Gender-based Violence Among Pregnant Women of Syangja District, Nepal.

OBJECTIVES: This study aims to determine prevalence of gender-based violence among pregnant women attending an antenatal care (ANC) clinic.
METHODS: Between September 2014 and December 2014, a cross-sectional study was conducted among 202 pregnant women attending the antenatal ward of the Primary Healthcare Centre (PHC) of Syangja district, Nepal. The data were collected using semistructure questionnaires with face-to-face interviews. SPSS software (IBM Corp, Armonk, NY, USA) was used for analysis the data.
RESULTS: The prevalence rate of gender-based violence was found to be 91.1% (184). Most of the respondents (87%) faced economic violence followed by psychological (53.8%), sexual (41.8%), and physical (4.3%) violence. Women experienced: (1) psychological violence with most complaining of angry looks followed by jealousy or anger while talking with other men, insults using abusive language and neglect; (2) economic violence with most complaining of financial hardship, denial of basic needs and an insistence on knowing where respondents were and restricting them to parents' home or friends/relatives' houses (jealousy); (3) physical violence by slapping, pushing, shaking, or throwing something at her, twisting arm or pulling hair, and punching and kicking; and (4) sexual violence by physically forcing her to have sexual intercourse without consent, and hurting or causing injury to private parts. Most (100%) of the perpetrators were found to be husbands and mothers-in-law (10.7%) who violated them rarely.
CONCLUSION: The prevalence of gender-based violence (GBV) among pregnant women attending the ANC clinic was greater in the Syangja district of Nepal. Women's empowerment, economic autonomy, sensitization, informal or formal training regarding GBV for men and women, and the need for large-scale population-based surveys are the major recommendations of this study.

Introduction

Gender-based violence (GBV) [1] is “violence involving men and women, in which the female is usually the victim; and which is derived from unequal power relationships between men and women. Violence is directed specifically against a woman because she is a woman, or affects women disproportionately.” As GBV remains one of the most rigorous challenges to women's health and well-being, it is one of the indispensable issues of equity and social justice [2]. There is no doubt that violence against women is a crime by all standards, and it remains a negative impact on women for years and may continue with it throughout her life [3].

As we know, women are susceptible to violence throughout their lifespan, but this is most common in their fertile years [4]. Violence during pregnancy escalates during a woman's gestation with serious consequences not only for the woman, but also for the fetus and ultimately for the child's development. Both mother and fetus suffer adverse effects, e.g., fetal death, low birth weight, preterm delivery, small size for gestational age in fetus, maternal mortality, mental health problems, kidney infections, reduced weight gain during pregnancy, and increased likelihood of undergoing operative delivery in pregnant women [2].

In Nepal, women are considered as second-class citizens in this patriarchal society. Thus, most of the families are headed by men and the women are treated as commodities or child producing machines. Women are affected disproportionately in different ways than men [5]. A study conducted among 350 postnatal mothers in Nepal showed that domestic violence was a frequent phenomenon during pregnancy [6]. The proportion of women experiencing violence during pregnancy was higher in women having three or more children, illiteracy, living in poverty, residing in rural and Terai areas of Nepal [2]. A cross-sectional descriptive study conducted at Paropakar Maternity and Women's Hospital of Kathmandu, Nepal, shows that 33% of women suffered from GBV, of whom 23% reported physical violence, 13% reported sexual violence, and 47% reported psychological violence [7]. Similarly, a cross-sectional study carried out in four major ethnic groups of Nepal also shows that more than half the women (51.9%) reported having experienced some form of violence in their lifetime [8].

Research has demonstrated that gender-based violence has implications for almost every aspect of health policy and programming, from primary care to reproductive health programs [9]. Accurate and comparable data on violence are needed at the community, national, and international levels to strengthen advocacy efforts, help policy makers understand the problem, and guide the design of interventions [10]. This study aims to determine prevalence of gender-based violence among pregnant women attending an antenatal care (ANC) clinic. Moreover, we also tried to identify types of violence faced among pregnant women.

Materials and methods

Between September 2014 and December 2014, a cross-sectional study was conducted in the antenatal ward of the primary healthcare center (PHC) of Syangja district, Nepal. This study protocol received ethical approval from the Department of Public Health of La Grandee International College. Additional permission for the study was obtained from the District Health Office of Syangja district of Nepal and Primary Healthcare Centers. Verbal informed consent was taken from the participant before distributing questionnaires. Anonymity and confidentiality of the individual were maintained.

The study populations were pregnant women attending the antenatal clinic in PHC of the Syangja district of Nepal at the time of the study. The sample size was determined using the formula n0 = z2pq/d2, where n0 is calculated sample size, d is degree of accuracy which is 0.07, z is the confidence interval (1.96) and p is the proportion which is 50%. The calculated sample size was 196. But when finite total expected pregnancy (N) at Syangja district was 7,802 then the final population correction n = n0/(1+n0/N) was applied. Now the required sample size for the study was 192 and it was increased to 202 to take care of nonresponse errors (5%). The required number of pregnant women were selected by a consecutive sampling method where simple random sampling methods were used to select three primary health centers from each of the three constituencies. All pregnant women who attended the antenatal clinic of the PHC facility were eligible for the study. Pregnant women were excluded if they were admitted for delivery and did not attain ANC at PHC.

The data were collected using a semistructure questionnaire with face-to-face interviews. Validity of the data collected was ensured by experts. A pilot study was conducted on 10% of the sample size in Sisuwa PHC, Kaski district. The local languages (Nepali and Gurung) were used for face-to-face interviews. Data analysis software (IBM SPSS Version 20; IBM Corp, Armonk, NY, USA) was used for data processing and analysis. Descriptive statistics (mean, median, mode, standard deviation) were preferred for data entry and analysis.

Results

The mean age of pregnant women attending the ANC was 22.96 ± 3.723 years (range 15–37 years). The majority, 77.7% (157), were from rural areas and 99% (200) were married, as shown in Table 1. Similarly, the mean age of marriage was 19.35 ± 2.356 years (range 13–27 years) and the majority, 70.3% (142), were arranged marriages. More than half, 54.5% (12), of the respondents had a monthly income less than NPR 10,000 (Nepalese Rupees). The majority, 46.5% (94), of respondents were housewives and more than half, 57.7% (116), of respondents had secondary education level. The majority, 33.7% (68), of respondents were 24–30 weeks pregnant. A total of 98% (197) of respondents became pregnant on the desire of both husband and wife.

Table 1

Socio-demographic characteristics.

Demographic characteristics	Frequency (n)	Percentage (%)
Residence (n = 202)
Rural	157	77.7
Urban	45	22.3
Religious (n = 202)
Hindu	193	95.5
Buddhist	6	3
Muslim	3	1.5
Age of the respondents (n = 202)
15–20 y	33	16.3
20–25 y	104	51.5
25–30 y	53	26.2
30–35 y	10	5.0
>35 y	2	1.0
Mean age: 22.96 ± 3.723 y; max age: 37 y; min age: 15 y
Age of marriage (n = 202)
≤ 20 y	121	59.9
> 20 y	81	40.1
Mean age: 19.35 ± 2.356 y; max age: 27 y; min age: 13 y
Type of marriage (n = 202)
Arranged marriage	142	70.3
Love marriage	60	29.7
Marital status (n = 202)
Married	200	99
Widowed	2	1
Occupation of pregnant women (n = 202)
Housewife	94	46.5
Unemployed	61	30.1
Services	15	7.4
Student	14	6.9
Agriculture	11	5.4
Business	7	3.5
Monthly income of respondents (NRP)
< 10,000	12	54.5
10,000–20,000	9	40.9
> 40,000	1	4.5
Education level of pregnant women
Illiterate	1	0.5
Primary	19	9.5
Secondary	116	57.7
Higher secondary	48	23.9
Bachelor's degree and above	17	8.5
Pregnancy (weeks)
12–18	25	12.4
18–24	19	9.4
24–30	68	33.7
30–36	58	28.7
> 36	32	15.8
Mean: 27.49 ± 6.889 wk; max: 40 wk; min: 12 wk
Pregnancy desire persons
Only husband	1	0.5
Both of you	197	98
Family	4	2

Max = maximum; min = minimum; NRP = Nepalese Rupee.

Table 2 explains that out of 202 respondents, 91.1% (184) experienced some kind of gender-based violence during pregnancy. Among them, the majority 39.7% (73) of respondents experienced only one type of GBV. Out of 91.1%, the majority (87%, 160) of respondents experienced economic violence where approximately half, 53.8% (99), experienced psychological violence followed by 41.8% (77) sexual violence, and 4.3% (8) physical violence.

Table 2

Types of gender-based violence experienced by pregnant women.

GBV	Frequency (n)	Percentage (%)
Experience of GBV (n = 202)
Yes	184	91.1
No	18	8.9
Faced of GBV
Only 1	73	39.7
2	68	37.0
3	37	20.1
4	6	3.3
Types of GBV (n = 184)
Control (economic violence)	160	87.0*
Psychological violence	99	53.8*
Sexual violence	77	41.8*
Physical violence	8	4.3*

*Multiple responses.

GBV = gender-based violence.

Table 3 shows irregularity in percentage distribution due to multiple answers of the respondents. The majority, 33.3% (67), of respondents felt violated by receiving angry looks, followed by 25.2% (51) who experienced jealousy or anger because of talking with other men. Forty-two women (20.8%) were insulted by use of abusive language, whereas 7.1% (14) were neglected. Only 0.5% (1) were threatened with being sent back to their parents' house. Similarly, the majority (71.8%, 145) of pregnant women were in financial hardship, whereas 14.5% (29) were denied basic needs and 11.9% experienced an insistence on knowing where they were and were restricted to their parents' home or friends/relatives' houses (jealousy), respectively. Of those who suffered physical violence, the majority, 87.5% (7), of respondents were slapped by their perpetrators, 75% (6) were pushed, shaken or had something thrown at them, whereas only 37.5% (3) respondents had their arms twisted or their hair pulled as well as punched with fists or with something, and just 12.5% (1) were kicked, dragged, or beaten. Of those who suffered sexual violence, the majority of pregnant women, 38% (77), were physically forced to have sexual intercourse without consent and only 1% (2) were hurt or subjected to injury on their private parts.

Table 3

Experience of different types of GBV among pregnant women.

Types of GBV	Frequency (n)	*Percentage (%)
Psychological violence (n = 99)
Ever frightened by angry looks	67	74.4
Jealousy or anger due to talking with other men	51	56.7
Insulted with abusive language	42	46.7
Not being involved in decision making	14	15.6
Ever neglected	14	15.6
Threatened to send parents' house	1	1.1
Ever sent to parents' house	1	1.1
Economic violence (control) (n = 160)
Created financial hardships	145	91.2
Denied basic personal needs	111	69.8
Insisted on knowing where respondents were	29	18.2
Restricted to parents' home or friends/relatives' houses (jealousy)	24	15.1
Physical violence (n = 8)
Slapped her	7	87.5
Pushed, shaken or threw something at her	6	75.0
Twisted arm or pulled her hair	3	37.5
Punched with fist or with something	3	37.5
Kicked, dragged or beat her up	1	12.5
Sexual violence (n = 77)
Physically forced her to have sexual intercourse with him even when she did not want to	77	100
Hurt or caused injury on respondent's private parts	2	2.6

*Multiple responses.

GBV = gender-based violence.

Table 4 shows that in most of the cases, the perpetrators were husbands and mothers-in-law, i.e., 100% (122) and 10.7% (13) respectively, the rest 0.8% (1) were fathers-in-law and sisters/brothers. Table 5 shows that about half 51.5% (104) of respondents were rarely violated by their perpetrators where 5% (10) were violated 2–3 times in a week, 3% (6) were violated almost every day and only 1% (2) were violated 4–6 Times a week.

Table 4

Percentage distribution of perpetrator involved in gender-based violence to pregnant women (n = 137).

Perpetrator	Frequency (n)	*Percentage
Husband	122	100.0
Mother-in-law	13	10.7
Father-in-law	1	0.8
Sister/brother	1	0.8

*Multiple responses.

Table 5

Percentage distribution of the respondents by the frequency of spousal violence.

Frequency of violated behavior	Frequency (n)	Percentage (%)
Rarely	104	51.5
2–3 times a week	10	5.0
Almost everyday	6	3.0
4–6 times a week	2	1.0

Discussion

In this study, the prevalence of GBV among pregnant women was found to be 91.1%. It clearly reflects that gender-based violence among pregnant women attending antenatal clinic is a major public health problem. These findings suggest that gender-based violence during pregnancy demands special attention, because it affects women in a moment of great physical and emotional vulnerability [11]. This was consistent with a study conducted in the Amhara regional state of Ethiopia [12] which shows that the prevalence of domestic violence was 78.0%. Unlike in our study, gender-based violence was incomparably higher than the prevalence of GBV among pregnant women at Paropakar Maternity and Women hospital, Kathmandu [7], study in Parsa District of Nepal [6], and the study in Nigeria [9]. Having patriarchal nature in the culture was the probable reasons for the high prevalence in this study. In the part of the country where the study was conducted, there is an obvious power imbalance between men and women [9]. Similarly, this might have been because rates of gender-based violence vary, depending on how gender-based violence is defined (e.g., physical, emotional or sexual abuse), the way the questions were posed (the number of and detail in the questions), and the way in which the questions were asked (e.g., written survey or face-to-face interview). Other differences may be due to the characteristics of the women studied, the use of single versus multiple interviewers, and whether women are questioned regarding current or past abuse [13].

The study revealed that the majority of respondents (87%) experience economic violence, where psychological violence was more prevalent than others in the studies conducted in Nigeria [9], in the Parsa District of Nepal [6], in the Amhara regional state of Ethiopia [12], and in Iran [4]. Similarly, sexual violence and physical violence were more prevalent in the study in north-central Nigeria [14] and the study in Nepal [15]. This might have been because of the traditional gender norm that supports men's superiority in the study area. The majority of the women had lived in rural areas, and most of them were housewives, which was the problem mostly common and deep-rooted [12]. The discrepancy seems to reflect the different degrees of inclination among women to reveal their violent experiences, as well as differences in culture and interviewers' skills [4].

Out of 79.2% who experience psychological violence, mostly pregnant women complain that the majority 33.3% (67) of respondents felt violated by angry looks followed by jealousy or anger from talking with other men, insulted by using abusive language, by being neglected, and being threatened to be sent to their parents' house. In case of economic violence mostly pregnant women complain the majority 71.8% (145) of pregnant women were in financial hardship followed by denial of basic needs and by insisting on knowing where respondents were and restricted to go to their parents' home or friends/relatives houses (jealous). Similarly, concealment was a major finding in a Parsa District of Nepal [6]. Likewise in case of physical violence, the majority (87.5%, 7) of pregnant women experience being slapped by their perpetrators followed by being pushed, shaken or having something thrown at her, by arm twisting or hair pulling as well as being punched with fists or with something, and by being kicked, dragged, or beaten. This was consistent with studies conducted in the Parsa District of Nepal [6], in Abuja, Nigeria [9], in south-western Nigeria [16], and in the Amhara regional state of Ethiopia [12]. This reflects the culture of the society that does not recognize the role of the girl, only marital home and multiple responsibilities that are not exempt specific health conditions [3]. Similarly, in the case of sexual violence, pregnant women experience the majority 38% (77) were physically forced to have sexual intercourse even she did not want to. This was inconsistent with the finding of the studies conducted in the Parsa District of Nepal [6], in the Amhara regional state of Ethiopia [12] and in south-western Nigeria [16]. The observed difference might be due to sexual autonomy imbalance [12] and more than half 57.7% (116) of pregnant women had secondary education level. So, they are able to recount their experience of sexual violence.

The perpetrators of gender-based violence were their husbands (100%). Similarly, concealment was a major finding in Abuju, Nigeria [9], at Paropakar Maternity hospital of Kathmandu, Nepal [7], and in the Parsa District of Nepal [6]. Approximately half (51.5%, 104) of the pregnant victims were violated rarely by their perpetrators. But it was different from the study conducted at the Paropakar Maternity hospital of Kathmandu, Nepal [7] which showed that 192 (61%) of pregnant women, the majority, faced violence regularly. This might have been because the respondent's husband had gone abroad for economic reasons; the sample collected was from rural areas and the areas were of upper caste groups having a good educational level that can tackle the violence themselves.

In this study, the prevalence of GBV among pregnant women attending ANC clinics was more than that found in other studies. It shows that GBV among pregnant women attending ANC clinics was a prevalent problem in the Syangja district of Nepal. The experience of one or more forms of gender-based violence were seen among pregnant women of the study area. Women's empowerment and economic autonomy, sensitization, informal or formal training regarding GBV for men and women, and the need for large-scale population-based surveys to better understand the best approach to screen for GBV during pregnancy were the major recommendations of this study.

Generalizations cannot be made on the basis of these results because this was a cross-sectional study and the focus was on a specific sample which was the limitation of this study. Similarly, it was not a population-based study and interviews of men were not carried out, therefore it was not possible to determine risk factors and reasons for the perpetration of violence against women.

Conflicts of interest

The authors declared no conflicts of interest. No funding was received for this study.