Background
Violence against women is recognized as a significant public health problem that relates to gross violation of women’s human rights, affecting millions of women worldwide [
1,
2]. Reports show that a woman is more likely to be hit, assaulted or murdered by her intimate partner than by a stranger, placing Intimate Partner Violence (IPV) as the most pervasive form of violence [
2,
3]. Globally, one in three women are reported to have experienced IPV in their lifetime, with higher estimates documented in African countries [
2], where prevalence rates range from 28 to 37% [
4‐
6]. In Tanzania, four in ten women experienced IPV in their lifetime [
7,
8].
Focusing on experiences of IPV during pregnancy, a review of African studies indicated that the prevalence of violence is one of the highest reported globally and ranged from 2 to 57% [
9]. Studies have indicated that IPV during pregnancy affects health of women and pregnancy [
10‐
12]. Peterson et al. conceptualized the effects of IPV to pregnancy and indicated that physical violence may cause direct injury to the gravid uterus leading to adverse pregnancy outcomes [
13]. Alternatively, trauma and stress may indirectly affect the pregnancy through influencing negatively the health seeking behavior, precipitate women prenatal risks such as alcohol and substance abuse. A recent study done among Vietnamese women has shown that IPV during pregnancy is associated with preterm delivery (below 37 weeks of gestation) and low birth weight (less than 2,500 g) [
10]. Preterm and low birth weight delivery impairs neonatal health leading to increased morbidity and mortality [
14]. In Tanzania, preterm delivery and low birth weight constitute significant public health problems where they are responsible for up to 80% of all neonatal deaths and one-third of all deaths among children under-five years of age [
15]. IPV during pregnancy have also been associated with pregnancy loss, miscarriage and stillbirth [
11,
12].
Due to the negative health consequences of IPV during pregnancy, previous research has focused on a general assessment of factors associated with experiencing violence among pregnant women so as to aid efforts in the prevention of IPV and mitigate its health consequences [
9,
12,
16‐
19]. There is evidence documenting risk factors associated with experiencing violence, which include young age [
9], alcohol use by women [
12] and their partner [
18], high parity [
19] and previous history of adverse pregnancy outcomes [
16].
One potential strategy for mitigating exposure to IPV during pregnancy is social support. In that regard, there is a growing focus on understanding the association between social support and IPV in order to inform future interventions to prevent IPV and reduce the resulting complications of violence, especially during pregnancy. Social support is defined as the assistance women receive from other people and through supportive social networks regardless of whether the support is merely expected (perceived) or actually received by the beneficiary [
20]. Social support may be grouped into five broad categories; emotional social support (advice, feedback), communication with family members, perceived social support from family members, group social support and practical social support (tangible help such as food, money and pregnancy care). The advantages of social support to maternal and fetal wellbeing are known [
21‐
23]. Women who receive social support are less likely to report depressive symptoms during pregnancy [
21] irrespective of educational level, wealth status, occupation, perceived work burden, food security, history of miscarriage or stillbirth and whether the pregnancy was planned or not. Dibaba et al. argue that social support during pregnancy plays a “buffering role” from depression [
21]. Women who reported being satisfied with social support during pregnancy had babies born with higher birth weights [
22]. On the other hand, women who lacked adequate social support had a higher risk of pregnancy complications such as miscarriage, pre-eclampsia and preterm births [
23]. It may be concluded that social support during pregnancy is an important factor for maternal and fetal wellbeing.
The association between social support and partner violence has been described in the general population of women [
24‐
26] but there is only limited knowledge regarding the association between social support and IPV during pregnancy [
27]. Social support has been known to be a protective factor for women who are exposed to abuse by their partner [
20,
23] and reduces the health consequences of violence [
21,
22]. Studying 500 women in Pakistan, Farid et al. found that women with social support were less likely to experience abuse from their partner [
27]. Wright et al. later showed that women who had social support from members of their family had reduced prevalence and frequency of IPV [
24]. Social support mediates the relationship between abuse and distress, leading to lower levels of negative psychological effects [
28], a mechanism responsible for positively influencing the negative health consequences that result from violence. In sub-Saharan Africa, Tanzania included, the majority of women who experience IPV find family members and friends to be their primary contacts when compared to formal institutions like police and legal aid [
29‐
31]. Tanzanian women make use of informal social support networks for maternal and child care [
32] but it remains unclear whether such networks influence the risk of exposure to IPV during pregnancy.
The need for strong evidence on the association between social support and experiencing IPV during pregnancy is necessary for designing future interventions to prevent violence against women during pregnancy. The aim of this study was therefore to determine the association between social support and IPV during pregnancy among women attending antenatal care in Moshi Municipality, northern Tanzania.
Methods
Study design and settings
This study was nested within a larger cohort study conducted among pregnant women attending antenatal care (ANC) before the 24th gestational week in Moshi Municipality, Tanzania, and used a cross-sectional study design. To limit the time burden to participants, the interviews were divided into three time periods; at enrolment where socio-demographic and reproductive health information were collected, at 34 weeks of gestation where exposure to IPV before and during pregnancy was assessed, and within 48 h post-delivery where gestation age at delivery and birth weight were determined.
The study was conducted at Majengo and Pasua Health Centers in Moshi Municipality, Kilimanjaro Region, Tanzania. The two clinics are located in the semi-urban areas of Moshi Municipality. There are 23 clinics in Moshi Municipality that offer primary ANC services to about 7,000 – 8,000 pregnant women annually. Nearly half of all the pregnant women in the Municipality receive ANC services at Majengo and Pasua Health Centers. About the Municipality, it is one of the seven districts of Kilimanjaro Region and with estimated population of 206,728 people. Located on the slopes of Mount Kilimanjaro, a snow-capped and the highest mountain in Africa, the municipality was once famous for its robust economy from coffee. The falling prices of coffee in the international market forced the residents of the municipality to start small scale farming of crops such as maize and banana. Apart from subsistence farming, women in the area do engage in selling agricultural produce to the market. Women have also opened small shops which are locally called ‘kiosk’ and sell either clothes or items for household use such as soap, sugar, salt and soft drinks.
Participants, recruitment and data collection
The study population included women registered at the two clinics for antenatal care between March 2014 and May 2015. Inclusion criteria were: pregnant women aged 18 years or above, who were planning to deliver within Moshi Municipality and with pregnancy gestational age of less than 24 weeks as confirmed by ultrasound scan. Exclusion criteria were: not living in Moshi Municipality, not willing to be followed up for the entire period of study and having multiple pregnancies.
The research assistants comprised six female nurses, aged above 35 years, who were experienced in research and committed fulltime for the entire period of the research. Research assistants were trained for five days on how to conduct this study with regard to its sensitive nature. The enrolment and follow-up interviews were conducted in a private room at the clinic where no one other than the research assistant and the participant were allowed to be present, except children under two years of age. All information was collected through face-to-face interviews in Swahili language. The standard enrolment interview questionnaire included information on socio-demographic and reproductive health characteristics. The follow-up interview assessed social support and exposure to IPV before and/or during pregnancy. The two interviews each lasted between 45 and 60 min.
Discussion
According to our knowledge, this is the first study to assess the association between social support and IPV during pregnancy in Tanzania. This study indicates that nearly four in ten women (39.2%) had ever experienced intimate partner violence, and close to one-third (30.2%) were exposed to IPV during pregnancy. Almost one-third of the women (29%) experienced repeated episodes of abuse during pregnancy. While women who had no one to depend on for financial help were at increased risk of experiencing IPV during pregnancy, those who were in communication with a member of their family of origin at least once a month and trusted that a member of the family would be there to offer support in case of need had decreased odds of experiencing IPV during pregnancy.
The results of this study show that acts of violence are a problem during pregnancy among Tanzanian women where three in ten women are exposed to IPV during pregnancy. These results are consistent with findings from a previous study done among pregnant women attending antenatal care in Dar es Salaam, Tanzania, where the prevalence of physical and sexual violence during pregnancy was 27% [
11]. The results of the present study are also comparable with findings from other studies done among pregnant women attending antenatal care in neighboring countries [
4‐
6]. While the prevalence of violence among 600 Ugandan women was 27.7% [
4], Makayoto et al. reported the prevalence of IPV among 300 pregnant women attending antenatal care in Kenya to be 37% [
5]. Comparable IPV prevalence of 35.1% among 600 pregnant women, assessed over a duration of 12 months that included the pregnancy period was reported in Rwanda [
6].
Nearly all women who had experienced violence during pregnancy (97%) reported that they had experienced repeated episodes. This implies that violence during pregnancy is not a one-off event. It appears as violence is common and a part of women’s lives during pregnancy. In Zimbabwe, one in ten women reported having experienced six or more episodes of violence during pregnancy [
33]. Although the negative health impacts of violence exposure may be assessed from the consequences of a single event, repetitive acts of violence are likely to be associated with higher health risk for the woman and the pregnancy.
The most important social support factors associated with IPV during pregnancy, and repeated episodes of violence, are the communication with and perceived support from members of the family of origin, and financial support. Although group support and emotional support are crucial inputs for pregnancy care, their association with experiencing violence during pregnancy was statistically insignificant.
Communication with a member of the family of origin and trusting that the family will offer support in case of problems has been found to be associated with decreased odds of exposure to IPV and decreased odds for exposure to repeated episodes of violence during pregnancy. This implies that the strong family ties and networks established between the woman and the family of origin are associated with decreased odds of exposure to violence during pregnancy.
The findings in our study, that women who communicate with a member of family of origin at least once a week were associated with increased odds of experiencing IPV during pregnancy than those who were talking at least once a month, were not expected and need to be discussed. While further exploratory research is needed to understand this association, we will try to suggest a plausible explanation. Women who are in a stressful state as a result of violence will likely be in dire need of emotional support. These women will likely disclose their relationship challenges to the family of origin. In turn, they are motivated to continue staying in their relationship. Such a sharing between the women and their family of origin would increase the frequency of communication. In other words, violence may change the communication habits of those exposed to violence. However, there is complexity around the association between communication and social support. This study provided no information about the nature of the contacts and whether such contacts were supportive or not. In that case, the frequency of communication with the family of origin may not be equivalent to social support, implying that the frequency of contact is not a good variable for assessing social support.
The results of our study are comparable to the findings from a large national representative survey in Turkey on what puts women at risk of violence from their husbands. The study showed that women who are close to the family of origin are likely to receive emotional and/or physical support from them, a role that in itself is associated with reduced risk of experiencing violence [
34]. Yuksel-Kaptanoglu et al. further showed that preventing women from contacting their family was associated with increased risk of experiencing violence. Underscoring the role of family of origin in violence, an additional study in Turkey found that women do prefer to disclose their experience of IPV to the family of origin compared to the family of the partner even though they may not receive any type of support from them [
35]. In the same study however, the support from the family of their partner was found to be associated with increased risk of violence and highlighted the contradicting role of families to the woman. It may therefore be noted that the response of the partners’ family is not predictable when it comes to a point of choosing who to support when conflict arise: their son or the woman who is abused. In Tanzanian culture, especially when the couple lives close to the family of the partner, conflicts may result when mothers-in-law exercise control and power in issues of space, food, finances and decisions. This complexity underscores the fact that IPV is part of gender based violence and therefore understanding the context in which it happens [
36] require another level of conceptualization of how family structures and patriarchal ideology affect women’s lives.
Of all actions that constituted practical support for women during pregnancy, the findings of this study confirm what has been documented in other studies, namely that economic dependency increases the risk of IPV [
37‐
39]. Unraveling the complex relationship between dependency and domestic violence, Schewe hypothesized that when there is dependence on others for financial assistance there is a possibility that the dependent member may be mistreated or exploited, regardless of the source of support [
37]. Focusing on IPV and studying 1,886 women from national representative data on IPV in USA, Golden et al. found that women who depended on their intimate partner economically were at increased risk of one or more types of IPV regardless of the women’s’ race or ethnic origin [
38]. Bornstein et al. showed that it is not only women’s economic dependency on men that leads to domestic violence, but also their emotional dependency [
39]. Women therefore become more vulnerable to IPV when they have to depend on their intimate partner economically and emotionally. Women’s dependency to their partners economically especially during pregnancy period may explain as to why in our study self-employed women were more likely to report IPV. In case of health related complications of pregnancy, some women may work less both at home and/or in other activities outside home, leading to decreased income that may have otherwise gained if she was not pregnant. Especially for self employed women in business, some of them are out of their job during their pregnancy period. They are then transiently or permanently economically dependent to their intimate partner increasing their vulnerability to IPV.
In many African settings, men are responsible for providing financial support to the family. The child to be born will create an economic challenge to the family, which is probably already in a situation of financial crisis, posing a new demand to care for the child and mother after delivery [
40]. The increasing number of children may therefore present uncertainties to the partner in terms of financial support to the family during pregnancy and after delivery [
41]. Bacchus et al. further found that men’s doubts about parenting of their awaited child increased physical and emotional violence for women during pregnancy. Women's constant requests for support may also increase frequency of abuse, especially when the intimate partners cannot support the woman economically. While financial dependency by itself was associated with experiences of repeated episodes of violence, it presents uncertainties in relation to women’s future support and may limit the way they will respond to prevent further violence.
Strengths and limitations of the study
This study has some limitations that should be considered in interpreting of the results. The cross-sectional nature of the study makes it 'impossible to draw causal inferences, preventing establishment of the direction of causality between social support and IPV during pregnancy. Experiences of intimate partner violence may be under-reported, considering the cultural sensitivity around issues of violence, leading to under-estimation of the strength of the association between social support and IPV; this could be a factor despite the fact that the research assistants interviewed women in a non-judgmental way after they established good rapport. Moreover, women who did fit the inclusion criteria of below 24 weeks pregnancy gestation may have different characteristics to those who register late at antenatal clinics for service, limiting generalization of the results. However, data show that at least two-thirds of women in the area of study register for their first antenatal visit before the 24
th week of their pregnancy and nearly all women attend antenatal care at least once over the entire period of their pregnancy [
7]. Although some measures of social support (communication, perceived support and group support) included time period before pregnancy, we may not ascertain whether there was change in social support received by women because of pregnancy. Also, this study did not measure the level of family income or poverty. However, the study recruited relatively a large sample size of pregnant women and used validated tools for assessment of violence. The use of validated tools ensures comparability with results from other studies done elsewhere.
Acknowledgements
The authors acknowledge the support from research assistants who worked tirelessly to collect information for the study. Participants are acknowledged for their time and valuable information that made this research possible.