Isn't pregnancy supposed to be a joyful time? A cross-sectional study on the types of domestic violence women experience during pregnancy in Malawi.

Background: Domestic violence against pregnant women exists in Malawi but its magnitude and types were, until recently published data, unknown due to scanty published data on the subject. This study aimed at identifying types of abuse women experience during pregnancy.
Methods: The study design was cross-sectional descriptive quantitative using a random sample of 292 pregnant women attending an antenatal clinic at Nsanje District Hospital, southern region of Malawi. A structured questionnaire was administered to each pregnant woman that consented to participate. Data was analyzed using SPSS software version 16. Descriptive statistics were computed for demographic data and type of violence.
Results: The findings indicate that a majority (59%) of women experienced more abuse during pregnancy, compared to 12.5% prior to current pregnancy. The women were psychologically (29%), sexually (28%) and physically (14%) abused during pregnancy. There was a significant association (P<0.05) between domestic violence and witnessing abuse as a child in the home. Additionally, domestic violence was significantly associated (P<0.05) with a woman being pregnant. No significant association (P>0.05) was found between domestic violence and other demographic variables; age, low education level and low income.
Conclusion: The pregnancy period is not a joyful time for all women. The study found high levels of psychological, sexual and physical domestic abuse among pregnant women. We advocate for community awareness creation on domestic violence, strengthening victim support units and One-Stop centres, and training health workers to screen for and counsel victims during antenatal care.

Introduction

Domestic violence (DV) against pregnant women has generally been a neglected area of research in Malawi1, yet evidence suggests that violence against women covers all stages of the woman's life2. According to National Statistical Office (NSO), 28% of all women and 5% of pregnant women are abused annually in Malawi2. DV is recognized as a major public health concern3, and a violation of human rights that is faced by all societies around the world, with 1 woman in 4 being abused during pregnancy worldwide4,5,6. About 13% of women experience DV during pregnancy in developing countries7. These include physical abuse which is the use of physical force with the intent to harm or frighten (examples includeslapping, kicking, punching or use of weapons), sexual abuse (examples includeforced sexual activity including rape, unwanted kissing or touching, or forcing someone to do something against their will, and psychological or emotional abuse (examples include the systematic use of fear where the perpetrator does or says things that make their partner feel scared or intimidated, for example, threatening to harm or kill them)7.

Literature from studies in other countries suggests that a great number of women are at risk of different types of DV during pregnancy. Between 4 and 12% of women who had been pregnant reported being beaten during pregnancy in Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia and Montenegro although the pregnancy period is often thought of as a time when women should be protected8. Furthermore, a study conducted at a state hospital in Trabzon, Turkey, found that during pregnancy, many Turkish women experienced physical and sexual abuse9. Consequently, DV during pregnancy is a risk factor for low birth weight, antepartum hospitalization, induced and spontaneous abortion, and other injuries10, 11.

The United Nations' declarations and conferences during the years 1993, 1994, 1999 and 2000 increased the efforts countries make to examine the causes, effects and strategies to prevent domestic violence12. The 2005 World Summit outcome reaffirmed the 2000 resolution “to combat all forms of violence against women”and expanded it to include violence against women during and after conflict7. Notably, screening programmes offer opportunities for women to disclose abuse and receive further interventions13.

In Malawi, efforts are underway to understand and address issues of DV. The Malawi government, prompted by the UN declarations, enacted the Prevention of Domestic Violence Law Act No.5 of 2006 as a commitment to ending gender based violence (GBV) and discrimination against women14, 15. In addition, the Malawi government conducted demographic health surveys (DHS) in 2004 and 2010 that included the collection of data on DV2. Moreover, the government created institutions for victims to report acts of violence and seek physical and emotional support, namely Victim Support Units, (VSU) based at Police stations, and One - Stop centres, based at some hospitals or at stand-alone premises. One-Stop centres offer multisectoral comprehensive case management services for survivors including health, welfare, counselling and legal services at one place. Evidently, most (70%) of the GBV cases that are reported in Malawi are DV related14, 15. Nevertheless, studies on DV during pregnancy are lacking in Malawi. The 2004 and 2010 MDHS included both pregnant and non-pregnant women, but did not isolate the types of DV pregnant women experienced. Therefore, the aim of this study was to determine the types of DV women experience during pregnancy in Nsanje district, southern Malawi.

Methods

Design

The study design was descriptive and utilized quantitative research methods.

Setting

The study was conducted at Nsanje District Hospital's antenatal clinic, a referral health facility for other facilities in the district situated in the southern region of Malawi. Data was collected between July and August 2011. The district had a population of 238,089 with 54,761 women being in the child-bearing age group.2 Principally, the district was chosen because it is one of the rural districts with high-recorded cases of violence against women. According to unpublished data from Nsanje Police VSU, 819 cases were recorded between 2007 and June 2010; with 52.5% of the cases being DV related.1 These high rates of GBV could be exacerbated by many factors including cultural practices, patriarchal norms and low socio-economic and low education levels prevalent in the district.

Sample

The study recruited 292 pregnant women randomly selected during their antenatal clinic visits at Nsanje District Hospital. The sample size was determined using a formula by Naing.16

Inclusion and exclusion criteria

Pregnant women who were in their third trimester, those above 15 years old, those who were able to communicate in either vernacular language (Chichewa or Sena) or English and those who consented to participate in the study were recruited. The study excluded women who were not in their third trimester of pregnancy, those below 15 years old, and those who did not consent to participate in the study, and those who could communicate in neither vernacular language (Chichewa or Sena) nor English. The third trimester provides an adequate period of exposure to DV and if women experienced abuse, they could definitely report the type of abuse experienced during that timeframe.

Data collection

Recruitment

The research team arrived early to the antenatal clinic. During routine health talks, potential participants were identified by reviewing their health passports. Consent was sought and information about the study was given to each potential participant. The first client was randomly selected from among the first two clients. Thereafter, clients with the kth numbers were asked to participate in the study. Once the client volunteered to participate in the study, detailed study information was given and informed consent was obtained, and was asked to return after antenatal assessment. The respondents who could read and write independently filled in the questionnaire by ticking and writing the responses in the spaces provided. For participants who could not read and write, the researchers read and filled the questionnaires on their behalf. To ensure validity, with permission, an already developed tool by Sricumsuk11 in Thailand was pretested and adapted with modification to suit the study objectives. On average, six clients were recruited per day and it took about 25 minutes to complete filling the questionnaire by both the researcher and the participant.

Data analysis

Data was quantitatively analysed using the Statistical Package for Social Sciences (SPSS) software version 16. Descriptive statistics were computed for the demographic data and types of violence. Tests for significant differences for the categorical variables (presence or absence) of DV were computed using Chi-square tests at 5% level of significance.

Ethical considerations

Ethical clearance was obtained from the College of Medicine Research Ethics Committee (COMREC) through Kamuzu College of Nursing ethical review committee. Permission was sought from Nsanje District Health Office to conduct the study at the facility. In addition, individual informed consent was obtained from each participant before administering a questionnaire. Anonymity and confidentiality were observed through giving the participants code numbers instead of their names on the questionnaires. Every effort was made to protect participants from harm and stress, reassuarance was given to the participants for the anticipated psychological risk and nurse/idwives were available for counselling.

Results

The study participants' ages ranged from 15 to 45 years with a mean age of 25.5 years (SD= 6.6, 95% CI; 24.7–26.3) (Table 1). The majority (57.2%, n=167) of the women were aged between 15 and 25 years old. Most of the women (98.3%, n=287) were married.

Table 1

Women's demographic characteristics

Characteristics		Frequency	%
	<=25	167	57.2
Marital Status	≥25	125	42.8
	Single	2	0.7
	Married	287	98.3
	Divorced	3	1.0
Tribe	Sena	256	87.7
	Other tribes	7	12.3
Religion	Christianity	285	97.6
	Other religions	7	2.4
Education levels	Never educated	89	30.5
	Primary level	172	58.9
	Junior Certificate	24	8.2
	MSCE	7	2.4
Employment status	Unemployed	288	98.4
Monthly income levels	<MK1, 000.00	185	63.4
	MK1, 000.00- MK 5,000.00	80	27.4
	MK5, 001.00- MK10, 000.00	16	5.5
	>MK10, 000.00	11	3.8
Parity	≤Two	169	57.9
	≥Three	123	42.1
Alcohol consumption	Yes	2	0.7
Use of illicit drugs	No	292	100
Witnessing abuse in the home	Yes	182	62.3

Regarding education level, over half (58.9%, n=172) and 56.8% (n=166) of the women and their partners attended school only up to primary school level respectively. Most of the women, (98.4%, n=288) were unemployed, and 63.4 % (n=185) had a monthly income of less than MK1, 000.00 ($1.4).

Regarding witnessing abuse as a child, 62.3% (n=182) of the women witnessed abuse while they were children in their homes. The sample was predominantly (87.7%, n=256) Sena and the majority (97.6%, n=285) were Christians. Two of the women (0.7%) reported drinking alcohol on rare occasions but none reported using illicit drugs.

Overall, the findings indicate that a majority (59%) of women experienced more abuse during pregnancy, compared to the proportion (12.5%) that experienced abuse prior to the current pregnancy. Additionally, a high percentage of the women who were abused (61%, n=178) were in relationships with their current spouse for less than 60 months. Specifically, the women experienced psychological (28.1%), physical (13.6%) and sexual (28.9%) abuse during pregnancy.

Regarding education level, over half (58.9%, n=172) and 56.8% (n=166) of the women and their partners attended school only up to primary school level respectively. Most of the women, (98.4%, n=288) were unemployed, and 63.4 % (n=185) had a monthly income of less than MK1, 000.00 ($1.4).

Regarding witnessing abuse as a child, 62.3% (n=182) of the women witnessed abuse while they were children in their homes. The sample was predominantly (87.7%, n=256) Sena and the majority (97.6%, n=285) were Christians. Two of the women (0.7%) reported drinking alcohol on rare occasions but none reported using illicit drugs.

Overall, the findings indicate that a majority (59%) of women experienced more abuse during pregnancy, compared to the proportion (12.5%) that experienced abuse prior to the current pregnancy. Additionally, a high percentage of the women who were abused (61%, n=178) were in relationships with their current spouse for less than 60 months. Specifically, the women experienced psychological (28.1%), physical (13.6%) and sexual (28.9%) abuse during pregnancy. Tables 2, 3, and 4 present the frequencies of psychological, physical and sexual acts of violence women experienced during pregnancy. There were significant associations between domestic violence and witnessing abuse as a child in the home and woman being pregnant (Table 5).

Table 2

Frequency of psychological acts of violence during pregnancy

Characteristics		Never	Rarely	Occasionally	Frequent
Partner /Husband called wife names	Freq.	240	22	24	6
	%	82.2	7.5	8.2	2.1
Partner /Husband shouted at wife	Freq.	165	58	34	35
	%	56.5	19.9	11.6	12.0
Partner made important financial decisions without talking to wife	Freq.	189	17	32	54
	%	64.7	5.8	11.0	18.5
Partner/ Husband was jealous and suspicious of wife's friends	Freq.	219	48	19	6
	%	75.0	16.4	6.5	2.1
Partner accused wife of having an affair with another man	Freq.	242	29	13	8
	%	82.9	9.9	4.5	2.7
Partner monitored wife's time and made her account for where she was	Freq.	190	43	42	17
	%	65.1	14.7	14.4	5.8

Table 3

Frequency of threats and acts of physical violence during pregnancy

Characteristics		Never	Rarely	Occasionally	Frequent
Partner kicked wall, door or furniture	Freq.	269	16	5	2
	%	92.1	5.5	1.7	0.7
Partner threw, broke or smashed an object	Freq.	277	12	3	0
	%	94.9	4.1	1.0	0
Partner t threw an object at wife	Freq.	271	12	7	2
	%	92.8	4.1	2.4	0.7
Partner shook finger or fist at wife	Freq.	222	32	33	5
	%	76.0	11.0	11.3	1.7
Partner destroyed wife's properties	Freq.	278	7	4	3
	%	95.2	2.4	1.4	1.0
Partner threatened to hurt wife	Freq.	248	32	11	1
	%	84.9	11.0	3.8	0.3
Partner threatened to destroy property	Freq.	280	10	2	0
	%	95.9	3.4	0.7	0
Partner threatened to kill himself or wife	Freq.	282	7	3	0
	%	96.6	2.4	1.0	0
Partner pulled wife's hair	Freq.	267	19	6	0
	%	91.4	6.5	2.1	0
Partner grabbed wife suddenly or forcefully	Freq.	253	17	19	0
	%	86.6	5.8	6.6	0
Partner beat up wife	Freq.	227	22	40	3
	%	77.7	7.5	13.7	1.0
Partner hit wife with an object	Freq.	262	15	13	2
	%	89.7	5.1	4.5	0.7
Partner burned wife with something	Freq.	290	1	1	0
	%		0.3	0.3	0

Table 4

Frequency of Sexual violence during pregnancy

Item
Partner demanded sex from wife whether she likes it or not	Freq.	204	26	35	27
	%	69.9	8.9	12.0	9.2
Partner forced wife to have sex (Marital rape)	Freq.	216		22	37
	%	74.0	5.8	7.5	12.7
Partner used an object on wife in a sexual way	Freq.	291	0	1	0
	%	99.7	0	0.3	0

Table 5

Relationship between demographic variables and domestic violence

Demographic variable	Result
	Chi-square Value	P-Value	Results
Participant age	2.5	0.78	Not significant
Women's low education level	1.9	0.58	Not significant
Women's monthly income	7.5	0.06	Not significant
Experiencing abuse before pregnancy	17.5	0.00	Significant
Being pregnant	2.9	0.00	Significant
Witnessing abuse during childhood at home	4.5	0.00	Significant

Discussion

The magnitude of domestic violence in this study was very high and regrettable that pregnant women experienced violence. Over half of the participants experienced at least one type of abuse in the form of psychological, physical and sexual violence. These results show that the national figures, as presented by the NSO, underestimate the magnitude of and under-report the types of DV women experience. The results are attributed to the fact that the NSO reports more on physical violence, thus it does not take into account the major forms of DV, which are psychological and sexual abuse. According to NSO, the overall percentage of women who have ever experienced physical violence during pregnancy has remained about the same (5%) over the past six years.2 The percentage of women who have ever experienced physical violence since attaining 15 years of age in Nsanje was about 32% and 19% experienced physical violence in the past 12 months preceding the 2010 MDH survey2; thus the magnitude of DV against pregnant women in the district is higher than previously reported and requires interventions.

Pregnancy, because of the hormonal and psychological changes that occur, coupled with young age,17 low socio-economic status,18 unwanted pregnancy18 and stress inherent during pregnancy, 19 may increase the risk of violent assaults resulting from minor events such as refusal to have sex or inadequate home care.20, 21 One of the reasons for its high magnitude is that DV is culturally viewed as inevitable and a private matter even among married couples.1 Many women therefore suffer in silence because they view reporting DV as revealing family secrets, which brings shame and embarrassment to the family.22 There is a need for the creation of awareness within the communities on the dangers of DV especially on pregnant women. In general, the Malawian society does not approve of women reporting their husbands to police and receiving punishments over marital misunderstandings. The society views such an act as biting the finger that feeds the woman. Subsequently, creating awareness among the pregnant women, strengthening services at One-Stop centres with adequate resources, and involving the hospital management and staff are critical steps to provide comprehensive services. Ultimately, there is an increase in reporting offences and demand for services when comprehensive service packages are accessed at One-Stop centres. The comprehensive service package include emergency medical care, laboratory tests for pregnancy, sexually transmitted infections (STI) and HIV, post exposure prophylaxis (PEP) and antiretroviral (ARV), and proper trauma counselling and court preparations against the culprits. Furthermore, changing the maximum sentence to 14 years imprisonment 23 for offenders will deter would-be-offenders. Moreover, the study found abuse among pregnant women in all the age categories inconsistent with NSO findings where abuse during pregnancy was more prevalent among women aged between 15 and 19 years.2 This inconsistency is attributable to a lack of reporting among old couples in the MDHS data compared to younger abused pregnant women.2 Besides, the results show that women were abused during pregnancy despite their education levels. These findings agree with those reported by Lamichhane.24 However, other studies found a high incidence of domestic violence during pregnancy among women with less formal education.20, 25 Similarly, majority of women in the study did not go beyond primary school therefore the comparative group was a minority that could not have had any significant influence on the results regarding the relationship between level of education and DV.

The study also found that women's monthly salaries were low. These results may explain why we found a higher proportion of domestic violence during pregnancy. According to WHO report, economic dependency on husbands is another risk factor for abuse during pregnancy.26 However, there was a lack of association between income and DV in this study and may be attributed to the fact that the comparative group was very small as the majority of the women had very low income. Notwithstanding, the study found that women who witnessed abuse in the home during childhood also experienced abuse during pregnancy. This finding could possibly make the women tolerate abuse from their partners as a norm in society. Worth mentioning, domestic violence is a violation of human rights and most often women fail to exercise their sexual and reproductive health rights, including accessing health services.26 The findings agree with those reported in other studies26, 27 and deplorably, DV during pregnancy is a risk factor for low birth weight, ante partum hospitalization, induced and spontaneous abortion and other injuries.8, 9 Thus, DV puts both the mother and neonate at a risk for morbidity and mortality. Hence, early detection of DV during pregnancy is critical for good maternal and neonatal outcomes. Therefore, in-service training for health providers to screen for DV on all antenatal mothers would improve referral and treatment at One-Stop centres and ultimately enhance pregnancy outcomes. The high prevalence of DV during pregnancy in Nsanje district calls for more research in this area to determine the causes of DV in various districts or regions of the country for prevention purposes.

Limitations

It is possible that during data collection, some women that might have been abused did not speak out because DV is a sensitive issue that is perceived to be a private internal matter between a husband and wife. In addition, some women may not have disclosed their experiences of abuse to avoid shame and embarrassment. Furthermore, this was a cross-sectional study and, as such, causality cannot be infered.

Conclusion

Pregnancy is not a joyful time for all women. The magnitude of domestic violence during pregnancy is high, thus putting pregnant mothers at risk of adverse maternal and neonatal outcomes and it is a violation of human rights. The finding that the majority of women in Nsanje district were victims of DV during pregnancy requires immediate attention from the government, non-governmental organizations including Women Lawyers Association of Malawi, Men for Gender Equality Now, and community dialogue including male involvement, to prevent and reduce risks of violence during pregnancy. Community awareness of DV and its condemnation, and training health workers to screen for DV during antenatal care is crucial in Nsanje. Lastly, strengthening the victim support unit within the police service and the One-Stop centre at the hospital to provide comprehensive packages of services to the survivors of DV is fundamental.