Burden of intimate partner violence in The Gambia - a cross sectional study of pregnant women

Intimate partner violence (IPV) as defined by the World Health Organization (WHO) refers to the range of sexually, psychologically and physically coercive acts used against adult and adolescent women by current or former male intimate partners [1]. Even though men may also be victims of partner violence, the preponderance of evidence suggests that women are much more likely to be abused [1-3]. IPV can also occur in same-sex relationships and does not require sexual intimacy to occur. Traditionally, IPV is classified into 4 main types – sexual violence, physical violence, threats and psychological/emotional violence. However, these different types of IPV tend to occur together in a relationship. The frequency and severity of violence varies greatly but the main goal of the perpetrators is usually to control their victims through fear and intimidation.

IPV is an important public health problem that cuts across geographic and cultural barriers. Women who have experienced any type of IPV are more likely to have poor physical and mental health and use medical resources more [4]. Women’s reproductive and sexual health is also affected by such gender based violence. These problems include sexual dysfunction, pelvic inflammatory disease, sexually transmitted infections (including HIV) and infertility. These women are also at risk of unintended pregnancies and its sequelae – unsafe abortion, low birth weight babies, maternal and neonatal deaths. A systematic review of IPV and birth outcomes showed that adverse pregnancy outcomes are significantly more likely in women with a history of IPV [5]. These adverse effects include preterm delivery, chorioamnionitis, increased operative delivery, placental abruption and intrauterine foetal death [5-8]. In a review on human immunodeficiency virus (HIV) and domestic violence, it was reported that violence against female partners increases when a female partner is known to be HIV positive [9]. Potential ways in which HIV infection may be linked to intimate partner violence include: physical vaginal trauma from forced sex; limited capability to negotiate safer sex due to partner violence or threat of it; violence following disclosure of a positive HIV result and perpetrators more likely to engage in risky sexual behaviour [10].

Cultural norms in most traditional African societies do not support physical violence against women during pregnancy; however, anecdotal evidence seems to suggest that it is quite common. In a survey, IPV during pregnancy ranged from about 2% in Australia and Denmark to 13.5% in Uganda among ever pregnant, ever-partnered women [11]. The prevalence appears to be higher in Latin American and African countries compared to European and Asian countries [11]. In countries where studies have been done, it is generally believed that IPV is under estimated because it is under reported and there is a lack of standardized definition and tools for diagnosis.

Even though wife beating is a criminal offence in The Gambia, its occurrence is believed to be quite common. The police typically consider such incidents as domestic problems that can be settled by the families concerned [12]. More than 80% of Gambian women believe that a man is justified to beat his wife [13]. The Gambian laws prohibit rape and assault; however, spousal rape is not recognized by the law [12]. Anecdotal evidence suggests that violence against women during pregnancy by an intimate partner is quite common in The Gambia but there are no studies to ascertain the burden of the problem. Thus, it has not been recognized as a public health priority and is usually not treated as a fundamental human rights problem. Public health priorities in the country are weighted in favour of prevention of communicable diseases as well as maternal and child health strategies. However, the relationship between intimate partner violence and maternal and infant health has not yet been fully appreciated or studied in The Gambia.

Recognizing the burden of IPV, the American College of Obstetricians and Gynecologists opined that healthcare providers should be involved in screening for IPV, offer support and review options for prevention and referrals [14]. The antenatal clinic provides a setting for such screening, as this is most often, the only contact women have with the healthcare system in many developing countries. In spite of anecdotal evidence suggesting that IPV is very common in The Gambia, such screening is not available in the public health system.

IPV occurs more commonly in women in the reproductive age group [15]. Alcohol and substance abuse is thought to play a role in IPV [15]. Victims of IPV may resort to alcohol or substance abuse in attempt to help themselves. Perpetrators are more likely to cause serious injuries after taking alcohol [15].

This study aims to ascertain the burden of IPV amongst pregnant women and the factors associated with IPV in The Gambia. This will serve as a basis to advocate for larger studies and ultimately direct policy towards including antenatal screening for IPV as part of routine antenatal care.