Magnitude of Domestic Violence and Associated Factors among Pregnant Women in Hulet Ejju Enessie District , Northwest Ethiopia

Introduction.Domestic violence during pregnancy is one of the barriers to achieve MDG 3 due to its adverse health consequences. Comparable population-based data on the problem are lacking as existing literatures differ in time periods explored. Such discrepancies among study findings indicate the importance of site specific studies, especially in rural parts of Ethiopia, where little is known about the problem. Objective. The aim of this study was to assess the magnitude of domestic violence and its associated factors among pregnant women in Hulet Ejju Enessie district, northwest Ethiopia.Methods andMaterials.Quantitative community based cross-sectional study was carried out from January 1 to 31, 2014. A total of 425 randomly selected pregnant women were involved in the study. A standard WHO multicountry study on women’s health and domestic violence questionnaire were used for data collection. Four trained female data collectors were involved. Odds ratio with 95% CI was estimated to identify factors associated with domestic violence during pregnancy using multivariate logistic regression. Statistical significance was declared at P value ≤0.05. Results.The prevalence of domestic violence during current pregnancy was 32.2%. The prevalence of psychological, sexual, and physical violence was 24.9%, 14.8%, and 11.3%, respectively.Married women at the age of≤15 years were about four times (AOR = 4.2, 95% CI 1.9–9.0) more likely to experience domestic violence during pregnancy than their counterparts. Meanwhile, interparental exposure to domestic violence during childhood (AOR= 2.3, 95%CI 1.1–4.8), having frequently drinker partner (AOR = 3.4, 95% CI 1.6–7.4), and undesired pregnancy by partner (AOR = 6.2, 95% CI 3.2–12.1) were the main significant factors that increase risk of domestic violence during pregnancy. Conclusion and Recommendation. In this study, the prevalence of domestic violence during current pregnancy is high which may lead to a serious health consequence both on the mothers and on their foetuses. Thus, targeted efforts should be made by all concerned stakeholders to reduce the problem in the study area.


Introduction
Domestic violence, also known as spousal abuse or intimate partner violence (IPV), is defined as "behaviour within an intimate relationship that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours" [1].In recent years, attention has been given to domestic violence during pregnancy as global public health problem due to its adverse health consequences and intervention potential [2][3][4].
Women may feel more physically vulnerable and emotionally dependent on their partners during the pregnancy [5].However, women are not immune from violence during pregnancy, given its potential impact on maternal health and newborn health that are further exacerbated by domestic violence [6,7].Research also indicates that pregnancy triggers the occurrence of domestic violence [8].
Studies demonstrate that violence during pregnancy is more common in developing countries (as high as 32%) than developed countries (less than 12%) [6].The consequence of domestic violence during pregnancy ranges from financial hardships and decreased intimacy to high rates of maternal and neonatal morbidity and mortality [9].Twenty percent of pregnancies have adverse pregnancy outcomes both for the 2 Advances in Public Health mother and unborn [2].Abused pregnant women are also twice as likely as nonabused women to report poor physical and mental health problems [10].Pregnant women, for fear of violence, are unable to refuse sex or negotiate safer sexual practices, thus increasing their vulnerability to HIV [11,12].Pregnant women who have experienced violence are also likely to delay seeking prenatal care [2,5].
In patriarchal societies, like in many sub-Saharan African countries including Ethiopia, with high social acceptance of violence and poor socioeconomic status, the level of domestic violence during pregnancy tends to be high [11,13].Women in Ethiopia are also characterized by low levels of education and lack of decision making power which further makes them less assertive and more dependent on their male partners, thereby increasing their likelihood of experiencing domestic violence during pregnancy [9,14].
Comparable population-based data on the prevalence of domestic violence during pregnancy are lacking.Available literatures also differ in time periods explored: some focus on domestic violence in any pregnancy, some on the last pregnancy, and others on the previous year among pregnant women, or at different time points during the pregnancy [5,6].Moreover, lack of uniform definitions and differences in methodology of domestic violence research during pregnancy have long made it difficult to compare prevalence data across studies [7].The majority of existing studies on domestic violence during pregnancy also measure physical violence, although sexual abuse and emotional abuse are also considered detrimental for women's and their children's wellbeing [2].
The existence of such discrepancies among study findings on domestic violence indicates the importance of site specific studies on it especially in rural parts of our country where access to health information is limited.
Though there are some literatures in Ethiopia on level of and factors associated with domestic violence in general, little is known about domestic violence during pregnancy.Moreover, this is the first to document and identify the level and associated factors of domestic violence during pregnancy in the study area.Addressing domestic violence during pregnancy provides an opportunity for different stakeholders to respond to the problem and decrease its adverse outcomes on pregnancy.It may also help health care providers be informed and aware of the possibility of violence as an underlying factor in women's ill-health during pregnancy.So, the aim of this study was to assess magnitude of domestic violence and its associated factors among pregnant women in Hulet Ejju Enessie district (one of the rural districts in Amhara National Regional State), northwest Ethiopia, from January 1 to 31, 2014.

Methods and Materials
The study was conducted in Hulet Ejju Enessie district, East Gojjam Zone, Amhara National Regional State.The district is located 375 Kms from Addis Ababa (capital city of Ethiopia) where 100% of its population is considered rural dwellers.The total number of pregnant women during the study period in the district is 4,247.The district is constituted by 46 rural kebeles or lowest administrative units in the country (11 highlands or dega, 27 midlands or weina dega, and 8 lowlands or kolla) [15].
A community based cross-sectional study was carried out from January 1, 2014, to January 31, 2014, among 434 systematically selected pregnant women who lived in the selected kebeles of the district for more than six months.A multistage sampling technique was used and sampling frame (list of all pregnant women that exists during the study period from each of the 13 randomly selected kebeles) was obtained from Health Extension Workers (HEWs) in the selected kebeles since they record all pregnant mothers in their location regularly to prepare them for antenatal care follow-up.Standard WHO multicountry study questionnaire for assessing women's health and domestic violence translated into local Amharic language and pretested on 10% of the total sample size was adapted and used.Data was collected by four trained grade ten complete data collectors (who are all females which creates an opportunity for disclosure of violence by the women).If the eligible woman was not present at home during the visit, a revisit was arranged three times and if women were absent during all the revisits, the correction factor was considered.One clinical nurse and the principal investigator supervised the data collection procedures.To increase the quality of data, translated and pretested standardized questionnaire was used, data collectors were trained, close supervision was made during the data collection, the collected data were cross-checked on each day of activity for consistency and completeness, double entry of data and cleaning of data using frequency, sorting, and listing to identify any missed value and outlier were made, and identified errors were cross-checked with the original questionnaire.
The collected data were double entered using EPI data software version 3.0.Then it was exported to SPSS version 16.0 for data processing and analysis.Exposure to mass media was measured as presence of at least one functional communication channel (radio, television, cell phone, phone, etc.) at home [11].The outcome variable, domestic violence during current pregnancy, was coded as YES = 1 (women who experience any of physical, psychological, or sexual violence) and NO = 0 (women who does not experience any of the three forms of violence acts).Descriptive tests like proportions, mean and standard deviations, and analytic tests like bivariate and multivariate logistic regression analysis were computed.Hosmer-Lemeshow goodness-of-fit is used to test model fitness.Odds ratio along with the 95% CI was estimated to ascertain the association between covariates and experience of domestic violence during pregnancy.Covariates that have  value of <0.2 at the bivariate analysis were included in the multivariate logistic regression to control all possible confounding factors.For all statistical tests,  value ≤0.05 was used as a cut-off point for statistical significance.
Ethical clearance was obtained from Haramaya University Institutional Research Review Committee (IRERC) prior to the study.Administrative bodies of the district and selected kebeles were asked for their willingness and cooperation.The female interviewers obtained verbal consent from partners of interviewees.Privacy and confidentiality was maintained (as participants were asked in private setting and their names will not be identified on the questionnaires).Informed and written consent was obtained from participants.During data collection, interviewees who are in need of health care and victims of the violence were linked to HEWs in the kebeles.Then, HEWs either provide counselling and care or refer them to nearby health facility.Their transport and other service costs were covered by the principal investigator.

Socioeconomic and Demographic Characteristics of the
Respondents.A total of 425 pregnant women were interviewed making a response rate of 97.9%.The mean (±5.8) age of mothers was 29.8 years.The majority of participants were between 25 and 34 years old (239) (56.2%).Of all respondents, 323 (76.0%) were farmers and 288 (67.8%) were illiterate.Respondents were also asked about their household's monthly income as compared to their neighbours and majority of respondents, 206 (48.5%), report medium monthly income.Among 420 (98.8%) pregnant women who were married or in a relationship, 250 (59.5%) women reported that the age at their first marriage was before age of 15.The median age at first marriage was 15 (±3.49) years.Regarding partner's characteristics, majority of women reported that their partners were illiterate, 182 (42.8%), and >35 years old, 196 (46.1%) (Table 1).

Factors Associated with Domestic Violence during
Pregnancy.The results of bivariate and multivariate analysis between domestic violence against women and selected independent factors are presented in Table 3. Accordingly, in the bivariate analysis, age at first marriage (≤15 years), having three or more children, interparental exposure to domestic violence during childhood, frequency of drinking by partner, and desiredness of current pregnancy by partner were the main significant factors associated with domestic violence during pregnancy, whereas, in the final model (multivariate analysis), results indicated that age at first marriage (≤15 years), interparental exposure to domestic violence during childhood, drinking status of partners, frequency of drinking by partner, and desiredness of current pregnancy by partner remained the main significant factors associated with domestic violence during pregnancy adjusting for all other variables (Table 3).

Discussion
In this study, the prevalence of domestic violence during current pregnancy is found to be 32.2%.This result is consistent with study from South Africa, where the prevalence of domestic violence during pregnancy was 31% [5], but is more than two times WHO's multicountry finding from Butajira, Ethiopia (15.1%) [10], and finding from Lebanon (11.4%) [16].This prevalence is also much higher than findings from other different developing countries [6,10,17].The prevalence of domestic violence in this study is even more than lifetime experience of domestic violence in eastern Ethiopia (19.6%) [18] (Table 2).
The variation in the prevalence could be due to the definition of domestic violence during pregnancy, research design, and screening instruments used that varied between settings, cultures, and populations [16].The WHO multicountry study used a standard instrument across settings and cultures, but it asked ever pregnant women about any abuse during their previous pregnancies which may suffer from recall bias [1].Though this study used the WHO multicountry standard instrument, pregnant women were asked about their violence experience during current pregnancy to avoid this recall bias.The other reasons for the observed differences may be cultural acceptability of domestic violence and hence underreporting and fear of disclosing the issue [18].The majority of studies on domestic violence during pregnancy measure only physical violence, but in our study psychological violence and sexual violence were the most common forms, which are also the most detrimental for women's and their children's well-being.In our study, psychological violence was accompanied by any physical or sexual violence that is attributed to the fact that physical or sexual violence can emotionally affect the women [12].
In this study, the association between respondent's and their partner's sociodemographic variables and experiences of domestic violence during current pregnancy was assessed.Respondents who married before age of 15 years were 4.2 times more likely to experience domestic violence than their counterparts (AOR = 4.2, 95% CI 1.9-9.0).The practices of early marriage, which is a case in the study area (median age at first marriage is the lowest in the country: 15 years), limit the education and development of women [19] and may also further trigger the occurrence of violence [20].In the study area, there is still a desire for virgin brides and a focus on more patriarchal and traditional value.Due to this patriarchal norm, women who have internalized such social norms that justify "acceptance of violence against women" as a normal part of life are at greater risk of violence [13] (Table 3).
Violence was confirmed as a learnt behaviour that passes from generation to generation [21].In our study, witnessing interparental violence as a child was about two times (AOR = 2.3, 95% CI 1.1-4.8)more likely to report experiences of domestic violence during pregnancy.This may be because pregnant women who witness violence against their mothers (as children) tolerate violence by their partners and respond in a passive manner [21][22][23].This is due the fact that witnessing violence lead to a normative understanding of violence, make women learned to conform to societal views of power imbalances within relationships and regarded as a fitting means of conflict resolution [9,14].In addition, the pregnant women could also have a tendency to select partners that are consistent with the distorted views within the context in which they live [9] (Table 3).In this study, the effect of partner's drinking status for women as victim and men as perpetrator is found to be significant in the experiences of violence during pregnancy.This is in line with other studies [5,17,24].Pregnant women having a partner who usually drinks (2-3 days per week) were two and half times (AOR = 2.4, 95% CI 1.1, 5.1) more likely experiencing violence as compared to pregnant women married to partners who drink rarely (occasionally).This risk is increased to three and half times (AOR = 3.4, 95% CI 1.6-7.4)more for those pregnant women having a partner drinking heavily (frequently).This may be attributed to alcohol consumption and intoxication leading to irresponsible behaviour, reduced inhibitions, clouded judgment, and impaired ability to interpret social cues, thus increasing the likelihood of violence [8,14,25,26] (Table 3).
This study also found a strongly significant association of undesired pregnancy by the partner and violence during pregnancy.Women whose partners do not desire their current pregnancy have about six times (AOR = 6.2, 95% CI 3.2-12.1)more risk than their counterparts.The risk is higher than study finding from Lebanon where the odds of abuse during pregnancy among women whose partners did not desire their pregnancy were 3.8 compared with other women [16].This may be because women who experience violence and undesired pregnancy mostly live in an environment of patriarchy and male dominance [6,16].However, it should be noted that domestic violence may lead to unwanted pregnancy through rape, by affecting a woman's ability to negotiate contraceptive use (use contraceptive methods in secret and stopped by their abusive partner) or abusive partner refuses to use a condom [2,16] (Table 3).Contrary to the general perception, household monthly income, level of education, and occupational status were found to have no significant association with domestic violence in our study.Studies that are in line with our finding suggest that occupation and socioeconomic status had minimal effect or do not reduce the likelihood of domestic violence during pregnancy [9,16,27] especially for women in low income countries (pregnant women work largely in informal sectors with low paid jobs) and in patriarchal societies (pregnant women are usually exposed to the same patriarchal social structures at the work place that may further strengthen the myth of male superiority) [11].This study also showed no effects of education on domestic violence experience among pregnant women which is consistent with study from Mozambique [9].This is true in societies where education may have been insufficient to counteract traditional gender roles [9] (Table 3).
Age of respondent, exposure to mass media, and number of children at home are not also significantly associated with experience of domestic violence during pregnancy.The finding of a lack of association could reflect effect modification on the basis of geographical or cultural contexts; that is, the association between these factors and domestic violence during pregnancy may only exist in certain contexts [23].This is evidenced as different literatures come up with contradicting findings (Table 3).
Limitations of the Study.The study is based on the woman's self-report and the issue is surrounded by taboo and stigma; this may have resulted in underreporting.The pregnant women were also asked about domestic violence during their pregnancy until the day when they were interviewed which may not have allowed for the detection of violence that begins later during pregnancy.This study could not address some of the proximate determinants (decision making power, autonomy of pregnant women, and perception and attitudes towards domestic violence in the family) in the experience of domestic violence during pregnancy which need to be studied qualitatively.This might introduce confounding effect.The measure of socioeconomic status was quite crude and was based on subjective report only which may explain why no association was seen.

Conclusions and Recommendations
In this study, 32.2% of the women reported domestic violence during their current pregnancy.This result is much higher than findings from other less developed countries.The prevalence is even more than lifetime experience of domestic violence in some parts of our country.Age at first marriage, interparental exposure to domestic violence during childhood, frequency of drinking by partner, and desiredness of current pregnancy by partner are found to be the main significant factors associated with domestic violence during current pregnancy in multivariate logistic regression.Thus, pregnant mothers in the study area are at higher risk of domestic violence which may affect the health of the mothers and their foetus.Based on the findings of the study, the following recommendations are forwarded.
(i) The district health office, in collaboration with zonal and regional health offices, should put screening programs and clear practice guidelines in place at health care facilities and should play role in introducing such screening programs into routine ANC service.This is particularly important because ANC services can provide a unique window of opportunity to address the needs of abused women and to safeguard health of both mothers and their unborn.Alternate modes of intervention to reach women who do not attend antenatal care are also crucial.
(ii) District health office, women's office, and NGOs working on maternal and child health programs should also target reduction of domestic violence among pregnant women.They should also work closely with other social sectors like district education office and district justice office to achieve a lasting impact of intergenerational transmission of violence and to challenge social norms that posit men's right to control women's behaviour.Such coordination efforts should also emphasize awareness creation to tackle problem of alcohol addiction in men.Couples discussion on the desiredness of pregnancy and family size they want to have (including FP utilization) should be encouraged through these coordination efforts.
(iii) Health extension workers, women committee, and development committee in the kebeles should also play a role in tackling the problem.
(iv) For researchers, further research especially to know about the contextual factors associated with the attitudes toward domestic violence during pregnancy is needed as evidences in this regard are still limited in our country.

Table 2 :
Prevalence and overlapping occurrence of different forms of domestic violence among pregnant women in Hulet Ejju Enessie district, northwest Ethiopia, March 2014 ( = 425).

Table 3 :
Factors independently associated with experience of domestic violence during pregnancy in Hulet Ejju Enessie district, northwest Ethiopia, March 2014.