Domestic violence and contraceptive use in a rural Indian village

Investigating the relationship between spousal violence against women and total fertility rate in Afghanistan

BACKGROUND

spousal violence against women (SVAW) is a common form of violence that occurs within the family context, with spouses being the main perpetrators. Afghanistan has one of the highest rates of SVAW in the world, and its impact on reproductive health and fertility is not well understood. This study aims to investigate the extent to which SVAW influences the total fertility rate (TFR) of Afghan women.

METHODS

In this study, a regression model of discrete-time survival models was used to calculate the total fertility rate (TFR), parity progression ratio (PPRs), and average closed birth intervals (CBI) between two children. The method used in this study has its roots in the works of Griffin Finney (1983) and was further developed by Redford et al. (2010). The study population utilized the 2015 Afghanistan Demographic and Health Survey, and sample weights were used to ensure accurate estimates for the population of Afghanistan as a whole.

RESULTS

The study found that women in Afghanistan who have experienced SV are more likely to progress to the next parity, start childbearing faster, and continue to do so. Women who have not experienced SV tend to progress to higher parities at a slower pace during their initial reproductive years. The study also suggests that women with spousal violence (SV) experience may have slightly higher fertility rates and shorter birth intervals for certain birth orders, although the differences between the two groups are generally small. Specifically, the total fertility rate (TFR) for women who experienced SV was 6.9, while the TFR for women who did not experience SV was 6.2.

CONCLUSIONS

These results provide valuable information for policymakers and public health professionals in developing effective policies and programs to address SVAW and improve maternal and child health outcomes in Afghanistan.

Association Between Disabilities, Educational Attainment, Literacy, and Intimate Partner Violence: Findings from the Indian National Family Health Surveys

Intimate partner violence (IPV) is widespread across the Global South, including India, due to cultural and patriarchal norms that encourage and facilitate such behaviors. These include age at marriage, community- and individual-level encouragement of IPV, and limited access to education across the Global South, particularly for women. Despite this, little research has sought to disentangle the role that disabilities play in affecting women's risk of IPV in India. The current study analyzes a sample of currently married women (N = 114,901) from the nationally representative 2015-2016 and 2019-2021 National Family Health Surveys (NFHS) to assess whether a relationship exists between these dimensions, while controlling for well-known IPV correlates, with physical IPV and controlling behaviors. Logistic regression analyses revealed that persons with cognitive/intellectual disabilities as well as blind respondents were more likely to experience physical IPV. Blind respondents were also more likely to experience controlling behavior. Further, findings indicate that those with no or some education were more likely to experience physical IPV relative to those with higher education. Findings from the current study demonstrate the need for IPV reduction policies to ensure that adequate accommodations are available to facilitate help-seeking behaviors among persons with disabilities. Tailored prevention policies are also needed which consider both context- and location-specific factors associated with risk.

Long-acting reversible contraceptives utilization and its determinants among married Yemeni women of childbearing age who no longer want children

Some contraceptive methods, such as long-acting and permanent methods, are more effective than others in preventing conception and are key predictors of fertility in a community. This study aimed to determine which factors were linked to married women of childbearing age who no longer desired children using long-acting reversible contraceptives (LARCs) in Yemen. We used a population-based secondary dataset from Yemen's National Health and Demographic Survey (YNHDS), conducted in 2013. The study analyzed a weighted sample of 5149 currently married women aged 15 to 49 years who had no plans to have children. Logistic regression analyses were used to investigate the parameters linked to the present use of LARCs. The final model's specifications were evaluated using a goodness-of-fit test. An alpha threshold of 5% was used to determine statistical significance. Of the total sample, 45.3% (95% CI: 43.3-47.4) were using contraception. LARCs were used by 21.8% (95% CI: 19.6-24.1) of current contraceptive users, with the majority (63.8%) opting for short-acting reversible contraceptives (SARCs). In the adjusted analysis, maternal education, husbands' fertility intention, place of residence, governorate, and wealth groups were all linked to the usage of LARCs. According to the findings, women whose spouses sought more children, for example, were more likely to use LARCs than those who shared their partners' fertility intentions (AOR = 1.44; 95% CI: 1.07-1.94; P = .015). In this study, married women of reproductive age who had no intention of having children infrequently used contraception and long-acting methods. Improving women's education and socioeconomic status could contribute to increasing their use of LARCs.

Understanding the Link Between Reproductive Coercion and Covert Use of Contraception as a Safety Strategy for Women Experiencing Violence in Nairobi's Urban Informal Settlements

This mixed-methods study examined the relationship between reproductive coercion (RC) and covert contraceptive use among intimate partner violence survivors in Nairobi, Kenya. Quantitative analyses utilize baseline data from the myPlan Kenya trial (n = 321). Purposive in-depth interviews (IDIs) (n = 30) explored women's reproductive safety strategies. Multinomial analyses indicated increased covert use and decreased overt use compared to nonuse, for women experiencing RC; logistic models similarly report increased odds of covert use with RC experience. Qualitative data contextualize women's reasons for use and challenges faced. Integration of reproductive safety strategies into family planning and violence services can improve the safe use of contraception.

Perceptions of Partners' Fertility Preferences and Women's Covert Contraceptive Use in Eight sub-Saharan African Countries

Covert use of contraception is a common but underreported and understudied phenomenon where one partner uses contraception without the other's knowledge. We used Demographic and Health Survey couple data to examine the relationship between wives’ perceptions of husbands’ fertility preferences and type of contraceptive use (overt vs. covert) in Benin, Ethiopia, Kenya, Mali, Nigeria, Sierra Leone, Uganda, and Zambia using logistic regression. Wives who perceived that their husbands wanted more children than them had increased odds of using covertly, compared to those who perceived that husbands wanted the same number of children in all countries except Benin, and the strength of the relationships ranged from adjusted odds ratio (aOR) 2.89 (95 percent confidence interval (CI) 1.75–4.76) in Zambia to aOR 4.01 (95 percent CI 1.68–9.58) in Mali. Wives who reported not knowing their husbands’ fertility preferences had increased odds of using covertly compared to wives who perceived that their husbands wanted the same number of children in all countries except Zambia, ranging from aOR 2.02 (95 percent CI 1.11–3.69) in Ethiopia to aOR 3.82 (95 percent CI 2.29–6.37) in Kenya. Our findings indicate that efforts to increase partner engagement to align couple's fertility preferences may encourage overt use.

Covert use of reversible contraceptive methods and its association with husband's egalitarian gender attitude in India

Background

In a patriarchal society, women often keep their use of contraceptives secret in order to meet their reproductive goals and satisfy their reproductive preferences. Nevertheless, to our knowledge, women’s covert contraceptive use and its association with husband’s gender attitude have not been studied in the Indian settings. The present study estimates the extent of covert modern contraceptive use (CCU) among women and its linkage with husbands’ gender attitudes in India.

Methods

The study is based on fecund and monogamous couples using modern, reversible contraceptive methods. The numbers of such couples were 4,825 and 7,824 in the national family health surveys 2005–06 and 2015–16 respectively. The outcome variable in the study was CCU, while the independent variables were husband’s gender attitude, women’s education, freedom of mobility, freedom to spend money independently, surviving number of children, concordance regarding additional children, couple-level information such as age and educational gap between spouses, and some socioeconomic status (SES) variables. We used latent class analysis to measure the gender attitude and used bivariate descriptive analysis and multivariate binary logistic regression to assess the linkages between husband’s gender attitude and CCU.

Results

This study found that the prevalence of CCU increased from 15% in 2005–06 to 27% in 2015–16. In both the time periods, contraceptive pills were the most preferred covert method, followed by intrauterine device (IUD). The results of the multivariate logistic regression show that women with husbands of moderate and low egalitarian gender attitudes were, respectively, 50% and 40% more likely to hide their contraceptive use than those with husbands of a high gender attitude. Women’s education, wealth index, number of living children, and region of residence were also found to be significantly associated with CCU.

Conclusion

The study reveals that husband’s low egalitarian gender attitude can be a potential barrier between spouses, preventing them from opening up about their fertility preferences and contraceptive needs to each other. A couple-oriented approach to family planning is needed so that both members of a couple can satisfy their fertility desires and preferences eventually.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12882-x.

Women's perceptions and experiences of reproductive coercion and abuse: a qualitative evidence synthesis

BACKGROUND

Reproductive coercion and abuse is a major public health issue, with significant effects on the health and well-being of women. Reproductive coercion and abuse includes any form of behaviour that intentionally controls another person's reproductive choices. The aim of this qualitative evidence synthesis is to explore women's experiences of reproductive coercion and abuse globally, to broaden understanding of the different ways reproductive coercion and abuse is perpetrated, perceived and experienced across settings and socio-cultural contexts.

METHOD

We searched Medline, CINAHL and Embase for eligible studies from inception to 25th February 2021. Primary studies with a qualitative study design that focused on the experiences and perceptions of women who have encountered reproductive coercion and abuse were eligible for inclusion. Titles and abstracts, and full texts were screened by independent reviewers. We extracted data from included studies using a form designed for this synthesis and assessed methodological limitations using CASP. We used Thomas and Harden's thematic analysis approach to analyse and synthesise the evidence, and the GRADE-CERQual approach to assess confidence in review findings.

RESULTS

We included 33 studies from twelve countries in South Asia, the Asia Pacific, North America, South America, Africa and Europe. Most studies used in-depth interviews and focus group discussions to discuss women's experiences of reproductive coercion and abuse. Reproductive coercion and abuse manifested in a range of behaviours including control of pregnancy outcome, pregnancy pressure or contraceptive sabotage. There were a range of reasons cited for reproductive coercion and abuse, including control of women, rigid gender roles, social inequalities and family pressure. Women's different responses to reproductive coercion and abuse included using covert contraception and feelings of distress, anger and trauma. Across contexts, perpetration and experiences of reproductive coercion and abuse were influenced by different factors including son preferences and social exclusion.

CONCLUSIONS

We reflect on the importance of socio-cultural factors in understanding the phenomenon of reproductive coercion and abuse and how it affects women, as well as how the mechanisms of power and control at both individual and societal levels work to perpetuate the incidence of reproductive coercion and abuse against women.

Women's experiences on the use of Implanon as a contraceptive method in a selected primary healthcare facility in KwaZulu-Natal

Background

The South African department of health recently introduced subdermal Implanon contraceptive implant with the aim to reduce teenage pregnancy and maternal mortality. First used in all public healthcare facilities across the country since early 2014, this method of contraception has been described as highly effective. However, some women have reported unbearable side effects, forcing them to remove the contraceptive implant early before its expiry date. Negligible emphasis has been placed on staff training and development to equip the nurses with new protocol and policies on Implanon.

Objectives

The objective of this study was to explore experiences of women using Implanon as method of contraception at a selected primary healthcare facility in KwaZulu-Natal province of South Africa.

Methods

A qualitative, descriptive and exploratory study design was used. A purposive sampling technique was used and a sample of seven women aged between 15 and 50 years was selected for this study. Semi-structured interviews were used in the data collection process. The Tesch’s method for data coding and data analysis was utilised. Necessary ethical measures were taken to ensure that the study is trustworthy. The study was conducted at Community Health Centre, KwaZulu-Natal between June 2017 and December 2018.

Results

The findings showed that some participants were still willing to continue using this method of contraception regardless of the unwanted side effects. Major side effects reported were heavy menstrual bleeding, pain and discomfort, weight loss, insomnia and decreased sexual interest, which resulted in most participants stopping the use of Implanon.

Conclusion

Most of the participants’ experience unwanted side effects because of poor screening, counselling and support. There is a clear demand to develop a screening tool and facilitate training of healthcare workers when initiating the use of Implanon.

Help-Seeking Behaviors of Intimate Partner Violence Victims: A Cross-National Analysis in Developing Nations

There is a dearth of research on help-seeking behaviors of intimate partner violence (IPV) victims, especially within developing nations. The current study uses the nationally representative population-based Demographic and Health Surveys (DHS) of 31 nations to address this gap in the literature. Specifically, the study (a) assesses the extent to which IPV victims sought help in developing nations, (b) investigates from whom IPV victims sought help, and (c) evaluates individual and national factors that influence the likelihood of help seeking among IPV victims in developing nations. Given the hierarchical structure of the data, multilevel modeling techniques are used (individual level N = 65,530; national level N = 31). Descriptive findings revealed 34.88% of IPV victims engaged in help-seeking behaviors and the majority of victims who sought help reached out to family members (63.10%). Few IPV victims (3.24%) sought help from formal institutions. Results from the hierarchical generalized linear regression models indicated the severity of abuse, attitudes toward IPV, and indicators of empowerment all affected the likelihood of help seeking. National-level factors, including whether the nation had a law against IPV, were not significant. While providing formal services is important, policies designed to help IPV victims must recognize and address cultural barriers that may inhibit help-seeking behaviors. Because the majority of IPV victims sought help from informal support networks, it is important that individuals in these extended networks receive information about gendered norms and IPV so they can extend help and respond appropriately to family and friends.

Structured Spatial Modeling and Mapping of Domestic Violence Against Women of Reproductive Age in Rwanda

The main objective of this study was to assess the risk factors and spatial correlates of domestic violence against women of reproductive age in Rwanda. A structured spatial approach was used to account for the nonlinear nature of some covariates and the spatial variability on domestic violence. The nonlinear effect was modeled through second-order random walk, and the structured spatial effect was modeled through Gaussian Markov Random Fields specified as an intrinsic conditional autoregressive model. The data from the Rwanda Demographic and Health Survey 2014/2015 were used as an application. The findings of this study revealed that the risk factors of domestic violence against women are the wealth quintile of the household, the size of the household, the husband or partner's age, the husband or partner's level of education, ownership of the house, polygamy, the alcohol consumption status of the husband or partner, the woman's perception of wife-beating attitude, and the use of contraceptive methods. The study also highlighted the significant spatial variation of domestic violence against women at district level.

Associations of Power Relations, Wife-Beating Attitudes, and Controlling Behavior of Husband With Domestic Violence Against Women in India: Insights From the National Family Health Survey-4

This study assesses the relationship of power relations, attitudes toward wife-beating, and controlling behavior of husband with violence against women in India using the recent National Family Health Survey (NFHS-4). In India, about 31% of ever-married women experienced domestic violence committed by their partner during 2015-16. Women's decision-making power was associated with a decreased likelihood of spousal violence. However, the justification of wife-beating and controlling behavior of husband increased the risk of intimate partner violence. This study emphasizes the need for prioritizing girls' education, enhancing women's autonomy, prevention of child marriage, and promoting gender equality in society to address the problem of spousal violence.

Exploring the relationship between spousal violence during pregnancy and subsequent postpartum spacing contraception among first-time mothers in India

BACKGROUND

There is a growing body of research exploring how intimate partner violence affects contraceptive decision-making, recognizing that these decisions are reflective not only of access and acceptability, but also spousal power imbalances. Unfortunately, there is a dearth of knowledge regarding contraceptive choices following gender-based violence during pregnancy. There are an estimated 7·8 million in India affected by violence during pregnancy, and an ongoing, heavy reliance on female sterilization as the dominant form of contraception. This study examines the relationship between abuse during pregnancy and subsequent postpartum spacing contraception in India.

METHODS

This analysis used cross-sectional, nationally representative data from first-time mothers of children aged 6-48 months in India. Multinomial regression models assessed relationships between spousal physical violence during pregnancy and postpartum spacing contraception (none, female-controlled, male-controlled).

FINDINGS

Two percent of first-time mothers (2·4%) reported spousal physical violence while pregnant. Women who reported abuse during pregnancy were less likely to subsequently use male-controlled contraception than no contraception (adjusted relative risk ratio [aRRR]=0·3, 95% CI 0·1-0·8; p = 0·02) and more likely to use female-controlled vs. male-controlled spacing contraception (aRRR=7·5, 95% CI 2·1-25·4, p<0·01).

INTERPRETATION

Women who experience spousal abuse during pregnancy have different postpartum contraceptive use patterns. The unique needs of this population should be incorporated into antenatal and postpartum contraceptive counseling. Efforts to increase spacing contraception use in India must consider experiences of gender-based violence and coercion.

Associations of reproductive coercion and intimate partner violence with overt and covert family planning use among married adolescent girls in Niger

BACKGROUND

In Niger the prevalence of girl child marriage and low female control over family planning (FP) has resulted in the world's highest adolescent fertility. Male control of FP is associated with intimate partner violence (IPV) and reproductive coercion (RC). We assessed associations of IPV and RC with FP use among married adolescent girls (ages 13-19 years) in Dosso, Niger (N = 1072).

METHODS

Multivariable, cross-sectional regression models assessed associations between physical IPV, sexual IPV, and RC and any FP use, FP use with husband knowledge (overt use), and FP use without husband knowledge (covert use).

FINDINGS

One in four married adolescent girls using FP reported doing so without husband's knowledge. Unadjusted and adjusted models indicated that physical IPV and RC were associated with covert FP use (vs. no use and vs. overt use), but not with overt use vs. no use. Only physical IPV remained significantly associated with covert use in models including all three forms of violence (AOR: 1.94 vs. any use; AOR: 3.63 vs. overt use).

INTERPRETATION

Married adolescents experiencing physical IPV or RC were more likely that others to use FP without their husbands' knowledge. No form of GBV affected odds of FP use with husbands' knowledge. Current results suggest caution regarding promoting engagement of men in decisions to use FP in this context, as this may undermine the reproductive autonomy of girls and women who will choose to use FP without the knowledge of their male partners.

Associations between intimate partner violence and married women's condom and other contraceptive use in rural India

Background The existing literature on the intersection between women's reports of spousal intimate partner violence (IPV) and contraceptive use in South Asia is conflicted. Results vary based on method of contraception use and form of violence (physical or sexual), and few examine the relationship between IPV and various methods of modern spacing contraceptive (MSC) use. This study examines associations between IPV and MSC use among a sample of married, not-currently pregnant couples in rural Maharashtra, India (n=861).

METHODS

Multinomial logistic regression models assessed wives' physical and sexual IPV victimisation (for the past 6-months) in relation to the wives' past 3-month MSC use (categorised as condom use, other MSCs [oral pills, Intrauterine device (IUD)] and no MSCs).

RESULTS

In terms of violence, 9% (n=78) and 4% (n=34) of wives reported recent physical and sexual IPV victimisation, respectively. The majority (72%; n=621) did not use any MSC method in the past 3 months; 14% (n=119) reported recent condom use, and the same proportion reported other MSC use. Recent physical IPV was associated with increased likelihood of recent condom use (AOR: 2.46, 95% CI: 1.20, 5.04), and recent sexual IPV was associated with increased likelihood of recent use of other MSC (AOR: 3.27, 95% CI: 1.24, 8.56).

CONCLUSIONS

These findings reinforce the need for integration of counselling around IPV prevention and intervention programming into existing family planning services targeting married couples in rural Maharashtra, India.

Household decision-making and its association with intimate partner violence: Examining differences in men's and women's perceptions in Uganda

Introduction

A vast body of evidence identifies intimate partner violence (IPV) as a public health and human rights issue with detrimental health consequences. The exploration of household decision-making, as an indicator of women's empowerment, and its association with IPV has so far yielded mixed results, mostly due to measurement issues. Given the sizeable investment in women's empowerment initiatives, and their potential to improve women's health, it is important to elucidate the relationship between household decision-making and IPV.

Methods

We conducted a secondary analysis of the 2011 Uganda Demographic and Health Survey (DHS) data to explore the relationship between women's household decision-making and experience of physical IPV. The dependent variable in our analysis was past year physical violence and it was constructed using men's reported perpetration of partner violence (men's questionnaire). Six independent variables were included - one each for men and women's perspectives on who usually makes decisions about the following domains: 1) how money earned is spent, 2) health care, and 3) large household purchases. We ran a probit model, controlling for variables featured in our theoretical framework.

Results

The association between household decision-making and women's likelihood of experiencing IPV depended on the decision-making domain and on who reported it. Women's reporting on decision-making did not predict their experience of IPV, whereas men's reporting on two decision-making domains (large household purchases and expenditure of husband's earnings) predicted likelihood of women experiencing IPV. Joint decision-making and women's decisions alone in both of these domains were associated with a lower probability of IPV compared to husband's making the decisions alone, where husband's reported decision-making.

Conclusion

This study demonstrates that men's views on coupled dynamics should be included in program design and evaluation to provide a more holistic picture of the ecological framework and risk and protective factors of IPV.

Food insecurity and intimate partner violence among married women in Nepal

Background

Intimate Partner Violence (IPV) is an important public health concern globally, including in Nepal. Food insecurity (being without reliable access to a sufficient quantity of affordable, nutritious food) has been associated with IPV, but no known studies have explored this relationship in South Asia, or Nepal specifically. Women’s level of empowerment is an important factor to consider when understanding the relationship between food insecurity and IPV.

Methods

Using data from the 2011 Nepal Demographic and Health Survey, we explore the relationship between different levels of food insecurity (none, mild, moderate, severe) and three types of IPV: physical, sexual and emotional. In a second set of models we adjust for indicators of women’s empowerment. We use multi-variable logistic regression to test for an association between these factors, adjusting for individual and household level demographic variables.

Findings

About half of married women in our sample experience food insecurity and approximately 10% of women experienced each of the three different types of IPV in the past 12 months: emotional, sexual and physical. Food insecurity is significantly associated with increased odds of experiencing emotional (odds ratio OR = 1.75 95% confidence interval CI = 1.06-2.77 for severe food insecurity) or physical (OR = 2.48, 95% CI = 1.52-4.04 for severe food insecurity) IPV, but not sexual IPV, after adjusting for individual and household level demographic variables. After adjusting for empowerment related factors, this relationship still holds, although it is somewhat attenuated. Women’s level of household decision-making power is significantly associated with higher odds of emotional, sexual and physical IPV, and whether she lives with her in-laws is protective against emotional IPV.

Conclusions

Among married women in Nepal, being food insecure is associated with higher odds of some types of IPV, specifically emotional and physical IPV. Accounting for women’s level of empowerment explains some of the relationship between food insecurity and IPV. It is essential that interventions to prevent IPV address household stressors such as food insecurity among married, Nepalese women, perhaps through cross-sectoral approaches. Such structural interventions are likely to reduce IPV for married women across South Asia who live in a similar levels of gender discrimination and food insecurity.

Spousal discordance on reports of contraceptive communication, contraceptive use, and ideal family size in rural India: a cross-sectional study

Background

Persistent low rates of spacing contraceptive use among young wives in rural India have been implicated in ongoing negative maternal, infant and child health outcomes throughout the country. Gender inequity has been found to consistently predict low rates of contraception. An issue around contraceptive reporting however is that when reporting on contraceptive use, spouses in rural India often provide discordant reports. While discordant reports of contraceptive use potentially impede promotion of contraceptive use, little research has investigated the predictors of discordant reporting.

Methods

Using data we collected from 867 couples in rural Maharashtra India as part of a men-focused family planning randomized controlled trial. We categorized couples on discordance of men’s and women’s reports of current contraceptive use, communication with their spouse regarding contraception, and ideal family size, and assessed the levels of discordance for each category. We then ran multinomial regression analyses to determine predictors of discordance categories with a focus on women’s empowerment (household and fertility decision-making, women’s education, and women’s knowledge of contraception).

Results

When individuals reported communicating about contraception and their spouses did not, those individuals were also more likely to report using contraception when their spouses did not. Women’s empowerment was higher in couples in which both couples reported contraception communication or use or in couples in which only wives reported contraception communication or use. There were couple-level characteristics that predicted husbands reporting either contraception use or contraception communication when their wives did not: husband’s education, husband’s familiarity with contraception, and number of children.

Conclusions

Overall there were clear patterns to differential reporting. Associations with women’s empowerment and contraceptive communication and use suggest a strategy of women’s empowerment to improve reproductive health. Discordant women-only reports suggest that even when programs interact with empowered women, the inclusion of husbands is essential. Husband-only discordant reports highlight the characteristics of men who may be more receptive to family planning messages than are their wives. Family planning programs may be most effective when working with couples rather than just with women, and should focus on improving communication between couples, and supporting them in achieving concordance in their reproductive preferences.

Trial registration

Clinical Trials Number: NCT01593943, registered May 4, 2012 at clinicaltrials.gov.

Measuring Women's Covert Use of Modern Contraception in Cross-Sectional Surveys

A proportion of women in couples use contraception without their partners' knowledge. There are two principal ways to measure this covert use in cross-sectional surveys like the Demographic and Health Surveys (DHS). First is a direct question, "Does your husband/partner know that you are using a method of family planning?" Second is an indirect method: the reports of both partners to the question on contraceptive use are matched, and if the woman reports a modern contraceptive method and the male partner reports nonuse, her use is considered covert. For 21 DHS surveys for which both estimates could be made, there are large discrepancies between the two. We found that a proxy variable-responses to the question, "Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision, or did you both decide together?"-has high sensitivity and specificity for classifying those in the open category for both methods and those in the covert category for both methods. Recommendations are that the direct question be reinstated in the DHS and that the indirect method not be used by itself but in conjunction with the decision-making variable.

An assessment of the association between asset ownership and intimate partner violence in Pakistan

OBJECTIVE

This study assessed the association between women's reports of asset ownership (home and land) and experience of three types of intimate partner violence (IPV): physical violence, emotional violence, and husbands' controlling behaviors.

STUDY DESIGN

Population-based secondary analysis.

METHOD

This cross-sectional study used data from a sub-sample of 658 women from the nationally representative Pakistan Demographic and Health Survey 2012-13. Logistic regression analyses were used to estimate the association between asset ownership and IPV.

RESULTS

Results from logistic regressions indicated that when women owned assets their husbands were 2.3 times more likely to use controlling tactics (P < 0.001) which was mitigated only when women had a say in household decisions. Physical or emotional violence, however, was not significantly associated with women's asset ownership.

CONCLUSION

The study findings highlight the importance of culture and context in policy implementation.

Like Mother(-in-Law) Like Daughter? Influence of the Older Generation's Fertility Behaviours on Women's Desired Family Size in Bihar, India

This paper investigates the associations between preferred family size of women in rural Bihar, India and the fertility behaviours of their mother and mother-in-law. Scheduled interviews of 440 pairs of married women aged 16–34 years and their mothers-in-law were conducted in 2011. Preferred family size is first measured by Coombs scale, allowing us to capture latent desired number of children and then categorized into three categories (low, medium and high). Women’s preferred family size is estimated using ordered logistic regression. We find that the family size preferences are not associated with mother’s fertility but with mother’s education. Mother-in-law’s desired number of grandchildren is positively associated with women’s preferred family size. However, when the woman has higher education than her mother-in-law, her preferred family size gets smaller, suggesting that education provides women with greater autonomy in their decision-making on childbearing.

Domestic Violence and Abortion Among Rural Women in Four Indian States

The prevalence of domestic violence and abortion in India is high, yet little is known about the relationship between these experiences. Data from two linked data sets, India's 1998-1999 National Family Health Survey (NFHS-2) and a follow-up survey in 2002-2003, were analyzed. The analysis examines how the experience of physical violence affects the subsequent uptake of abortion, and how the experience of abortion affects subsequent experience of physical, sexual, and verbal violence. Women who experienced physical violence have significantly higher odds of reporting a subsequent induced abortion, whereas women who had an induced abortion have significantly higher odds of reporting subsequent sexual and verbal violence. There was no significant relationship between domestic violence and spontaneous abortion.

Domestic violence against women in India: A systematic review of a decade of quantitative studies

Domestic violence (DV) is prevalent among women in India and has been associated with poor mental and physical health. We performed a systematic review of 137 quantitative studies published in the prior decade that directly evaluated the DV experiences of Indian women to summarise the breadth of recent work and identify gaps in the literature. Among studies surveying at least two forms of abuse, a median 41% of women reported experiencing DV during their lifetime and 30% in the past year. We noted substantial inter-study variance in DV prevalence estimates, attributable in part to different study populations and settings, but also to a lack of standardisation, validation, and cultural adaptation of DV survey instruments. There was paucity of studies evaluating the DV experiences of women over age 50, residing in live-in relationships, same-sex relationships, tribal villages, and of women from the northern regions of India. Additionally, our review highlighted a gap in research evaluating the impact of DV on physical health. We conclude with a research agenda calling for additional qualitative and longitudinal quantitative studies to explore the DV correlates proposed by this quantitative literature to inform the development of a culturally tailored DV scale and prevention strategies.

Circumstances leading to intimate partner violence against women married as children: a qualitative study in Urban Slums of Lahore, Pakistan

BACKGROUND

Child marriage (<18 years) is prevalent in Pakistan which is associated with negative health outcomes including intimate partner violence (IPV). Our aim is to describe the types and circumstances of IPV against women who were married as children in urban slums of Lahore, Pakistan.

METHODS

Women of reproductive age (15-49 years) who were married prior to 18 years, for at least 5 years were recruited from most populous slum areas of Lahore, Pakistan. Themes for the interview guide were developed using published literature and everyday observations of the researchers. Interviews were conducted by trained interviewers in Urdu language and were translated into English. The interviews were tape-recorded, transcribed, analyzed and categorized into themes.

RESULTS

All 19 participants were married between 11 and 17 years. Most respondents were uneducated, poor and were working as housemaids. Majority of participants experienced verbal abuse, and threatened, attempted and completed physical violence by their husbands. A sizeable number of women reported unwanted sexual encounters by their husbands. Family affairs particularly issues with in-laws, poor house management, lack of proper care of children, bringing insufficient dowry, financial problems, an act against the will of husband, and inability to give birth to a male child were some of the reasons narrated by the participants which led to IPV against women.

CONCLUSIONS

Women married as children are vulnerable to IPV. Concerted efforts are needed from all sectors of society including academia, public health experts, policy makers and civil society to end the child marriage practice in Pakistan.

Gender inequality and the use of maternal healthcare services in rural sub-Saharan Africa

In this study, we measure gender inequality both at individual level by women׳s household decision-making and at contextual level by permissive gender norms associated with tolerance of violence against women and assess their impact on maternal healthcare services utilisation in rural Africa. We apply multilevel structural equation modelling to Demographic and Health Survey (DHS) data from Ghana, Kenya, Tanzania and Uganda to gain better measure and effect of the gender norms construct. The results show that women in Ghana and Uganda, who live in areas where gender norms are relatively tolerant of violence against women, are less likely to use skilled birth attendants and timely antenatal care. In Tanzania, women who live in this type of environment are less likely to attend four or more antenatal visits. In contrast, the effects of a woman׳s decision-making authority on maternal health service use are less pronounced in the same countries.

Gender attitudes and fertility aspirations among young men in five high fertility East African countries

The relationship between women's attitudes toward gender equality and their fertility aspirations has been researched extensively, but few studies have explored the same associations among men. Using recent Demographic and Health Survey data from five high fertility East African countries, we examine the association between young men's gender attitudes and their ideal family size. Whereas several DHS gender attitude responses were associated with fertility aspirations in select countries, men's greater tolerance of wife beating was consistently associated with higher fertility aspirations across all countries, independent of education, income, or religion. Our findings highlight the overlapping values of male authority within marriage and aspirations for large families among young adult males in East Africa. Total lifetime fertility in East Africa remains among the highest worldwide: thus, governments in the region seeking to reduce fertility may need to explicitly scrutinize and address the reproduction of prevailing masculine values.

Spousal violence against women and its association with women's mental health in Pakistan

In Pakistan, the issue of spousal violence is under-researched and still not considered a public health problem. To assess the association of spousal violence with women's mental health, a hospital-based cross-sectional survey was conducted through a structured interview schedule with 373 randomly selected ever-married women of reproductive age in eight randomly selected hospitals in the cities of Lahore and Sialkot, Pakistan. After controlling for sociodemographic variables, women's experiences of past and current psychological, physical, and sexual violence remained significantly associated with women's poor mental health. The situation warrants urgent action to mitigate the violence-induced damages done to women's mental health.

Inequity in India: the case of maternal and reproductive health

Background

Millennium Development Goal (MDG) 5 is focused on reducing maternal mortality and achieving universal access to reproductive health care. India has made extensive efforts to achieve MDG 5 and in some regions much progress has been achieved. Progress has been uneven and inequitable however, and many women still lack access to maternal and reproductive health care.

Objective

In this review, a framework developed by the Commission on Social Determinants of Health (CSDH) is used to categorize and explain determinants of inequity in maternal and reproductive health in India.

Design

A review of peer-reviewed, published literature was conducted using the electronic databases PubMed and Popline. The search was performed using a carefully developed list of search terms designed to capture published papers from India on: 1) maternal and reproductive health, and 2) equity, including disadvantaged populations. A matrix was developed to sort the relevant information, which was extracted and categorized based on the CSDH framework. In this way, the main sources of inequity in maternal and reproductive health in India and their inter-relationships were determined.

Results

Five main structural determinants emerged from the analysis as important in understanding equity in India: economic status, gender, education, social status (registered caste or tribe), and age (adolescents). These five determinants were found to be closely interrelated, a feature which was reflected in the literature.

Conclusion

In India, economic status, gender, and social status are all closely interrelated when influencing use of and access to maternal and reproductive health care. Appropriate attention should be given to how these social determinants interplay in generating and sustaining inequity when designing policies and programs to reach equitable progress toward improved maternal and reproductive health.

Physical domestic violence and subsequent contraceptive adoption among women in rural India

This study examines the relationship between male to female physical domestic violence and contraceptive adoption among women in four economically and culturally distinct areas of India. Data from India's 1998-1999 National Family Health Survey-2 and a follow-up survey in 2002-2003 for which the same women in four states were reinterviewed are analyzed. The focus of the analysis is on how baseline exposure to physical domestic violence is associated with the intersurvey adoption of contraception. Women who experience physical violence from their husbands are significantly less likely to adopt contraception in the intersurvey period, although this relationship varies by State. This study builds upon previous work by using an indicator of physical domestic violence exposure that is measured before contraceptive adoption, thus allowing the identification of how exposure to violence shapes the adoption of contraception. The results demonstrate that for women living in Bihar and Jharkhand there is a clear negative relationship between physical domestic violence and a woman's adoption of contraception; this relationship was not found for women in Maharashtra and Tamil Nadu. The results point to the need to include domestic violence screening and referral services into family planning services.

Intimate partner violence and its association with women's reproductive health in Pakistan

OBJECTIVE

To determine the prevalence of intimate partner violence in Pakistan and its association with reproductive health outcomes.

METHODS

A cross-sectional survey was conducted in 8 hospitals in Lahore and Sialkot between October 2008 and January 2009. Information from randomly selected ever-married women of reproductive age was collected via a structured interview. Psychologic, physical, and sexual violence was categorized as "no" or "severe" violence. Associations between reproductive health outcomes and violence were assessed by multivariate logistic regression.

RESULTS

Among 373 women interviewed, 75.9% reported severe psychologic, 34.6% reported severe sexual, and 31.9% reported severe physical violence at least once in marital life. Women who experienced severe physical violence were more likely to have their husband's noncooperation in using contraceptives (adjusted odds ratio [AOR], 3.31; 95% confidence interval [CI], 1.93-5.68), poor prenatal care (AOR, 2.11; 95% CI, 1.23-3.69), unplanned pregnancies (AOR, 2.29; 95% CI, 1.39-3.76), and poor self-reported reproductive health (AOR, 2.95; 95% CI, 1.71-4.91) as compared with non-abused women. Similar associations existed for other types of violence.

CONCLUSION

The results highlight the magnitude of violence and its association with reproductive health of women. Urgent action is needed to mitigate the violence and its consequential damage to health.

'Good parents' strive to raise 'innocent daughters'

This paper analyses the views of parents in a slum setting in Pakistan regarding the marriage preparedness of their daughters. Twenty-five parents participated in four gender-specific focus group discussions. Latent content analysis was used to explore parents' views and experiences with regard to their daughters' marriage and how they prepared them for it. The main theme identified was that 'good parents' strive to raise 'innocent daughters'. Three sub-themes contributing to the main theme were: a daughter-a responsibility and a burden; social and sexual innocence; and parents' roles in the preparation for marriage. The theme and the sub-themes together illustrate how parents saw themselves as responsible for raising 'innocent daughters' and arranging good marriages. Parents realised, though, that bringing up daughters for marriage required not only training in submissivness, but also building confidence and knowledge during their childhood.

Narrative possibilities: poor women of color and the complexities of intimate partner violence

This article shows how a narrative methodological approach is particularly suited to examining the dynamics of intimate partner violence, especially among poor women of color in South Africa. We show how a narrative approach allowed women to represent their experiences of violence according to their own frames of meaning, examining the complexities of abuse as it is informed by sociocultural factors of gender, poverty, and deprivation. In particular, we show how a narrative approach departs from other qualitative work by enabling women to construct particular forms of identity, thereby giving them agency in authoring their own stories of violence.

Security lies in obedience--voices of young women of a slum in Pakistan

BACKGROUND

Existing literature shows that young people, especially women, have poor knowledge about sexuality and reproductive health. Many of the difficulties young women experience are related to beliefs and expectations in society making them more vulnerable to reproductive ill health. The objective of this study was to explore how young women living in a slum in Islamabad are prepared for marriage and how they understand and perceive their transition to marriage and the start of sexual and childbearing activity.

METHODS

Twenty qualitative interviews and three focus group discussions were conducted with young women residing in a slum of Islamabad. Content analysis was used to explore how the participants represented and explained their situation and how decisions about their marriage were made.

RESULTS

The main theme identified was security lies in obedience. The two sub-themes contributing to the main theme were socialization into submissiveness and transition into adulthood in silence. The theme and the sub-themes illustrate the situation of young women in a poor setting in Pakistan.

CONCLUSION

The study demonstrates how, in a culture of silence around sexuality, young women's socialization into submissiveness lays the foundation for the lack of control over the future reproductive health that they experience.

Responses to intimate partner violence in Kakuma refugee camp: refugee interactions with agency systems

Intimate partner violence (IPV) has been recognised as a significant problem amongst forcibly displaced communities, and great progress has been made by the United Nations High Commission for Refugees (UNHCR) in responding to IPV and other forms of sexual and gender based violence. However, they have not always effectively engaged refugee communities in these activities, with potentially negative consequences for the health and protection of women. This study was conducted in Kakuma refugee camp, north-west Kenya. Eighteen focus group discussions were conducted with 157 refugees from various nationalities, including Sudanese, Somali, Ethiopian, and Congolese. They focused on the nature and consequences of IPV in Kakuma. The aim of this paper is to explore how refugees in Kakuma talk about the ways that IPV is dealt with, focusing particularly on the ways that community responses are said to interact with formal response systems established by UNHCR and its implementing partners. Refugees talked about using a 'hierarchy of responses' to IPV, with only particularly serious or intransigent cases reaching UNHCR or its implementing agencies. Some male refugees described being mistrustful of agency responses, because agencies were believed to favour women and to prioritise protecting the woman at all costs, even if that means separating her from the family. Whilst community responses to IPV might often be appropriate and helpful, the findings of the current study suggest that in Kakuma they do not necessarily result in the protection of women. Yet women in Kakuma are reported to be reluctant to report their cases to UNHCR and its implementing agencies. A more effective protection response from UNHCR might involve closer co-operation with individuals and structures within the refugee communities to develop a co-ordinated response to IPV.

Intimate partner violence and contraception use among women in Sub-Saharan Africa

OBJECTIVE

To determine the association between contraceptive use and intimate partner violence (IPV) in Sub-Saharan African women.

METHOD

The data analyzed were from national Demographic Health Surveys conducted between 2003 and 2006 in 6 Sub-Saharan African countries: Cameroon, Kenya, Malawi, Rwanda, Uganda, and Zimbabwe. Women of childbearing age completed surveys regarding the use of contraception and about their experience of physical, emotional, and sexual violence inflicted by their partners. Analyses were conducted using logistic regression.

RESULTS

Of the 24311 women who responded to the violence modules, 39.8% reported that they had experienced IPV. Women who had experienced IPV were significantly more likely to report that they had used contraception compared with women who had not experienced IPV (odds ratio 1.30; 95% confidence interval, 1.22-1.38).

CONCLUSION

Intimate partner violence appears to be associated with increased contraception use in the African setting. Among women who have experienced IPV, modern contraception is used more commonly than traditional and folkloric contraceptive methods.

Women's satisfaction with delivery care in Nairobi's informal settlements

OBJECTIVE

To quantify women's satisfaction with delivery care in informal settlements of Nairobi, Kenya, and to determine characteristics of women and delivery care associated with satisfaction.

DESIGN

Household survey data analysis of 1266 women who delivered in health facilities in 2004 or 2005.

SETTING

Two densely populated informal settlements 7 and 12 km from Nairobi's center, where residents work primarily in the nearby industrial area or in the informal sector. Outcome Satisfaction was assessed by whether women would recommend the delivery care facility and deliver there again.

RESULTS

Over half (56%) of women would both recommend and deliver again in the same facility. In multivariate analysis, women's satisfaction with delivery care was associated with greater provider empathy (OR = 3.68, 95% CI 2.27, 5.97). Women's satisfaction with delivery care was also associated with the pregnancy having been wanted (OR = 2.75, 95% CI 1.82, 4.14) or mistimed vs. unwanted. Women delivering at private facilities in the settlement near the industrial area were more satisfied than women delivering at private facilities in the more distant and marginalized settlement (OR = 2.12, 95% CI 1.45, 3.09). The association of women's satisfaction and provider empathy was stronger among women who experienced complications compared to those who did not.

CONCLUSION

Health providers should be sensitized to the finding that unintended pregnancy is associated with lower satisfaction with delivery care. Maternal health programmes should focus on increasing provider empathy, especially for women who experience complications, in both private and government health facilities.