The Association Between Domestic Violence and Adverse Pregnancy Outcomes in Pregnant Women Seeking Antenatal Care at Public Hospitals in Gedeo Zone: A Prospective Cohort Study

Introduction

Domestic violence (DV) is a grave violation of human rights and a major public health issue that affects millions of women around the world which occurs when an intimate partner inflicts physical, sexual, or psychological harm on their partner, through acts such as hitting, forcing sex, insulting, or controlling.^1–4 It can have devastating consequences for women’s health and well-being, especially during pregnancy in which pregnant women who experience DV face a higher risk of adverse pregnancy outcomes, such as preterm birth, low birth weight, pregnancy loss, bleeding, infection, abdominal injury, fetal injury, and death.^5–7 DV can also affect the mental health of pregnant women, leading to depression, anxiety, post-traumatic stress disorder (PTSD), suicidal thoughts, and other psychological problems.^8–10

The prevalence of DV during pregnancy varies widely across countries and regions. According to the World Health Organization (WHO) and other studies, about 30% of women globally have experienced physical and/or sexual intimate partner violence (IPV) in their lifetime, and 29% have experienced IPV during their lifetime. However, in some settings, the prevalence of DV during pregnancy can be much higher.^11–13 Moreover, DV during pregnancy can be more prevalent in some settings, posing a serious threat to the health and well-being of both the mother and the baby in low- and middle-income countries.^14–16

According to a report by the National Partnership for Women & Families, domestic violence during pregnancy can lead to low birth weight, perinatal death, maternal injury, and other complications, such as high-blood pressure, bleeding, and preterm birth.^17–19 In Ethiopia, two-thirds (64.6%) of pregnant women reported experiencing DV during their current pregnancy, with physical violence being the most common form (44.1%), followed by psychological (39.1%) and sexual (23.7%) violence.^20–22

Ethiopia is also a low-income country with high maternal and perinatal mortality rates. According to the Ethiopian Demographic and Health Survey (EDHS) report from 2016, the maternal mortality ratio was 412 deaths per 100,000 live births, and the perinatal mortality rate was 46 deaths per 1000 pregnancies level.^23,24 These rates indicate a great need for further efforts to reduce maternal and perinatal deaths and improve maternal and child health in which one of the potential factors that could contribute to these high mortality rates is DV during pregnancy.^23,24 Thus, it is crucial that healthcare professionals provide support and care to women who experience domestic violence during pregnancy.^3,25

Nevertheless, there is limited evidence on the causal relationship between DV during pregnancy and adverse pregnancy outcomes in Ethiopia and there are no cohort studies conducted in the study area where a high prevalence of DV during pregnancy is suspected.^24,26,27 Due to recent attempts to reduce adverse pregnancy outcomes in Ethiopia, we believe that there is some available information about domestic violence as the root cause.²⁴ Additionally, the low level of attention given by medical professionals for pregnant mothers who complain of their pregnancy and subsequent social implications of domestic violence has drawn attention to the issue.^24,28,29

The study’s output will help the government know domestic violence and its association with adverse pregnancy outcomes to enhance their attempt to address Sustainable Development Goals (SDG-16) aiming to significantly reduce all forms of violence and related death rates everywhere by 2030. It will also help health professionals focus on the root causes of adverse pregnancy outcomes and intervene accordingly.^28–30 Community health workers can create awareness on the impact of domestic violence on pregnancy outcomes and, researchers can use this study as a baseline.

Therefore, despite other causes contributing to maternal and perinatal mortality, domestic violence against pregnant women is an increasing public health concern particularly in low- and middle-income countries. The purpose of this study is to measure the association between domestic violence during pregnancy and the risk of adverse pregnancy outcomes in Gedeo Zone Public Hospitals, Southern Ethiopia.

Materials and Methods

The Aim, Design and Setting of the Study

A facility-based prospective cohort study was conducted in Gedeo Zone public hospitals of SNNPR, Ethiopia from May 2022 to July 2022 to investigate the relationship between domestic violence and adverse pregnancy outcomes.

Population

The source population for the study was all pregnant women inhabitants living in Gedeo Zone. The study included pregnant women who were in their third trimester and attending selected public health institutions for antenatal care follow-up. The study included pregnant women with a gestational age below 28 weeks. Women with multiple pregnancies, those who planned to deliver outside the selected public health institutions in the Gedeo Zone, and women with known medical diseases were excluded from the study.

Starting and End Points of Follow Up

The study recruited both pregnant women exposed to domestic violence and unexposed who were before 28 weeks of gestation during their ANC visit. Follow-up started at 28 weeks (3rd trimester) of pregnancy and continued until 24 hours after delivery or drop-out. The duration of the follow-up period for a subject was a maximum of 14 weeks (from 28 weeks onward).

Sample Size, Methods, and Procedure

The sample size was calculated using two sample proportion formulas in Epi-Info version-7 for windows. Calculation assumed that type I error of 5%, power of 80% and two exposed to one non-exposed in which the sample size proportion of adverse pregnancy outcome in the non-exposed cohort (10.2%) and in the exposed cohort (29.7%) had taken from retrospective cohort study done in Ghana.^31,32 The minimum sample size was 138 (46 exposed and 92 non-exposed) and adding 10% drop-out rate, the final sample size was 152 (51 exposed and 101 non-exposed). (Let P= p1+ rp2/1+r and r=n2/n1; Where; P1=proportion of adverse pregnancy outcome among exposed P2=proportion of adverse pregnancy outcome among non-exposed, α=level of significance, Zα/2=1.96 at 95% CL, Power=80%=1-β, Zβ=1.28, n=the minimum required sample size in each group).

The study used a systematic random sampling technique to select samples for the study. Study subjects were identified based on the annual eligibility plan of deliveries in each hospital of Gedeo Zone health office. The total sample size was met by proportionally allocated samples from each hospital. Systematic random sampling technique was employed to get all cohorts.

The data was collected from study subjects using a pre-tested, interview-guided structured questionnaire which was adopted from the Swahili version of the “WHO Multi-Country Study on Women Health and Domestic Violence against Women” tool that had been validated in the Amhara region of Ethiopia.^28,33 The questionnaire was developed in English and translated into Gedeofa and/or Amharic, then back to English to check for its consistency.

Socio-demographic data, causes of violence against pregnant women, and health facility factors leading to adverse pregnancy outcomes were collected at the time of recruitment. During a follow-up interview at 34 weeks’ gestation, the women’s exposure to emotional, sexual, and physical violence was determined. Within 24 hours after delivery, documentation of gestational age and measurement of birth weight was done. The duration of the first and second interviews was 30 to 45 minutes; the post-delivery interview lasted for 10 to 15 minutes. Women who delivered before 34 weeks of gestation were considered dropouts.

The study recruited 152 pregnant women (51 exposed and 101 non-exposed) who attended antenatal care, met the inclusion criteria, and agreed to participate. They were interviewed near the Antenatal Clinic at the time of recruitment and at the end of the day. Out of these, 142 pregnant women (47 exposed and 95 non-exposed) completed their follow-up and were interviewed again. A gestational age assessment was done using the last normal menstrual period (LMP) and/or date of fetal quickening for gestational age below 14 weeks and head circumference (HC) for gestational age 14–28 weeks for women having unknown LMP or ambiguous date of fetal quickening. Each participant was allocated a unique identification number. Information on socio-demographics, causes of violence against pregnant women, and health facility factors leading to adverse pregnancy outcomes were obtained through a face-to-face interview questionnaire.

Data Collection Method

The study data was collected using a pre-tested interview guided structured questionnaire that had five main parts: socio-demographic, psychological (emotional), physical and sexual violence, Household Conditions, others, and adverse pregnancy outcomes.

Data Quality Assurance

To ensure data quality, a professionally designed data collection tool was prepared, and data collectors were trained. Supervisors examined some of the collected data each day and provided immediate solutions for any problems. Before actual data collection, the questionnaire was tested on 5% of the total sample size (8 pregnant women) at Hawassa Adare Hospital to check the context of data. A minimum of 1 week recruitment and 4 weeks follow-up period were needed to perform the pre-test. After the pre-test was done, the questionnaire was revised accordingly.

Data Processing and Analysis

The collected data were checked for completeness, cleaned, processed, and entered EPI-info version-7 and then transported to SPSS version-24 computer software for analysis. Frequency distribution tables and statistical graphs were used to describe variables. Cross-tabulation and logistic regression were done to examine the association between dependent and independent variables. Variables with a p-value of less than 0.2 were entered into multivariable analysis and adjusted odds ratio (AOR) was seen to control confounding variables. A 95% confidence level and p-value of less than 0.05 were considered statistically significant.

Result

Socio-Demographic, Social Habits, and Reproductive Health Characteristics

In this study, 152 pregnant women at 28 weeks of gestational age were recruited and followed for approximately 14 weeks. Of these women, 51 were exposed and 101 were not exposed to the exposure variable (domestic violence). However, only 142 women (47 exposed and 95 non-exposed) completed the follow-up, resulting in a response rate of 93.4%. The mean age of pregnant mothers included in the study during their last birth was 25.04 (±SD=5.113) years. Most cohorts experienced less than three pregnancies, with 83 (58.5%) of non-exposed and 37 (26.1%) of exposed women falling into this category. In terms of educational status, 77 (54.2%) and 81 (57.0%) of non-exposed women and 42 (29.6%) and 42 (29.6%) of exposed women were literate, respectively.

The study assessed the employment and income status of the woman and her partner, as well as the drinking and chewing habits and frequency of her partner, and the history of extramarital relationships of both parties. Seventy-one (50.0%) of women who were not exposed to domestic violence and 39 (27.5%) of those who were exposed were unemployed. Additionally, more than 32 (22.5%) women who were not exposed and 12 (8.5%) who were exposed had no income per month (Table 1).

Table 1 Socio-Demographic, Social Habits and Reproductive Health Characteristics of Pregnant Women Attending at Gedeo Zone Public Hospitals, Southern, Ethiopia 2022 (n=142)

The study also examined the adverse pregnancy outcomes that the pregnant women had experienced before. Out of the 26 women who had a history of such outcomes, bleeding during pregnancy was the most common among the non-exposed group (19.20%), while perinatal death was the most common among the exposed group (19.20%) (Figure 1).

Figure 1 Types of adverse pregnancy outcomes that previously faced among women attending at Gedeo Zone Public Hospitals, Southern, Ethiopia 2022 (n=142); **Adverse pregnancy outcomes like breathing difficulty (asphyxia), fetal and maternal infection, and preterm birth.

Magnitude of Domestic Violence

The study scrutinized different variables to identify types of domestic violence. Among the 47 pregnant mothers who completed their follow-up as an exposed group (exposed to domestic violence), about 23.2% experienced psychological violence, which was the most common type (Figure 2).

Figure 2 Types of domestic violence that pregnant women experienced among women attending at Gedeo Zone Public Hospitals, Southern, Ethiopia 2022 (n=142).

Household Condition and Perception Related Factors

At the time of recruitment, household ownership was assessed as a baseline data in which 27.4% of non-exposed and 40.4% of exposed groups had rented houses. On the other hand, about 56.8% of non-exposed and 66.0% of exposed groups were living with more than three individuals in their household. Regarding desire of the current pregnancy, 86.2% of non-exposed and 61.7% of exposed group were having their current pregnancy based on their desire (Table 2).

Table 2 Household Condition and Perception Related Factors of Domestic Violence Among Pregnant Women Attending at Gedeo Zone Public Hospitals, Southern, Ethiopia 2022 (n=142)

Adverse Pregnancy Outcome Related Variables

The gestational age during delivery of the current pregnancy was analyzed. Ninety-three (97.9%) of the non-exposed group and thirty-seven (28.5%) of the exposed group were delivered at term (after 37 weeks) of gestational age. Even though 78 (82.1%) mothers from the non-exposed group and 25 (53.2%) from the exposed group delivered normal-weight babies, 17 (17.9%) from the non-exposed group and 22 (46.8%) from the exposed group delivered low birth weight babies with a birth weight ≤2500 grams.

Out of all the women in the study, 8.4% of the non-exposed group and 21.3% of the exposed group experienced bleeding during late pregnancy. Regarding complications faced during and/or after pregnancy, 18.9% of the non-exposed women and 46.8% of the exposed group experienced perinatal death (Table 3).

Table 3 Adverse Pregnancy Outcomes Due to Domestic Violence Among Pregnant Women Attending at Gedeo Zone Public Hospitals, Southern, Ethiopia 2022 (n=142)

Associated Factors Between Any Domestic Violence and Preterm Birth, Low Birth Weight, Late Trimester Bleeding and Perinatal Death

The study examined the association between birth status in terms of gestational age, birth weight of the newborn, Late Trimester Bleeding, and perinatal death with domestic violence. The results showed that preterm birth and perinatal death had a statistically significant association with domestic violence. However, according to the study, neither low birth weight nor late trimester bleeding had any significant association with domestic violence. We found a statistically significant association between domestic violence and birth status in terms of gestational age. Thus, preterm birth is more than four times (AOR= 4.392, 95% CI: 1.117, 6.588) more likely to occur among pregnant women exposed to domestic violence. However, after adjustment of the stratified analysis (AOR), low birth weight and late trimester bleeding had no statistically significant association with domestic violence during pregnancy. In this study, the occurrence of perinatal death was found to have a significant association among women exposed to domestic violence. Women exposed to domestic violence were 2.5 times (AOR= 2.562, 95% CI: 1.041, 6.308) more likely to face perinatal death when compared with those who were unexposed to DV (Table 4).

Table 4 Bivariate and Multivariable Analysis to Show the Associated Factors Between Any Domestic Violence and Adverse Pregnancy Outcomes Among Pregnant Women Attending at Gedeo Zone Public Hospitals, Southern, Ethiopia 2022 (n=142)

Discussion

This study examined how domestic violence affects pregnancy outcomes among women who visited public health institutions. Pregnant women who were exposed or unexposed to domestic violence before 28 weeks of gestation were enrolled and followed up from their third trimester (28 weeks) until 24 hours after delivery or drop out. Our study found that psychological violence was the most prevalent form of domestic violence among pregnant women, affecting 23.2% of those who were exposed. This finding is consistent with studies from Brazil and Southeast Ethiopia.^26,34 This finding is higher than those of other studies from India and Ethiopia.^5,26,35–37 This might be because we only included pregnant women who visited healthcare institutions for any reason and followed them up during the data collection period, which could have increased the result.

Thus, this study found that the overall prevalence of domestic violence was 33.1%. This study is in line with studies done in Turkey, Brazil, and a meta-analysis review. Nevertheless, it is lower than studies conducted in Iran, Portugal and Southeast Oromia, Ethiopia. This may be due to the fact that the studies were conducted in large community-based surveys which could reveal the large prevalence of domestic violence.^38,39 Domestic violence shortens the duration of pregnancy and increases the risk of preterm birth. Women who suffer from domestic violence have a fourfold higher chance (AOR= 4.392, 95% CI: 1.117, 6.588) of delivering too early. This result is consistent with several studies from both developed and developing countries.^10,17

Our study did not find a significant link between domestic violence during pregnancy and low birth weight which agrees with a study from Nepal.⁴⁰ Contrary to this result, a study from the Center on Trauma and Adversity at Case Western Reserve University, a systematic review and meta-analysis, a study done on Asian Immigrants, and studies from Northwest Ethiopia all reported different findings.^19,41–44 A probable reason for this difference is that our sample size was too small, and we had a selection bias during the recruitment phase of our study. We also did not find a significant link between domestic violence and bleeding in the late trimester, unlike some studies from Canada and Bangladesh.^45,46 This may be because we only included pregnant women and not their husbands and had different population characteristics.

This study revealed a significant link between domestic violence exposure and perinatal death. Women who were exposed to DV had a 2.5 times higher risk (AOR= 2.562, 95% CI: 1.041, 6.308) of losing their babies than women who were not exposed to DV. This finding is consistent with studies from Nepal and Bangladesh.^18,40 An explanation for this is that domestic violence can cause physical and psychological stress, infections, injuries, and complications that can affect the health of the mother and the baby.

Conclusion

This prospective cohort study reveals the alarming prevalence and consequences of domestic violence against pregnant women in southern Ethiopia. Domestic violence during pregnancy not only harms the mothers, but also puts their babies at risk of preterm birth and perinatal death. These outcomes are unacceptable and preventable. The Ethiopian government and other stakeholders must act urgently to protect pregnant women from intimate partner violence. Moreover, to enhance the health care systems’ response to domestic violence in developing countries, we need more evidence-based knowledge on its effects on pregnant women, more training and support for ANC staff to deal with domestic violence, and more effective interventions to address this issue.