described that their intimate partners beat them when they consumed excessive alcohol. This might be due to the fact that when they consumed alcohol, they may have been more likely to become aggressive [31, 32].

One fifth of pregnant women experienced intimate partner physical violence in their current pregnancy. Some of the pregnant women who experienced IPPV reported that they were kicked in the abdomen while pregnant. Age at first marriage less than 18, women’s education, residence, intimate partner’s education and alcohol consumption were factors associated with intimate partner PV during pregnancy. One quarter of pregnant women believed that intimate partners have the right to beat their wives even when pregnant.