Prevalence of domestic violence and associated factors among pregnant women attending antenatal care service at University of Gondar Referral Hospital, Northwest Ethiopia

Violence against women committed by intimate partners is an important public health and human rights issue [1]. Domestic violence against women is a common practice in all countries of the world though the prevalence varies from country to country [2]. According to the World Health Organization (WHO) multi-country study, the problem ranges from 15% in Japan to 71% in rural Ethiopia [3].

More commonly, pregnancy is considered to be a critical time at which domestic violence begins or amplifies due to women’s increased physical and mental vulnerability [4]. Studies conducted in Kisumu district hospital, Kenya [5], Rwanda [6], Kwazulu-Natal, South Africa [7], and Sao Paulo, Brazil [8], showed that one in three pregnant women experienced either physical, emotional, sexual violence or both by intimate partners during pregnancy.

Domestic violence can lead to poor physical [9, 10], mental [9, 11‐14], sexual and reproductive health outcomes [10]. Violence during pregnancy is particularly harmful as it threatens both maternal and fetal life. Previous studies revealed that pregnant women who experienced violence were found to have increased risks of ante-partum hemorrhage [15], intrauterine growth retardation [16], premature rupture of membrane [17, 18], cesarean delivery [18‐20], preterm birth [21, 22], low birth weight babies [17, 18, 21, 23], stillbirth [15, 23, 24], and neonatal mortality [24, 25] when compared with those who did not experience the problem.

Despite this substantial health burden, previous studies focused on the prevalence and determinants of domestic violence against women; so little is known about the extent of violence on the most at risk pregnant women in Ethiopia as well in the study area. Moreover, evidence is unavailable on what factors put pregnant women at increased risk of domestic violence during their pregnancy. Hence, this study aimed to assess the prevalence of domestic violence against women and associated factors among pregnant women visiting the University of Gondar Referral Hospital for ANC services. The findings are expected to increase the awareness of health care providers working with pregnant women in screening, detecting and readily supporting pregnancies vulnerable to domestic violence. The information will also help health programmers and policy makers at large to design preventive and controlling strategies to alleviate the problem.

This is one of the first studies reporting the prevalence of domestic violence among pregnant women during pregnancy in Ethiopia, particularly in the study area (Gondar and its surroundings). The study found that over half (58.7%) of pregnant women suffered domestic violence by an intimate partner during pregnancy. Emotional violence was the most common, followed by physical and sexual violence. The finding is consistent with that of study conducted among native Americans (52.5%) [26]. Our finding is significantly higher than those of studies conducted in Kisumu district hospital, Kenya (37%) [5], Rwanda(35.1%) [6], Sao Paulo, Brazil(34.6%) [8], KwaZulu-Natal, South Africa(31%) [7], Mulago Hospital, Uganda(27.7%) [17], Lima, Peru (45.1%) [27], Portuguese health institutions (43.4%) [28], Pakistan (51%) [29], Hull Maternity Hospital, UK (17%) [30]. It is also higher than that of a systematic review of African studies conducted between 2000 and 2010 and found that the prevalence of intimate partner violence ranged from 2 to 57% with an overall prevalence of 15.23% [31]. This difference might be due to differences in sampling techniques to recruit study participants. For instance, studies in Rwanda and Portugal used a convenient sampling technique which might have led to a lower proportion of domestic violence because volunteers are different from non-volunteers. The outcome assessment tool might also be the possible reason for the differences in the prevalence of domestic violence. Studies conducted in Uganda and UK used a woman abuse screening tool, whereas this study used the WHO tool to assess the outcome variable. The other possible explanation for the difference might be the type of data collection technique (self-administered versus interview) the researchers used and the study settings.

However, the current finding is lower than that of a study conducted in southern Appalachia (81%) [32]. The possible reason for the difference is that the former work was conducted on a smaller sample (104) and only pregnant women in the lower socioeconomic status, resulting in the over estimation of the prevalence of the problem.

Like other studies conducted in different parts of the country, this work identified factors associated with domestic violence during pregnancy. Women’s occupation was one of the factors associated with the violence. Thus, the likelihood of domestic violence during pregnancy was three times higher among housewives compared to employed women. The possible explanations could be the fact that most housewives in this study didn’t complete higher education and stayed at home carrying out domestic activities which made them more dependent on their husbands. This is evidenced by the fact that women with no education are four times as likely to face violence during pregnancy as women with more than secondary education [33]. As long as the husband is the family financial source, housewives remain more vulnerable, less autonomous, and economically more dependent on their husbands, which results in disagreements and different forms of violence.

Women’s personal income was one of the factors influencing domestic violence during pregnancy in this study. Women with no salary of their own were three times as likely to experience domestic violence during pregnancy compared with pregnant women who had their own earnings. This finding is supported by those of studies conducted in Awi zone, Ethiopia [34], rural Bangladesh [35], Lima, Peru [27]. The possible reason is that women lacking own income might be exposed to specific stresses, frustration, and a sense of inadequacy for having failed to live with their partners. This might in turn lead to marital disagreements or poor relationships, making it more difficult for women to avoid violent [36].

The likelihood of domestic violence during pregnancy was five times higher among women whose husbands took alcohol daily compared to those who never consumed alcohol. The finding is consistent with those of studies conducted in Gondar [37], western Ethiopia [38], Awi zone, Ethiopia [34], Shimelba, Eritreans’ refugee camp, Ethiopia [39], Kisumu district hospital, Kenya [5], Rwanda [6], Sao Paulo, Brazil [8], the 9 countries of the WHO multi-country study, including Ethiopia [40]. This also was a determinant variable that increased the risk of domestic violence during pregnancy in the systematic reviews of 19 African journals(2000-2010GC) [31]. This is due to the fact that alcohol consumption directly affects the consumers’ cognitive (the ability to perceive, integrate, and process information) and physical functions. This distortion in thinking might cause the users to behave aggressive in the relationship, increase the sense of power and control, leading to exercising the power and control on partners [41].

The likelihood of domestic violence on pregnant women who believed pregnancy decision was the responsibility of women was two times as likely compared to women who didn’t believes. This is in line with the results of studies conducted in Mulago hospital, Uganda [17], Sao Paulo, Brazil [8], Portuguese health institutions [28], Pakistan [29], and South Lebanon [42]. Evidence suggests that pregnancy should be decided by both partners’ willingness and participation. But the mismatch of intentions and decisions to have children might result in harsh relationships between partners, resulting in further emotional and physical violence on female partners.

Women who didn’t obey their husbands were two times more likely to face domestic violence during pregnancy than women who did. This is due to the fact that in Ethiopia there is a deep rooted belief that women should obey and serve their husbands even though it is not supported by law. It is usual that if women didn’t obey their husbands, they should be punished by their husbands by being stubbed, boiled, and kicked.

The first strength of this work is the authors’ use of an adopted standard and a validated instrument of WHO multi-country study on women’s health and domestic violence against women. Its second merit is the adequacy of the training given to data collectors and the pretesting of the tools in an appropriate setting. On the other hand, cross-sectional nature of the work made the determinations of the directions of associations between variables difficult is one of its limitations. Besides, the fact that the data collection technique was not qualitative might have limited the richness and the integrity of the data.

The prevalence of domestic violence among pregnant woman visiting the University of Gondar Referral Hospital for antenatal care services was high. Being housewives, lack of own salary, partners’ daily consumption of alcohol, mothers’ refusal to obey, pregnancy decisions were positively and significantly associated with domestic violence during pregnancy. Evidence based women empowerment, especially the empowerment of women with no salary of their own, partners’ education, and building positive relations between partners is very important to minimize violence during pregnancy.