Intimate partner violence against women during and after pregnancy: a cross-sectional study in Mumbai slums

A violation of human rights with health and development impacts [1], violence against women is a global public health concern [2]. Intimate partner violence (IPV), defined as “behaviour within an intimate relationship that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours” [3, 4], is suffered by between 15% and 71% of women at some point in their lives [3].

Data were provided by 2591 women over 9 months in 2009. Interviews were not achieved in 452 cases (17%), in which women consented to and completed the questionnaire on maternal and newborn health, but withdrew from the IPV module either before or shortly after it began. Lack of privacy played a part in this (310, 12%). There were no appreciable differences in socioeconomic status, education, or age between respondents and non-respondents. The analysis was based on information provided by 2139 women.

Table 1 summarizes responses to the question, “Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations?” Over one-third of respondents felt that IPV was justifiable in some situation (768, 36%), including 748 (35%) who said that it would be justified if a woman disrespected her in-laws or argued with her husband, failed to provide good food, housework and childcare, or went out without his knowledge. Overall, 318 (15%, 95% CI 13, 16%) women reported facing IPV in the year that included pregnancy and the postpartum period (Table 2). Physical IPV was reported by 247 (12%, 95% CI 10, 13%), and coercive sex by 35 (2%, 95% CI 1, 2%). Emotional violence was reported by 167 women (8%, 95% CI 7, 9). Slaps, kicks and punches were the most common forms of physical violence.

Table 3 shows that about one-third of women said that IPV reduced during pregnancy and the postpartum period, but that 69% said that it either remained at the same level or increased. When asked if IPV was more likely when spouses had been drinking alcohol, 58/149 (39%) women said that it was. Help-seeking to stop IPV was limited (15%) and mostly within the natal family (13%). No women had sought help from a friend or neighbour, religious leader, doctor, lawyer or helpline; 5 had involved the police. Half of women who reported physical IPV in the last year said that it happened sometimes or often. The commonest physical sequelae were pain, cuts and bruises, and a few women reported complications such as vaginal bleeding or early labour. Medical treatment was needed by about one-fifth of women who reported physical IPV. Some said that their ability to care for themselves (17%) or their baby (8%) had been compromised.

Table 4 compares the profiles of women who reported emotional, physical or sexual IPV with those who did not. In multivariable models, the odds of IPV were greater for women living in poorer families, the prevalence reaching 28% in the poorest quintile. Greater odds were seen in Muslim families, women in paid employment, and women whose husbands used alcohol. There was no evidence that having a female baby affected the risk of IPV (aOR 1.07; 95% CI 0.82, 1.39). However, in both univariable and multivariable models, women who reported a previous miscarriage were more likely to have reported IPV in the recent pregnancy (aOR 1.76; 95% CI 1.20, 2.58).

Table 5 summarizes the findings on IPV as a potential determinant of health problems related to pregnancy. Women who reported IPV in the study were more likely to have reported illness during the index pregnancy and use of modern methods of family planning in the preceding 3 years. We speculated that IPV might be associated with parous women having not yet provided a son, or with a substantial age difference or difference in education between wife and husband [15]. We tested several scenarios and found no such associations (data not shown). Women who reported IPV were more than twice as likely to have said that it was justifiable in at least one scenario in Table 1.

In interviews with over 2000 women living in Mumbai slums, IPV – physical (12%), emotional (8%) or sexual (2%) – was common during and after pregnancy. Although IPV appears to be less common in urban than in rural settings, new evidence suggests that urban women may be at higher risk after adjustment for socioeconomic status [11]. IPV was more likely to be reported by women in poorer families, Muslim homes, and those whose husbands used alcohol. Although 18% of women who had suffered physical IPV sought clinical care for their injuries, seeking help from organizations outside the family to address IPV itself was rare [14].

Limits to the study included self-report – important given the risk of adverse consequences – and the fact that we used a module within a longer questionnaire administered by researchers who, though trained and a familiar presence within the study areas, were not themselves counselors. They were trained by IPV counselors, were female, and had been interviewing mothers since October 2005. The module on IPV followed less disquieting modules on demography and maternal and newborn care. It was based on modules used in other large surveys, but involved a recall period of up to a year and the questions were relatively closed.

At 15%, reported IPV during maternity accords with other studies from India. Domestic violence during pregnancy (which includes but is not limited to IPV) was described by 18% of respondents in surveys in Uttar Pradesh state in the mid-1990s [29], 21% in a postnatal sample at a Delhi hospital [27], and 28% in pregnant women admitted to hospital in Chandigarh [42]. A large study from Bhopal reported domestic violence in 13% of pregnancies [41], and a multisite study described figures of 26% for physical, 22% for sexual and 63% for psychological violence during pregnancy [26]. The figure of 15% is almost certainly an underestimate: information was incomplete for 17% of the sample, and underreporting is usual in surveys. In some cases, women wanted to share information, but family members were unwilling to ensure privacy in spite of repeated requests by the investigators.

Reports of emotional and sexual IPV were relatively uncommon. We used definitions based on questions comparable with other studies, nested in comparable types of interview. There are two (not mutually exclusive) possibilities for the lower frequencies: that they were underreported or that they were true findings. Achieving participation, confidentiality and disclosure of IPV may have been especially difficult in this study. Mumbai’s slum homes are small, and the practice of confinement to the home in the postpartum period limited the researchers’ likelihood of achieving interviews outside. The second possibility is that rates of emotional and sexual IPV may actually be lower in Mumbai’s poorer communities than in rural settings and some other cities, and during pregnancy and postpartum. To address both these possibilities, we are incorporating service provision for women experiencing IPV within an initiative that integrates multiple activities for women’s and children’s health. The continuous presence of fieldworkers, peer-activists, and counselors in the community allows us to identify IPV prospectively and we hope will contribute to a clearer understanding of its frequency.

In adjusted models, IPV during maternity was more likely in conditions of poverty, Muslim faith, women’s paid employment, and spousal alcohol use. The association with poverty was expected [8, 11, 12, 15, 46, 54]. As a determinant, faith is more difficult to interpret, but has been noted before [11, 27]. Muslim families in Mumbai’s slums are relatively worse-off and it is possible that the increased risk of IPV reflects residual confounding within a matrix of poverty [48, 67].

The finding that women who were employed were more likely to have reported IPV is supported by studies across a range of locations in India [10, 11, 16, 43, 68]. It has not been replicated in all studies [42]: a small sample in a Kolkata slum suggested that unemployment was a risk factor [12]. Some authors have suggested that women’s work represents a challenge to the patriarchal structure that might provoke spousal violence [11, 48, 49]. However, employment may be an effect rather than a cause, a means of survival rather than a manifestation of empowerment. A woman may be more likely to seek work if her family is poor, her home environment unstable, and her husband drinks or is having extramarital sex [15, 53]. A large study in 18 Indian states suggested that, while working women were at higher risk of IPV, women engaged in unskilled labour were most at risk [7]; and a study from Mysore suggested that, although women with jobs were more likely to suffer IPV than women without jobs, those with skilled occupations were at lower risk [69]. Chibber and colleagues suggest that women who contribute to household income are at greater risk than non-contributors, but women who are solely responsible for household income are at lower risk [49]. Perhaps stability and reliability within relationships are important. When women have more resources in terms of land and assets, IPV seems to be less common [16, 54]. A study involving 744 married women in Bangalore slums suggested that the risk of IPV increased if unemployed women became employed, or if their husbands lost their jobs [70]. It also suggested that violence was more common in love marriages, women who worked before and after marriage, and participants in social and vocational groups. Because of social structures in India, it is possible that love marriages are more likely to be accompanied by financial adversity and involve emotional strain.

Spousal alcohol use is a determinant of IPV [10‐13, 15, 41, 42, 51, 71]. We did not see increased odds of IPV in older or less educated women, or in those who had married younger, which have been described [11, 13, 55, 56]. We speculated that the risk of IPV might be higher if there were substantial differences in education or age between husband and wife [11, 12, 50, 58], but we saw no evidence for this in subsidiary analyses.

Although spousal drunkenness, suspected infidelity, unwillingness to have sex, and dowry were not now seen as justifiable triggers, one-third of women felt that violence was a justifiable response to what might be described as a failure to live up to the role of wife and mother within her husband’s family. This finding echoes those of Jejeebhoy in rural Uttar Pradesh and Tamil Nadu [54]. However, a recent analysis of the NFHS-3 found that women who justified partner violence were less likely to suffer it. The authors suggest that this might reflect submissive avoidance [11]. We found the opposite: that women who reported IPV were more than twice as likely to say that there were situations in which it was justifiable. Whether this represented self-protective rationalization or was part of the causal matrix is unclear. There is also some evidence that justification is associated with less likelihood of care-seeking for illness. For example an analysis of NFHS-3 data from Uttar Pradesh suggested that women who accepted any justification of violence were less likely to seek care for sexually transmitted infections [38].

IPV during pregnancy has implications for the health and wellbeing of mothers and fetuses, and with less likelihood of prenatal care and care for intercurrent problems [26, 34]. Studies have found that physical IPV in pregnancy increases the likelihood of miscarriage or low birth weight [31, 72‐76]. Again, we are unsure about the cause structure. One could sketch a pathway from IPV to compromised fetal growth and miscarriage. Equally, one could propose that the association is residually confounded by the socioeconomic and cultural milieu, so that poor outcomes are corollaries of IPV but not caused by it. For example, miscarriage may be the result of IPV, but may also add to family stress and make subsequent violence more likely. IPV during pregnancy may lead to illness (early labour and vaginal bleeding were mentioned by respondents), but concerns about IPV might also increase the likelihood that a woman will report illness when asked about it in an interview. Ackerson and Subramanian found a strong association between IPV and increased child mortality rates, and suggested that violence impaired women’s ability to take care of their children and caused psychological stress in the children themselves [32]. Some of our respondents reported difficulty in taking care of themselves during pregnancy and difficulty in caring for their babies.

Unwanted pregnancies and the number of living children have been associated with IPV in several studies [32, 77‐80]. The increased likelihood of family planning in women who reported IPV is counterintuitive, since it is a lack of control over women’s reproductive health choices that has been discussed previously [80, 81]. It is just possible that women are making choices to limit conception in a stressful situation, but we emphasize that we have no evidence for this intriguing speculation.

Intimate partner violence against women during maternity was unacceptably common in Mumbai’s slums. One in seven women suffered violence during or shortly after pregnancy. IPV begins in a culture that condones it – indeed, justifies it - and is abetted by poverty and alcohol use. The elements of the violent milieu are mutually reinforcing and need to be taken into account collectively in responding to both individual cases and framing public health initiatives.