Intimate Partner Violence around the Time of Pregnancy: A Public Health Challenge

Abstract

Intimate partner violence (IPV) around the time of pregnancy is known to have multiple detrimental consequences for the health and welfare of the mother, the developing fetus and the newborn infant. While results from past research suggest much continuity of IPV, it is unclear whether pregnancy interrupts or augments these patterns. Furthermore, the influence of pregnancy may depend on the type of IPV women experience. Little is known about how physical, sexual, and psychological IPV changes and overlaps throughout a woman’s transition to parenthood. Given the potentially profound effects that IPV during pregnancy can have on the physical and mental wellbeing of women and their children, it is important to understand the impact of IPV on pregnant women’s health-seeking behaviour in low and middle-income countries including Bangladesh. It is also unclear how the experience of IPV before, during, and after pregnancy affects women’s psychological health during the postpartum period. Additionally, IPV during pregnancy may compromise women’s exclusive breastfeeding (EBF) efforts, which can further compromise the health of their newborn. Understanding the patterns, correlates and consequences of IPV around the time of pregnancy has important theoretical and clinical implications. The present study, therefore, examines the prevalence, co-occurring nature, changing patterns, potential correlates for; and the consequences of physical, sexual, and psychological IPV around the time of pregnancy amongst a sample of women in Bangladesh. Cross-sectional survey data were collected between October 2015 and January 2016 in the Chandpur district of Bangladesh from 426 new mothers, aged 15–49 years, who had at least one child six months of age or younger. Postpartum mothers who visited vaccination centres to receive their children’s vaccinations constitute the sampling frame. IPV was assessed with a validated set of survey items. Multivariate logistic regression models were used to estimate the association between IPV and the outcome variables, adjusted for socio-demographic, obstetric and reproductive, and psycho-socio-cultural confounding factors. The results indicate a notable continuity in IPV victimisation before, during, and after pregnancy. Physical IPV is the only type to exhibit a significant reduction during pregnancy and post-partum, compared to before pregnancy, but it commonly overlaps with psychological IPV, which shows little change throughout this period. The prevalence of physical IPV before, during, and after pregnancy was 52.8%, 35.2%, and 32.2%, respectively. The comparative figures for psychological IPV were 67.4%, 65%, and 60.8%, and for sexual IPV were 21.1%, 18.5%, and 15.5%, respectively. Physical violence appears to diminish slightly during and after pregnancy. At the same time, pregnancy and childbirth offer little protection against IPV for women in relationships characterized by psychological or sexual victimisation, both of which commonly overlap with physical IPV. Furthermore, physical and/or psychological IPV prior to pregnancy are important risk markers for continued exposure during pregnancy and beyond. Women who report limited social support and have controlling husbands are at significantly increased risk for all three types of IPV during pregnancy. Women who cling to traditional gender roles and those with low self-esteem exhibit increased risk for physical and psychological IPV during pregnancy. Psychological IPV during pregnancy is also correlated with low decision-making autonomy and childhood exposure to violence. Women whose husbands demand a dowry at marriage are at increased risk of sexual IPV during pregnancy. Almost 70% of the women surveyed reported patterns consistent with delayed entry into prenatal care. Accounting for the influence of other covariates, women who experienced physical IPV during pregnancy were 2.61 times more likely (95% CI [1.33–5.09]) to have delayed entry into prenatal care than their counterparts who did not report physical IPV. Neither sexual nor psychological IPV victimisation during pregnancy was linked with late entry into prenatal care. Both gender role attitudes and levels of autonomy mediate the effect of IPV on prenatal care. The results suggest that the high rates of IPV in Bangladesh have effects that can compromise women’s health-seeking behaviour during pregnancy, putting them and their developing fetus at risk. Approximately 35.2% of this particular group of women experienced postpartum depression (PPD) within the first six months following childbirth. The odds of PPD, controlling for confounders, were significantly greater among women who reported exposure to physical (AOR: 1.79, 95% CI [1.25–3.43]), sexual (AOR: 2.25, 95% CI [1.14–4.45]) or psychological (AOR: 6.92, 95% CI [1.71–28.04]) IPV during pregnancy as opposed to those who did not. However, both before and after pregnancy, only physical IPV evidences a direct effect on PPD. The findings confirm that exposure to IPV significantly increases the odds of PPD. The association is particularly strong for physical IPV during all periods and psychological IPV during pregnancy. While the initiation rate of breastfeeding was 99.3%, at the time of the woman’s interview the overall EBF rate had fallen to 43.7%. Based on the adjusted model, women who experienced physical IPV (AOR: 0.18, 95% CI [0.08–0.42]) after childbirth, women who reported childhood sexual abuse (AOR: 0.33, 95% CI [0.14–0.80]) and PPD (AOR: 0.22, 95% CI [0.10–0.45]) were significantly less likely to exclusively breastfeed their infants than those who had not reported these experiences. Moreover, women with an intended pregnancy and high social support exhibited a higher likelihood of EBF. The results reinforce the need to conduct routine screening during pregnancy to identify women with a history of IPV and to be able to offer help and support. Healthcare professionals involved in obstetrics and midwifery need to be aware of the risk factors of IPV during pregnancy, to be able to identify women who may be at risk for delayed entry into prenatal care, experiencing postpartum depression and early termination of exclusive breastfeeding, and to be able to offer them necessary support.