Magnitude of domestic violence and its socio-demographic correlates among pregnant women in Delhi.

CONTEXT: Domestic violence is violation of basic human rights, and poses a threat to the physical, mental, and social health aspects of women and her children. The causation of domestic violence is precipitated by many risk factors. AIMS: Aim was to estimate the magnitude of domestic violence overall, and its sub-types, among pregnant women. The study also aimed to find the associated socio-demographic determinants of domestic violence among the subjects. SETTINGS AND
DESIGN: The study was designed as a cross-sectional study to estimate the prevalence of domestic violence and to find socio-demographic correlates in its causation. A total of 1500 apparently healthy pregnant women, with gestation up to 20 weeks were interviewed. METHODS AND MATERIALS: A pre-tested semi-structured interview schedule was used to collect data on socio-demographic variables and details of domestic violence, after explaining the purpose of study to the subjects and obtaining informed consent. STATISTICAL ANALYSIS USED: Data was entered in Ms-Excel and IBM SPSS Version 25 was used for statistical analysis.
RESULTS: The findings revealed overall prevalence of domestic violence to be 29.7%, with emotional and verbal type of violence being most common type. Caste, religion, literacy status of study subjects, and occupational status of spouses of study subjects were reported as significant correlates affecting the causation of domestic violence among the subjects.
CONCLUSIONS: The findings highlight the burden and thus, stress for the need for effective involvement of all sectors in the elimination of domestic violence against women as a public health issue and develop zero-tolerance towards it. Copyright:

Introduction

Violence in any form is a major public health issue, and a violation of the basic human rights, particularly with reference to intimate partner violence and sexual violence.[1] Domestic Violence as defined under the “The Protection of women from Domestic Violence Act, 2005” in India, includes the spectrum of all harms, injuries, harassment, or endangerment to the women. The abuses or harms under the act have been classified mainly under four sections viz, Physical abuse, Sexual abuse, Verbal and Emotional abuse, and Economic abuse.[2] Violence against women is defined by United Nations (UN) as “any act of gender-based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.”[3] The issue of domestic violence has persisted globally, variably at different levels at different places. The global estimates by World Health Organization (WHO) indicate that 35% of women have experienced physical and/or sexual violence in their lifetime, which translates to every 1 in 3 women suffering from the same. Intimate Partner violence is most commonly reported. Geographical settings and developmental status do not affect significantly the occurrence of intimate partner violence, which is evident from the prevalence estimates ranging from 23.2% in high-income countries and 24.6% in the WHO Western Pacific region to 37.0% in the WHO Eastern Mediterranean region, and 37.7% in the WHO South-East Asia region (SEAR).[1] Estimates of domestic violence in India are provided by the National Family Health Survey (NFHS-4) 2015-16, which reported a prevalence of ever married women who have ever experienced spousal violence to be 28.8%. The prevalence was reported to be much higher in rural areas (31.4%), in comparison to the figures for urban areas (23.6%).[4]

Various common social and demographic determinants have been found to be related to domestic violence. A variety of factors at different levels of woman's life, and within different contexts have been related to domestic violence globally. These factors include various individual factors (education level, financial autonomy, level of empowerment, previous history, etc.), partner factors (communication with partner, employment status of partner, etc.), and factors related to immediate social context (inequalities in mobility, economic power, autonomy, etc.).[5] Studies in India have reported age, illiteracy, belonging to lower caste, lower household income, duration of marriage, urban residence and so forth as the various risk factors of domestic violence in India.[16789] WHO reports gender inequality and norms on acceptability of violence against women as a root cause. Violence during pregnancy has been reported to increase the incidence of miscarriage, pre-term delivery, still births and low birth weight babies. In addition to this, it also has an impact on children, who may suffer from a range of behavioral and emotional disturbances, and also, higher rates of morbidity and mortality.[1] A working knowledge of the burden and factors affecting the perpetration of domestic violence will aid in inputs for policy making and development of a sustainable and effective response of the public health system, especially at the primary care level.

With the above stated background, the following study was planned to estimate the magnitude of domestic violence and its various subtypes, experienced by pregnant women in Delhi. The study also aimed to analyze the associated socio-demographic factors or determinants among them, in relation to occurrence of domestic violence.

Subjects and Methods

The study was designed as a cross-sectional study, which was conducted in the Ante-natal Clinic (ANC) of Lok Nayak Hospital (LNH), a tertiary-care hospital situated in the Central District of Delhi. The inclusion criteria were defined to include pregnant women with gestation period up to 20 weeks, who are residing in Delhi for more than 1 year and are attending the ante-natal clinic in Lok Nayak Hospital. Pregnant women with mental handicap or incapacitating physical health problems, were excluded from the study. Women who were apparently healthy, based on self-reports, and gave consent for inclusion in study, were recruited for the study. The sampling done was consecutive sampling, and a total sample size of 1500 was taken, which was estimated based on NFHS-4 figures for urban areas in NCT of Delhi, which reported the prevalence to be 23.6%, and taking 10% relative error.[10] The data collection was done by a pre-tested semi-structured interview schedule, administered by trained staff. They were validated by back translation to Hindi language and retranslation to English. The questionnaire collected data on socio-demographic variables, and assessment of any form of violence present during pregnancy.

Approval for the study was obtained from the Institutional Ethical Committee (IEC) (25/11/2013). The purpose of the study was explained to all the study subjects beforehand, and confidentiality of data was ensured. Written informed consent was obtained from all the study participants before inclusion in the study.

The data was entered in Ms-Excel, and later, analyzed using the software Statistical Package for Social Sciences (SPSS) Version 25 by IBM Corporation. Appropriate statistical tests were applied and a P value of < 0.05 was considered to be significant.

Results

Analysis of socio-demographic details of the study subject revealed that, majority (84.3%) of the study subjects belonged to the age group of 20–29 years. Age at marriage was in the age group of 18–25 years for 84.4% of the study subjects. One in 10 study subjects were married before the age of 18 years. Majority of the study subjects were of General Caste (82.9%), resided in a joint family (68.1%), and were housewives by occupation (95.7%). More than 50% study subjects were educated up to high school and above [Table 1].

Table 1

Socio-demographic details/characteristics of the study subjects

Characteristics of the study population	Number of pregnant women n (%) (n=1500)
Age in years
10-19	52 (3.5)
20-29	1264 (84.3)
>=30	184 (12.3)
Age at marriage
<18	154 (10.3)
18-25	1266 (84.4)
26-30	76 (5.1)
31-35	4 (0.3)
Duration of Stay in Delhi
≥1 to<3 Years	272 (18.1)
≥3 to 5 Years	96 (6.4)
≥5 years	1132 (75.5)
Caste
General	1243 (82.9)
OBC	152 (10.1)
SC	100 (6.7)
ST	5 (0.3)
Religion
Hindu	652 (43.5)
Muslim	848 (56.5)
Type of family
Joint	1022 (68.1)
Nuclear	478 (31.9)
Education status
Illiterate	198 (13.2)
Below Primary	42 (2.8)
Primary	366 (24.4)
High School	384 (25.6)
Senior Secondary	272 (18.1)
Graduate and above	238 (15.9)
Occupation Status
Unemployed/Housewife	1436 (95.7)
Unskilled worker	11 (0.7)
Semi-skilled worker	11 (0.7)
Skilled worker	18 (1.2)
Clerical/Shop owner	3 (0.2)
Semi-Professional	5 (0.3)
Professional	16 (1.1)

Among the partners of the study subjects, only 12.7% were illiterate, and majority (>60%) were educated up to high school or above. Only 1.5% partners of the study subjects were unemployed, and 75.7% were unskilled, semi-skilled, or skilled workers.

The magnitude of any type of domestic violence as reported by the study subjects was found to be 29.7% (N = 445). Out of these 445 study subjects who experienced domestic violence, the prevalence of the types of domestic violence viz. physical, economical, emotional and verbal, and sexual violence were 26.9%, 37.0%, 79.1%, and 33.2%, respectively. The prevalence of emotional and verbal type of violence was reported to be maximum, compared to the other types. The responses to the typology of domestic violence were not mutually exclusive, with many study subjects reporting more than one or all types of violence [Table 2].

Table 2

Domestic Violence among the study subjects during the study period

Domestic Violence	n (%) (n=1500)
Present	445 (29.7)
Absent	1055 (70.3)
Type of Domestic Violence	n (%) (n=445)
Physical	120 (26.9)
Economical	165 (37.0)
Emotional and Verbal	352 (79.1)
Sexual	148 (33.2)

Table 3 shows the relationship between domestic violence and the socio-demographic determinants among the study subjects. The magnitude of domestic violence was significantly higher in women belonging to general caste, compared to those belonging to other castes viz. SC, ST, OBC (P value = 0.024). With respect to religion, the study subjects of Hindu religion, experienced domestic violence significantly more (P < 0.001) in comparison to those of Muslim religion. Study subjects who were illiterate had reported a significantly higher prevalence of domestic violence (36.9%) with a P value of 0.008. The study subjects whose spouses were unemployed reported a significantly higher proportion of domestic violence (52.2%) [Table 3].

Table 3

Relationship between domestic violence and the socio-demographic determinants of the study subjects

Socio-demographic Determinant	Antenatal women who suffered from Domestic Violence n (%) (n=445)	Antenatal women who did not suffer from Domestic Violence n (%) (n=1055)	P
Age Group (years)
10-19 20-29	15 (28.8) 361 (28.6)	37 (71.2) 903 (71.4)	0.61
≥30	49 (26.6)	135 (73.4)
Age at Marriage (years)
10-17	61 (39.6)	93 (60.4)	0.024
18-25	362 (28.7)	904 (71.3)
26-30	20 (26.3)	56 (73.7)
≥31	2 (50.0)	2 (50.0)
Caste
General	361 (29.0)	882 (71.0)	0.024
SC	46 (46.0)	54 (54.0)
ST	0 (0.0)	5 (100.0)
OBC	38 (25.0)	114 (75.0)
Religion
Hindu	224 (34.4)	428 (65.6)	0.0004
Muslim	221 (26.1)	627 (73.9)
Type of Family
Joint	292 (28.8)	723 (71.2)	0.271
Nuclear	153 (31.5)	332 (68.5)
Education Status of study subjects
Illiterate	73 (36.9)	125 (63.1)	0.008
Below Primary	12 (28.6)	30 (71.4)
Primary	93 (25.4)	273 (74.6)
High School	133 (34.6)	251 (65.4)
Senior Secondary	73 (26.8)	199 (73.2)
Graduate and above	61 (25.6)	177 (74.4)
Occupational Status of study subjects
Unemployed/Housewife	422 (29.4)	1014 (70.6)	0.270
Unskilled Worker	6 (54.5)	5 (45.5)
Semi-skilled Worker	3 (27.3)	8 (72.7)
Skilled Worker	8 (28.6)	20 (71.4)
Clerical/Shop Owner	1 (33.3)	2 (66.7)
Semi-professional	0 (0.0)	5 (100.0)
Professional	5 (31.3)	11 (68.7)
Education Status of spouses of study subjects
Illiterate	67 (35.1)	124 (64.9)	0.114
Below Primary	6 (25.0)	18 (75.0)
Primary	75 (24.1)	236 (75.9)
High School	136 (30.5)	310 (69.5)
Senior Secondary	84 (32.6)	174 (67.4)
Graduate and above	77 (28.5)	193 (71.5)
Occupational Status of spouses of study subjects
Unemployed	12 (52.2)	11 (47.8)	0.048
Unskilled Worker	115 (31.6)	249 (68.4)
Semi-skilled Worker	112 (30.2)	259 (69.8)
Skilled Worker	125 (31.3)	275 (68.7)
Clerical/Shop Owner	50 (23.9)	159 (76.1)
Semi-professional	14 (24.1)	44 (75.9)
Professional	17 (22.7)	58 (77.3)

*Percentage shown are among the specific label of the socio-demographic determinant

However, no significant association of domestic violence was found with the age, age at marriage, type of family, occupational status of the study subjects. Also, no significant relationship was found with years of marriage and years of cohabitation. Age of spouse and educational status of the spouses of the study subjects were also not found to be associated with domestic violence.

Discussion

The results highlight an overall prevalence of domestic violence in pregnant women to be 29.7%, which is slightly lower than the global reported prevalence of 35.0%.[1] The findings are similar to study by Rathore AM et al., who reported an experience of abuse among pregnant women in Delhi to be 21.0%. Majority of the women (93.5%) reported recurrent abuse during pregnancy. The figures were reported in 1999, thus highlighting an increase in prevalence over the years, suggesting the role of socio-demographic indicators as a contributing factor for the same.[9] A recent study by Priya A et al. in an urbanized village in Delhi, reported 23% screened to be positive for domestic violence, with subtype analysis reporting prevalence of physical violence to be 60%.[10] A study by Dasgupta A et al. in Mumbai found similar results, with 29.4% women reporting physical and/or sexual violence in the year prior to pregnancy.[11]

The prevalence figures reported in the study are similar to the prevalence of 28.8% reported in the factsheet of NFHS-4 (2015-16) for India.[4] As per the NFHS-4 (2015-16) findings for the National Capital territory of Delhi, prevalence of domestic violence was reported to be 26.8%, and it is a significant increase from the prevalence of 16.3% reported in the NFHS-3 survey (2005-06).[12] A much higher prevalence of domestic violence (56.0%) among women has been reported in a study by Babu BV et al. in Eastern India, with husbands being responsible for the same in majority of the cases. Psychological form of violence was reported to be maximum among the subtypes at 52% prevalence. The figures for prevalence of emotional and verbal violence reported in our study were much higher at 79.1%. Similarly, slightly higher figures were also seen for prevalence of physical (26.9%) and sexual (33.2%) violence among pregnant women in our study, in comparison to the figures reported for the same (16.0% and 25.0%, respectively) among women in Eastern India.[78] A multicentric study covering 18 states in India, by Mahapatro M et al., concluded that overall 39.0% women were abused. Psychological violence and physical/sexual violence were reported at 37.0% and 14.0%, which are much lower than the figures reported in our study.[6] Psychological viz. Emotional violence is the most common violence reported in our study, with similar findings being reported in many national, international, and multi-country analyses.

The socio-demographic determinants related to domestic violence, as revealed in the above study are caste (General), Hindu religion, illiteracy and occupation status of spouses (unemployment) of study subjects. Study by Priya A et al. in 2019 in a similar setting reported the predictors for domestic violence as educational status of the spouses and substance abuse by the spouses.[10] Similar spectrum of risk factors has been reported in various studies across India and globally. Urban residence, older age, lower education, lower family income were reported as significant risk factors for occurrence of domestic violence against women in Eastern India by Babu BV et al.[78] The multicentric study by Mahapatro M et al. in 2012 reported the risk factors of domestic violence in India to be lower household income, belonging to a lower caste, illiteracy, and drinking/betting habits among spouses, by using Multivariate logistic regression analysis.[6]

A multi-country study report by WHO in 2011 analyzed various factors associated with recent intimate partner violence among women. They reported secondary education, high socio-economic status, and formal marriage as protective against domestic violence. Whereas, on the other hand, alcohol abuse, cohabitation, supportive attitude, and young age were reported as factors associated with increased risk of the same. The association was much more when the factors were reported in both the women and partner.[13] Studies conducted in other countries like Bangladesh, Egypt have reported similar determinants for domestic violence viz. young age, illiteracy/lower education, low income, positive history of family disputes and so forth in the causation of domestic violence.[1415]

The above study findings highlight the significant prevalence and determinants of domestic violence in pregnant women. The presence of domestic violence at this stage is a major health hazard to both the mother and the coming child. Antenatal Care clinic attendance can be utilized as a unique opportunity for screen for presence of domestic violence and mount suitable intervention for the same. Along with the provision of routine screening in primary care, inclusion of the practice of pre-marital counseling sessions, as well as health education sessions in schools/universities are also recommended, based on the findings. It is also required to sensitize the concerned agencies, in order to effectively implement the laws against domestic violence. Higher prevalence among illiterates highlights the role of educating the females as a preventive factor for incidence of domestic violence. The higher rates of urban migration in India, contribute to a much higher population density, and thus, higher rates of unemployment are seen, both among women and their partners. Hence, provision of jobs and thus, financial protection to all may serve as an overall protective factor for domestic violence.

Hence, the above findings stress the need for engagement of all sectors in eliminating tolerance for domestic violence against women, and that too especially with more focus on those who are affected by the related determinants of violence. Also, there is a need to improve the existing health sector's capacity to respond effectively to domestic violence against women, in order to ascertain effective response where required, and thus, prevent adverse health outcomes.

A pre-experimental study by Arora S et al. demonstrated that counseling sessions by trained counselors for women suffering from domestic violence during the antenatal period, developed their ability to recognize the impact of violence and the need to speak against it. Also, they reported better health status after the intervention. This highlights the probable utility of individual counseling at primary care level and above, as a tool for prevention and minimizing the impact of domestic violence among women.[16] Studies have highlighted the critical role of the health system in India to address the domestic violence in relation to both immediate biomedical concerns, as well as her overall well-being.[17] Development of a system that provides more constructive and sustainable response to domestic violence in India, will definitely lead to a positive improvement in women's health and well-being.

Financial support and sponsorship

DHR and ICMR, MoHFW.

Conflicts of interest

There are no conflicts of interest.