Intimate partner violence during pregnancy among married women in Putalibajar municipality, Nepal

Introduction Intimate partner violence during pregnancy (IPVDP) is increasingly being recognized as a significant problem in the developing world due to its adverse health consequences on both pregnant women and children. The objective of the study is to measure the magnitude of intimate partner violence during pregnancy and the factors associated with IPVDP. Methods A community-based cross-sectional study was conducted among 263 married women in their extended postpartum period between October 2019 and March 2020 in Putalibajar municipality, Nepal. A face-to-face interview was conducted and data were collected using an interview schedule. A Chi-square test and logistic regression analysis were performed to examine the association between IPVDP and the independent variables. Results Among the 263 women interviewed, 30% experienced IPV during pregnancy, the most common type of violence was controlling behavior (20.2%) followed by emotional (18.6%), sexual (10.6%), economic (6.1%), and physical violence (5.3%). It was observed that IPV was more likely to occur among women whose husbands consumed alcohol (AOR = 3.171; CI 95%: 1.588–9.167), women whose husbands consumed tobacco (AOR =3.815; CI 95%: 2.157–7.265), women who sometimes received family support during pregnancy (AOR =2.948; CI 95%: 1.115–7.793) and women who did not decide on marriage timing (AOR =2.777; CI 95%: 1.331–5.792). Conclusion Three out of ten pregnant women experienced IPVDP. To prevent violence, and ensure women’s empowerment, formulating strict laws and discouraging the element of a violent milieu is important.


Introduction
Intimate partner violence (IPV) is defined as any act of physical, sexual, or psychological controlling actions or economic violence that takes place between intimate partners. It is regarded as global public health and human rights issue (García-Moreno et al., 2005). Globally, 30% of women experience violence by their intimate partner (García-Moreno et al., 2013). In recent years, intimate partner violence during pregnancy (IPVDP) is increasingly being recognized as a significant problem in the world due to its prevalence and its adverse health consequences on both pregnant women and children. The World Health Organization (WHO) estimated that, globally, the proportion of ever-pregnant women who reported violence during pregnancy varied from 1 to 28%. Physical violence exceeded 5% in 11 out of 15 settings where one-half of the women reported being punched or kicked in the abdomen and the majority (90%) of abuse was perpetrated by the biological father of the child she was carrying (García-Moreno et al., 2005).
Women experiencing violence during pregnancy are less likely to receive prenatal care and may experience adverse health outcomes such as poor nutrition, miscarriage, premature labor, trauma, placenta abruption, low birth weight (LBW), stillbirth, UTI, Chronic Pelvic infection, depression, and maternal death (García-Moreno et al., 2005;Nejatizade et al., 2017;Regmi et al., 2017). Nepal is a diverse ecological, ethnic, cultural, and multi-language society but is predominantly a Hindu country where it has its own cultural practices, norms, and values regarding men and women. In the context of Nepal, the key structural factors that make women vulnerable to IPV are economic dependency on men, cultural obligations, early marriage, giving birth to a girl, dowry practices, and lower social position which constructs and reinforces male dominance in society (Office of the Prime Minister and Council of Ministers, 2012; Deuba et al., 2016;Gurung and Acharya, 2016).
According to the Nepal Demographic Health Survey (NDHS) 2016, 26% of ever-married women have ever experienced physical, sexual, or emotional violence at the hands of their husbands. Of the 6% of women who have ever been pregnant and experienced physical violence during pregnancy, the majority of them experienced violence that was perpetrated by their current husbands (Ministry of Health Nepal, 2016). Studies conducted in Nepal showed a significant prevalence of IPVDP, 28.9% in Dhanusha and 53.2% in Kathmandu (Regmi et al., 2017;Singh et al., 2018). The aim of the study was to identify the magnitude of IPVDP and the factors associated with IPVDP.

Methodology Study design and population
A community-based cross-sectional analytical study was carried out among 263 married women aged 15 to 49 years who had at least one child aged 12 months and younger in Putalibajar municipality, Gandaki Province, Nepal from October 2019 to March 2020. The sample size was calculated by using the finite population formula: A sample size of 263 was determined based on a 28.9% prevalence of IPVDP from a previous study conducted in Dhanusha, Nepal, with a 10% non-response rate and an estimated population of children aged 0-11 months in 2075/76 (2018/2019) of Putalibajar municipality (N) of 954 (Singh et al., 2018). Married women aged 15 to 49 years who had at least one child aged 12 months or younger were eligible for the study but mothers who were temporary residents, who refused to participate, who had no contact with their husband during the period of pregnancy, who could not answer, and who did not understand the Nepali language were excluded. A multi-stage random sampling technique was followed where 4 out of 14 wards were selected using a simple random technique; participants from each selected ward were determined proportionately based on the sample population. Finally, a systematic random sampling technique was carried out to select individual study participants where the sampling interval (K) was determined by dividing the total population size by the sample size.

Data collection and quality control
A face-to-face interview was carried out using an interview schedule to gather the information. To ensure the validity of the study, a tool was developed by using a standard questionnaire on IPVDP from the instrument of the WHO multi-country study questionnaire (García-Moreno et al., 2005). The Cronbach's alpha values for the physical and psychological IPV scales of the WHO multi-country study questionnaire were 0.78 and 0.75, respectively, in a study conducted in Bangladesh (Islam et al., 2017). Reliability was ensured by pretesting the tool among 10% of the estimated sample size. The tool was developed in both English and Nepali language.

Variables
The interview schedule included questions about sociodemographic characteristics such as family type, ethnicity, religion, the main occupation of the family, the woman's age, education, and involvement in an income-generating activity. The participants also provided information about their partner's characteristics such as age, education, involvement in an income-generating activity, substance use, gambling, presence of polygamy, and partner's preference for the specific sex of their child. Obstetric and reproductive characteristics such as age at marriage, type of marriage, the decision on marriage timing, duration of the marriage, gravida, previous history of miscarriage or induced abortion, number of living children, pregnancy intention, family support, and timing of 1 st antenatal care (ANC) visit.
The dependent variable (IPVDP) was measured through a structured questionnaire regarding physical, sexual, emotional, and economic violence and controlling behavior from the instrument of the WHO multi-country study (García-Moreno et al., 2005). Participants answered yes or no whether they have experienced each of five forms of IPV.

Data analysis
Data entry was done using EPI-DATA and data analysis was done using SPSS. Descriptive statistics were used to describe the study population, which included means, ranges, frequencies, and percentages. The first step in the analysis was to find out the association between IPVDP and independent variables using the chi-square test. Variables that were significant in the chi-square test with a value of p < 0.05 were further analyzed by using bivariate and multivariate logistic regression to assess the strength of the association.

Ethical consideration
The study was given ethical approval by the Nepal Health Research Council (NHRC

Association between variables and IPVDP
Association between socio-demographic characteristics and IPVDP Intimate partner violence during pregnancy was significantly associated with family size (p < 0.01), ethnicity (p < 0.01), the main occupation of the family (p < 0.05), and women's education (p < 0.05; Table 2).

Association between the participants' husband's characteristics and IPVDP
IPVDP was strongly associated with the husband's alcohol consumption, frequency of alcohol consumption, and the husband's tobacco consumption (p < 0.001). Similarly, family support during pregnancy and the husband's involvement in gambling were also associated with IPVDP (p < 0.01; Table 3).

Association between obstetric and reproductive characteristics and IPVDP
IPVDP was significantly associated with decisions about marriage timing by the participants (p < 0.01) and family support during pregnancy (p < 0.001; Table 4).

Bivariate and multivariate logistic regression analysis between IPVDP and selected variables
In multivariate logistic regression analysis, after adjusting for potential confounding factors, IPV was significantly associated with  (Table 5).

Discussion
The prevalence of IPVDP in this study was 30% among the 263 participants, which is consistent with another study from Dhanusha, Nepal, showing a prevalence of 28.9%. This may be due to the similarities in the population based on the setting (Singh et al., 2018). The prevalence figures of this study were also consistent with the global prevalence of IPVDP estimated by the WHO in a multi-country study (García-Moreno et al., 2005).
However, our prevalence figure is lower than that of other studies conducted in Ethiopia (Abebe Abate et al., 2016), Nigeria (Ezeudu et al., 2019), Vietnam (Hoang et al., 2016), Kenya (Makayoto et al., 2013), Rwanda (Ntaganira et al., 2008), South Korea (Lee and Lee, 2018), and Gambia (Idoko et al., 2015) but higher than the studies conducted in Belgium (Van Parys et al., 2014) Japan (Doi et al., 2019), South Africa (Groves et al., 2012), Guatemala (Johri et al., 2011), and India (Jain et al., 2017). Such a difference may be attributed due to the differences in methodologies, population, and assessments that have been used in the previous research. A strong association was found between alcohol use by the husband and the experience of IPVDP by women. Consistent with our findings, strong links have been found between alcohol use and the occurrence of IPV in many countries such as India (Das et al., 2013), Kenya (Makayoto et al., 2013;Owaka et al., 2017), Rwanda (Ntaganira et al., 2008), Brazil (Teixeira et al., 2015), and Zimbabwe (Shamu et al., 2013). Our study showed that women whose husbands consumed alcohol were more than three times more likely to experience violence than women whose husbands did not consume alcohol. Studies from other countries showed that women who had partners who drank alcohol were more than two times as likely in Kenya (Makayoto et al., 2013), and four times as likely in Rwanda (Ntaganira et al., 2008), to experience violence. This might be explained due to the low-socioeconomic status of the family, societal beliefs, or the impulsive personality of the husband, which accounts for an unhappy and stressful partnership, thus resulting in violence. However, our study does not determine that the increased stress from the use of alcohol leads to IPV or that the abuse of alcohol is a result of the stress of IPV but the association is significant.
Women whose husbands consumed tobacco were more than three times more likely to experience violence than women whose husbands did not consume tobacco. Similar to our finding, a study conducted in Iran showed an association between a smoking partner and psychological violence during pregnancy where women whose partner smoked were more than two times more likely to experience violence during pregnancy (Hajikhani Golchin  , 2014). However, this study took only one type of violence to show their association while in our study, the association was shown with the experience of any type of violence as a whole.
A significant association was found between family support and IPVDP. Our study revealed that women who never received any assistance from family members in taking care of them during pregnancy or helping with household chores were almost six times more likely to experience violence during pregnancy. Similar literature on this topic was not found in previous studies. However, this variable is very important since pregnancy is a time when women need more care and support from their families. No support during this period might cause quarreling and violence in the family. However, our study does not determine that a lack of care during pregnancy led to the generation of a stressful relationship between the woman and their intimate partner or that the experience of IPV led to a lack of care during pregnancy but there remains a strong association.
Similarly, a strong association was found between the woman's decision on marriage timing and the experience of IPVDP. Our study showed that women who did not decide upon their marriage timing were more than two times more likely to experience IPVDP.

Conclusion
Our results demonstrate that in Putalibajar municipality, Syangja, three out of ten women experienced IPVDP. Controlling behavior inflicted by the husband was the most common type of violence followed by emotional, sexual, economic, and physical violence. To prevent violence, educating young people about respectful relationships, ensuring women's empowerment by focusing on higher education opportunities as well as discouraging the element of a violent milieu are important. Appropriate laws prohibiting violence against women and actions regarding screening of IPVDP at antenatal visits with proper management and referral to relevant care are needed.

Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement
The studies involving human participants were reviewed and approved by IRC, Pokhara University Research Center and ERB, Nepal Health Research Council. The patients/participants provided their written informed consent to participate in this study.

Author contributions
RS and HPK: conceptualization, data curation, formal analysis, methodology, visualization, and writing-review and editing. RS: funding acquisition, investigation, and writing-original draft. HPK: supervision and validation. All authors contributed to the article and approved the submitted version.