Intimate Partner Violence during pregnancy and victim’s perception on miscarriage

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Biswas, A., Dalal, K., Rahman, F., Deave, T. (2015)

Intimate Partner Violence during pregnancy and victim’s perception on miscarriage.

International Journal of Public Health Research, 3(2): 58-63

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Intimate Partner Violence During Pregnancy and

Victim’s Perception on Miscarriage

Animesh Biswas

, Koustuv Dalal

, Fazlur Rahman

, Toity Deave

2_{Centre for Injury Prevention and Safety Promotion, School of Health and Medical Sciences, Örebro University, Örebro, Sweden} 3_{Dept. of Public Health Sciences, Örebro University, Örebro, Sweden}

4_{Centre for Child & Adolescent Health, Health & Applied Sciences, University of the West of England, Bristol, UK}

Email address

animesh.biswas@oru.se (A. Biswas), ani72001@gmail.com (A. Biswas)

To cite this article

Animesh Biswas, Koustuv Dalal, Fazlur Rahman, Toity Deave. Intimate Partner Violence During Pregnancy and Victim’s Perception on Miscarriage. International Journal of Public Health Research. Vol. 3, No. 2, 2015, pp. 58-63.

Abstract

Introduction: Women who suffer intimate partner violence (IPV) encounter reproductive health problems including miscarriages. IPV in Bangladeshi women is known to be acute socio- medical problem. The aim of the current study was to determine the prevalence of intimate partner violence from the husband during pregnancy and to explore the victims’ perceptions of IPV and miscarriage. Methods: Women who were admitted to a sub-district level hospital in Bangladesh due to miscarriage between July and December 2007 were invited to participate. A cross-sectional study was performed using mixed methods. Descriptive statistics were applied to the quantitative data and the qualitative data were analysed using thematic analysis. Results: Majority of women aged between 18 – 30 years (68.4%), more than 38% had no education and most of them had low socio-economic conditions. 43 (56.6%) women reported that they had experienced sexual violence in the last four months. 20 (26.3%) women suffered this once a week and 30% (n=23) faced sexual violence twice or more in a week. 29 (38.2%) women believed that current miscarriage was due to their husband’s sexual violence. The women reported that their husband forced sexual intercourse on them and that they were highly controlling over their day-to-day lives. Conclusion: Sexual violence during pregnancy is a hidden health problem for women in rural Bangladesh. Education and information need to be made more widely available to improve maternal health and child survival.

Keywords

Intimate Partner Violence, Sexual Violence, Pregnancy, Miscarriage, Bangladesh

1. Introduction

Intimate partner violence (IPV) is increasingly being recognized as a global health problem around the world with significant social and clinical outcome [1-5]. The World Health Organization has defined IPV as a ‘‘behaviour within an intimate relationship that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours’’ [6-8]. It has been estimated that one in five women will experience some form of IPV in their lifetime and that 42 million women undergo pregnancy termination each year, frequently under unsafe conditions [9]. The association between IPV and reproductive health has been widely reported in many high-income and low-income countries [10-13]. IPV can lead to be unintended pregnancies,

abortions, irregular vaginal bleeding, genital injury, dysmenorrhea, sexually transmitted infections, sexual dysfunction and miscarriage [10-11, 14-18]. However, there is a paucity of evidence from low income countries, especially Asia [19-21]. One Indian study IPV was suffered by 21 -28 % women during pregnancy [22]. Another study, in Pakistan, found that following IPV, 75.9% women experienced severe psychological problems, 34.6% severe sexual difficulties and 31.9% severe physical violence at least once in marital life [23]. A study in Bangladesh estimated the association between IPV and childbirth related outcomes and found that more than study found that, based on men’s self-reported perpetration, 75% of married Bangladeshi women were subjected to physical or sexual abuse [24].

Context-relevant studies are needed to support the development of evidence-based interventions that improve

International Journal of Public Health Research 2015; 3(2): 58-63 59

maternal, fetal and newborn health following IPV, especially for the rural areas where the prevalence of IPV is high [19-21]. As followings understanding time victim’s understanding of IPV is crucial. Therefore, this current study aimed to determine the frequency of IPV during pregnancy and to assess the victim’s perceptions of miscarriage in rural settings in Bangladesh.

2. Methods

2.1. Study Design and Place of Study

The study was conducted using mixed methods. A patient survey and in-depth interviews were conducted with women who presented with signs and symptoms of abortion at the emergency department or emergency obstetric ward of Kumudini medical college hospital, a 500 bedded teaching hospital in Mirzapur, a largely rural sub-district in Bangladesh. The data were collected between July and December 2007.

2.2. Study Population

Inclusion criteria: The study included women between

ages 17 – 42 years, with a confirmed history of being pregnancy taken by the medical doctor, who presented at the emergency department or emergency obstetric ward with a complaint of lower abdominal pain and vaginal bleeding. These women were screened by the obstetrician-on-call and those with a clinical diagnosis of abortion and admitted into the ward or emergency department were recruited into the

study.

A total of 95 women were invited to participate in the study and informed consent was obtained for 76 (80%) of them. Despite repeated reassurance about the confidentiality of the data collected, 19 women (20%) refused to participate due to the sensitivity of discussing any IPV experience.

2.3. Data Collection

Two trained female physicians working in the Gynecology and Obstetrics Department of the Medical College Hospital undertook the interviews. The data collectors undertook a two day training using the tools and interviewer guide prepared for the study. A pre-tested semi-structured questionnaire was used to collect quantitative data on socio demographic factors, past obstetric history, current pregnancy history, violence during current and previous pregnancies and frequency of violence in the current pregnancy. After the women had received treatment for the abortion event, open-ended questions were used to obtain history of presenting symptoms and perception of likely causes of miscarriage at hospital ward.

Intimate partner violence was defined along the three main domains – emotional, physical and sexual violence. Operational definitions were used when collecting the history of IPV (Figure 1). Current IPV history was obtained over a 4 month recall period and the frequency of event was calculated by asking how many times violence occurred in the past week.

Figure 1. Operational definitions of IPV

2.4. Quantitative Data Analysis

The primary outcome variable, intimate partner violence, was operationalized as a binary variable and was disaggregated into emotional, physical and sexual violence. The frequencies and percentages of IPV events (and of each of the 3 domains) were determined. The proportion of women with a history of current abortion who reported IPV (and each of the 3 domains of violence) were also determined.

The percentage was undertaken to describe the independent variables, including socio demographic variables such as age, religion, educational status, age at marriage,

family monthly income, occupational status, housing facilities, family size and husband’s educational status were conducted. Mean duration and range of current pregnancy (in days) prior to abortion was also determined.

All quantitative data was entered in Epi-Info 6 and then exported to statistical software package SPSS version 11.5 for analyses.

2.5. Qualitative Data Analysis

The qualitative data on perception of causes of miscarriage were analyzed using different theme. All entries were coded

independently using an open coding method by two experienced researchers engaged in the data analysis. The coded data were later grouped into categories and emerging themes. The percent agreement comparing codes between the two researchers was determined. Discordant codes were examined by a third researcher and the final codes were agreed upon by the three researchers on a consensus basis.

2.6. Ethical Permission

Ethical permission for the study protocol was obtained from the Kumudini Women’s Medical College Hospital authority. Informed consent was obtained from each participant. The right to withdraw at any time during the study was emphasized.

3. Results

3.1. Quantitative Data Analysis

3.1.1. Violence During Pregnancy

Seventy-six currently pregnant women with clinical symptoms and signs of abortion participated in the study, of whom 67% (n= 51) reported experiencing IPV in the last 4 months prior to the interview. Forty-three of these (56.6%) were due to sexual violence, 3.9% (n=3) due to emotional violence and 6.6% 5 (n=5) due to physical violence [figure – 2].

Figure 2. Violence in pregnant women in the previous four months (n=76)

All the women who suffered physical and emotional violence reported that this occurs usually once every week. 20 (26.3%) women who suffered sexual violence reported that this took place as a weekly occurrence and more than 30% (n=23) reported it taking place two or more times a week [figure -3].

3.1.2. Socio-Economic Characteristics of the Women and Their Husbands

Most of the respondents (n= 61, 80%) were between the ages of 18 and 30 years of age with a mean age was 25.37 and 52 (68.4%) of them were married before their 18th birthday. Twenty-nine (38.2 %) of the women had no education whereas about (25) 33% completed up to five grade studies. Most of the women (n=63, 83%) were full-time housewives and were economically dependent on their husbands. The family income for a majority (55.3%) was between 1000 – 5000 BDT (13 – 65 USD) per month [Table: 1].

Characteristic n (%) Age of women Below 18 years 19 – 29 years 30 and above 4 (5.3) 50 (65.8) 22(28.9) Age at marriage Below 18 years 18 years and above

52 (68.4) 24 (31.6) Educational level

No education

Up to five grade ( Primary education level ) Up to ten grade ( Secondary education level ) Eleven grade and above ( Higher secondary)

29 (38.2 ) 25 (32.9) 18 (23.7) 4 (5.3) Occupation Housewife Daily labour Agricultural work Others 63 (82.9) 3 (3.9) 2 (2.6) 8 (10.6) Housing facilities

Mud /Tin made (Kancha) Roof concrete made (Pacca)

59 (77.6) 17 (22.4) Family size 2-5 members 6-7 members 8 and above 50 (65.8) 13 (17.1) 13 (17.1) Family income per month ( I USD = 78 BDT)

13 – 64 USD 64.1 – 128 USD > 128 USD 42 (55.3) 16 (21.1) 18 (23.7) Husband’s level of education

No education

Up to five grade ( Primary education level ) Up to ten grade ( Secondary education level ) Eleven grade and above ( Higher secondary)

26 (34.2 ) 18 (23.7) 17 (22.4) 15(19.7) Husband’s occupation Service Daily labour Agricultural work Business Others 24 (31.6) 17 (22.4) 20 (26.3) 12 (15.8) 3 (3.9)

Figure 3. Average frequency of violence in women during the previous week

3.1.3. Information on Pregnancy and Abortion

One third (31.6%) of women had conceived for the first time (i.e. it was their first pregnancy), for 34.1% women, it was their second pregnancy, the rest of the women it was their third or more. Mean duration of pregnancy for these women presenting with signs of abortion was 88 days, range 40 days to 125 days.

International Journal of Public Health Research 2015; 3(2): 58-63 61

3.2. Qualitative Data Analysis

Interviews were undertaken with 76 women, they took place in the gyane ward of the medical college hospital. They lasted an average of 10 minutes, ranging between 8 and 15 minutes. Of the 76 women who were interviewed, 38.2% (n=29) perceived that the current abortion occurred due to IPV during their current pregnancy. Out of IPV cases, the majority of them (n=27 35.5%) suggested that the abortion was a result of intensive sexual violence, while 2.6% (n=2) women felt that it occurred due to physical violence. Other perceived causes of the abortion include ‘excessive’ household chores and other injuries [figure -4].

Injury = caused by IPV and other issues, HH work = household works

Figure 4. Perception of cause of miscarriage reported by women

participants (n=76)

During in depth discussion on the sexual violence issue, women mentioned that they have been faced forced to do sexual abuse, in some cases, women tried to explain why she didn’t want to do sexual intercourse and also described the risk of doing that. Moreover, it has also identified from the discussion that husband had a physical need to do forceful intercourse or in all cases it was found to be choice of the husband, not from the women side. In case of sexual violence, one of the participants who was 21 years old said:

“I feel so panic when I remembered those night scene- my husband used to do forceful sexual intercourse more than one time and I was thinking of my child. Almighty God did everything, punished me for my work – I did”

The majority of the women reported that they were forced into sexual intercourse. One woman said, “I had nothing to do, my husband wanted to do sexual intercourse and I was bound to do”.

Another women mentioned, “I tried to let my husband understand that if we do sexual intercourse, the inside child might suffer. But he never understood. He always forced me to have sex”.

Another victim said, “One of my relative told me earlier that first four months of pregnancy is risky and I have to be very careful, not lying in the bed with husband in sexual issue. I discussed it with my husband; he just dropped the issue and did everything. It was so horrible for me”.

“Even I was four months pregnant, I had to relentlessly work from morning till night. After finishing my

household works, I had to face the forceful sex by my husband. This was so painful for me. My husband had told me that he was giving me food and subsistence, therefore I must give him sex every night”

A young women aged 19 years described “I got married just a few months back, my husband is double aged than me, I had no option to stop him from doing sexual intercourse, I always feel scared to talk to him but my mind was focused on my baby inside, I couldn’t save the life”.

4. Discussions

Intimate partner violence is a widespread women’s health problem in rural Bangladesh. Earlier studies have linked IPV during pregnancy and miscarriage [19, 24, 27]. The current study has highlighted the views of pregnant IPV victims. More than one third of pregnant women (35.5%) suggested that their miscarriage was due to sexual intimate partner violence during their pregnancy. It was also noted that the majority of the participants (57%) experienced sexual violence during last previous four months of pregnancy and then went on to have a miscarriage. A finding that has not been reported in previous findings is that almost one-fourth women (23%) felt that excessive household work was one of the causes of their miscarriage. Miscarriage is the most common negative gestational outcome that occurs in about 20% of clinically identified pregnancies [28]. A study conducted in Guatemala found that physical or sexual victimisation by an intimate male partner in the previous 12 months was significantly associated with miscarriage [29]. A study in Bangladesh also found that, along with IPV, the victims’ also experienced extreme control over their daily life such as their diet and subsistence [20]. It is important to note that husbands may not know of the adverse effects on pregnancy and miscarriage of their control over their wives and of sexual IPV. The majority of the husbands of the participants were illiterate and /or educated only to a primary level, thus suggesting that they may lack knowledge and awareness. Moreover, women education and empowerment also find as one of the component to facing violence. Policy makers in Bangladesh can think of utilizing various channels, including media, non-governmental organizations (NGOs) and religious institutions for raising awareness and providing information about IPV, especially during pregnancy.

The sample size was selected purposively from the sub-district level medical college hospital and therefore may not represent the entire country data. However, it is likely that the participants’ views are quite similar to other women’s experiences who live in rural sub-districts in Bangladesh.

5. Strengths and Limitations of the

Study

We have 20% women enrolled initially, however, after knowing details they regret to take part in the study. The

eligible women were Muslim, illiterate and/or primary educated. A recently published report highlighted this issue and suggested involving religious organizations to increase the acceptance rate [30]. Due to the rural context, the financial and resource constraints we recruited from just one hospital over a six month period.

A mixed methods approach was appropriate and enabled the prevalence of IPV to be explored and ensured that the context of the IPV to women was described. Seventy-six interviews were undertaken with the female participants and they spoke about sensitive and important information about their experiences of IPV that has limited number of information in similar settings. The women who participated in the interviews had full freedom to speak about intimate partner violence, they appeared comfortable in front of a female medical doctor to speak out in-depth. In that setting, they were not scared to speak on violence related issues, about their husband or in-laws.

The current study has not assigned causality between sexual IPV and background factors, we have described the experiences of women and the frequency and type of IPV that they suffer whilst pregnant. The causation cannot be implied because of the observation study. The current study could be considered as a pilot study as preparation for a nationwide large-scale study to explore the prevalence of IPV and women’s experiences in the wider population.

6. Conclusions

Intimate partner violence during pregnancy in rural Bangladesh is prevalent phenomena. Female victims perceive that their miscarriages are mainly due to sexual IPV, excessive household works and injuries caused by IPV of Women in rural Bangladesh have a very underprivileged position where, on a day-to-day basis, they have to face several hurdles and severe sexual intimate partner violence during pregnancy.

Acknowledgment

We would like to thank the medical college staff (Doctors and nurses) including Director, Hospital in the Kumundini Medical College for their support and help with recruiting participants. We would also like to thank all the women participants for their time and sharing their experiences with us. We also acknowledged to Dr Olakunle Alonge of International Research Unit, Johns Hopkins Bloomberg School of Public Health, USA for providing support in analysis of the findings.

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