"Silent sufferers: A study of domestic violence among pregnant women attending the ANC OPD at a Primary Health Care Centre".

INTRODUCTION: Domestic violence against women is one of the most pervasive abuses of human rights in the world. Violence during pregnancy leads to both acute injuries and profound long-term challenges to health and wellbeing. Pregnancy provides a good opportunity for healthcare personal to screen women for domestic violence. AIM: To identify the pattern of domestic violence amongst pregnant women and to plan appropriate interventions. SETTINGS AND
DESIGN: This cross-sectional study was carried out at Primary Health Care Centre. METHODS AND MATERIAL: 90 pregnant women attending the ANC OPD and fulfilling the inclusion criteria were interviewed using a semi-structured questionnaire. Data were compiled and analyzed using SPSS version 24. Percentages were calculated and Chi-square test was used wherever applicable.
RESULTS: Violence was mostly seen in the women who were married for five years (47.36%) and many among them experienced it within one year of marriage (34.28%). The most common violence faced by the women was verbal violence (44.73%), followed by financial violence (27.63%). Physical violence was experienced by 22.36% women. The Perceived risk factor for violence was mostly addiction of spouse in 26.31% of women and insufficient dowry and demand for male child in 19.73%.
CONCLUSIONS: As occurrence of violence was found to be significantly associated with duration of marriage, educational status, and earning status of women asking about intimate partner violence should be a part of routine antenatal care for early detection and identification of cases, their counseling, and appropriate interventions. Copyright:

Introduction

Domestic violence against women is one of the most pervasive abuses of human rights in the world. It is a barrier to women's empowerment and hinder their equal participation in society. World Health Organization has defined domestic violence as “the range of sexually, psychologically, and physically coercive acts used against adult and adolescent women by current or former male intimate partners“.[1] Prevalence of domestic violence in pregnancy in both developing and developed countries is reported to be 33%.[2]

Violence against pregnant women has been persistent social issue that has multiple health implications on the mother as well the child thus understanding its impact could help in shaping context-specific intervention programs. Various non-government organizations like Society for nutrition, education, and health action (SNEHA) are working to improve the health of women and children in Mumbai and for the prevention of violence against women and children.[3]

Aim and Objectives

The aim of the study was to identify the factors and patterns of domestic violence amongst pregnant women and to evolve recommendations to plan intervention services for them.

To identify the socio-demographic factors of pregnant women who have experienced domestic violence

To determine the type of domestic violence and the circumstances under which it was experienced by the women.

Material and Methods

This is a cross-sectional descriptive study that was approved by Institutional Ethics Committee (IEC) of Seth GS Medical College & KEM Hospital, Mumbai. It was carried out from 1 September to 15 October, 2018 at the Primary Health Centre affiliated to the Department of Community Medicine. The primary health center runs weekly ANC clinics. Approximately 20 − 25 pregnant women visit the clinic every week. Although it was planned to interview all pregnant women visiting the clinic, 90 of them agreed to participate in the study. Those women who refused to participate in the study and those who were accompanied by their family members were excluded to ensure confidentiality. Rapport building was done with the help of accredited social health activist (ASHA) worker and auxiliary nurse midwife (ANM). After obtaining informed consent, data were collected with the help of a pretested and semi-structured interview schedule. Study participants were interviewed in a separate room available at primary health center (PHC) and privacy and confidentiality were maintained throughout. Each and every participant of the study were counseled in general along with detailed personal counseling of women who were suffering from domestic violence encouraging the utilization of antenatal care services to prevent the health consequences of domestic violence. A trained counselor from SNEHA NGO counseled the women in case a history of domestic violence was disclosed. If needed, family members were also called up for counseling. The participants were further guided and provided with legal help if needed. Approval for the study was obtained from the Institutional Ethical Committee (IEC)(05/05/2018). Collected data were compiled and analyzed using SPSS version 24. Percentages were calculated and Chi-square test was applied wherever necessary.

Results

The number of pregnant women interviewed in this study was 90. It was found that 84.44% (76) women experienced one or the other form of violence. Table 1 shows the socio demographic profile of respondents. A total of 70% (63) were Hindus and 18.88% (17) were Muslims. A total of 50 (55.54%) women were in the age group of 20 − 25 years. A total of 56.65% (53) of the women who experienced violence were educated upto middle school. Most of the women in the study, i.e., 66.6% (60) were housewives and had no source of income, as against 33.3% (30) who had some source of income. According to the type of family, 42 (46.66%) of the females who experienced violence were living in three generation families.

Table 1

Relationship between Domestic violence and socio-demographic determinants of the respondents

Sociodemographic variable	Violence			Statistical value ‘P’
	Present (n=76)	Absent (n=14)	Total (n=90)
Religion
Hindu	54 (60%)	9 (10%)	63 (70%)	0.56
Muslim	13 (14.44%)	4 (4.44%)	17 (18.88%)
Others	9 (9.99%)	1 (1.11%)	10 (11.12%)
Age group in years
<20	2 (2.22%)	0	2 (2.22%)	0.07
20-25	42 (46.66%)	8 (8.88%)	50 (55.54%)
25-30	29 (32.22%)	6 (6.66%)	35 (38.88%)
>30	3 (3.33%)	0	3 (3.33%)
Earning status
Earning	22 (24.44%)	8 (8.88%)	30 (33.3%)	0.03
Non-earning	54 (60%)	6 (6.66%)	60 (66.6%)
Socioeconomic status
I	6 (6.66%)	3 (3.33%)	9 (10%)	0.02
II	5 (5.55%)	4 (4.44%)	9 (10%)
III	20 (22.2%)	3 (3.33%)	23 (25.55%)
IV	18 (20%)	3 (3.33%)	21 (23.33%)
V	27 (30%)	1 (1.11%)	28 (31.11%)
Type of family
Nuclear	16 (17.77%)	7 (7.77%)	23 (25.55%)	0.03
Joint	18 (20%)	4 (4.44%)	22 (24.44%)
Three generation	42 (46.66%)	3 (3.33%)	45 (50%)

Table 2 shows that out of 84.44% of women who experienced violence 27.77% (25) were educated upto primary while (25) 27.77% women were educated upto middle school. Husbands of these women who were involved in violence were mostly educated upto primary 28.88% (26) and middle school 31.11% (28). 22.22% (20) women who were having more than one female child experienced violence.

Table 2

Relationship between other variables and domestic violence

Sociodemographic variable	Violence		Total	Statistical value ‘P’
	Present	Absent
Education of women
Illiterate	3 (3.33%)	2 (2.22%)	5 (5.55%)	0.01
Primary	25 (27.77%)	2 (2.22%)	27 (30%)
Middle school	25 (27.77%)	3 (3.33%)	28 (31.11%)
High school	17 (18.88%)	2 (2.22%)	19 (21.11%)
Intermediate and above	6 (6.66%)	5 (5.55%)	11 (12.22%)
Education of husband
Illiterate	8 (8.88%)	2 (2.22%)	10 (11.11%)	0.03
Primary	26 (28.88%)	1 (1.11%)	27 (30%))
Middle	28 (31.11%)	3 (3.33%)	31 (34.44%)
High School	8 (8.88%)	4 (4.44%)	12 (13.33%)
Intermediate	6 (6.66%)	4 (4.44%)	10 (11.11%)
Number of female children
0	5 (5.55%)	1 (1.11%)	6 (6.66%)	0.8
1	18 (20%)	3 (3.33%)	21 (23.33%)
>1	20 (22.22%)	2 (2.22%)	22 (24.44%)
Property in her name
Yes	14 (15.55%)	2 (2.22%)	16 (17.77%)	0.7
No	62 (68.88%)	12 (13.33%)	74 (82.22%)

Table 3 shows the various determinants of violence. The perpetrators of violence were mostly husbands in 56.57% (43) of cases and mother in law in 30.26% (23). Some of the women were abused by both their husbands as well as their mother-in-law. 30.26% (23) of the women faced violence daily and 38.15% (29) of them faced violence weekly. In 47.36% (36) women violence was mostly seen who were married for five years. In (26) 34.28% women violence started within one year of marriage. 77.63% (59) of women discussed about violence with their family members while others suffered in silence believing it will get over.

Table 3

Determinants of Violence

Determinant variable	Number (percentage) (n=76)
Frequency of violence
Daily	23 (30.26%)
Weekly	29 (38.15%)
Monthly	24 (31.57%)
Perpetrator
Husband	43 (56.57%)
Mother in law	23 (30.26%)
Sister in law	10 (13.15%)
Violence started after marriage
In Less than one year	26 (34.28%)
1-5 year	36 (47.36%)
After 5 years	14 (18.42%)
Discussed with family
Yes	59 (77.63%)
No	17 (22.36%)

Table 4 the most common violence faced by the women was Verbal violence (34) 44.73%, followed by financial violence (21) 27.63% and physical violence (17) 22.36%. There were multiple types of violence faced by each woman. Most common kind of physical assault was slapping and punching in (6) 35.29% of respondents followed by pushing and throwing objects in (4) 23.52% and 3 (17.64%) of respondents respectively.

Table 4

Types of violence experienced by the respondents

	Number (Percentage)
Types of violence
Physical	17 (22.36%)
Sexual	4 (5.26%)
Verbal	34 (44.73%)
Financial	21 (27.63%)
Type of Physical violence
Slapping/Punching	6 (35.29%)
Pushing	4 (23.52%)
Throwing objects	3 (17.64%)
Hitting with rod or stick	2 (11.76%)
Kicked	2 (11.76%)

Table 5 the Perceived risk factor for violence was mostly addiction of husband in (20) 26.31% of women and insufficient dowry and demand for male child in (15) 19.73%.

Table 5

Reasons given by respondents for violence

Reason	Number (Percentage)
Addiction	20 (26.31%)
Dowry	15 (19.73%)
Demand for male child	15 (19.73%)
Poor family income	12 (15.78%)
Arguing back	7 (9.21%)
Husband extramarital relationship	1 (1.31%)
Unknown	6 (7.89%)

Discussion

In the present study, most of the women (84.44%) experienced violence in some form or other. Most of them were in the age group of 20 − 25 years (46.66%) while in a study done by George J et al.[4] in South India maximum violence was seen in the age group of 18 − 34 years and violence was comparatively less among women above 35 years of age. A total of 2.22% of women who were below 20 years of age faced violence showing that younger age group women are prone to violence which may be due to their early marriages as they may not be mature enough. More than half (55.54%) of the women who experienced violence were educated upto primary or middle school similar results were found by Shambhavi et al.[5] were almost 45% of women who experienced violence were not educated. Thus showing that education of women plays a significant role in determining the occurrence of violence. Similar results were seen by Bontha V Babu et al.[6] who did a study in eastern India. Housewives or women who were financially dependent on their husbands were affected more with violence in this study as compared to women who were working, similar to findings by D. Ghosh[7] and this association between the earning status of women and domestic violence was found to be significant. Husbands of women who were facing violence were mostly educated up to middle (28.88%) or high school (31.11%). Education of the husband was also found to be significantly affecting violence similar to the results of Kalokhe AS.[8] 50% of the women who experienced violence belonged to socioeconomic status V and IV similar to the study done by Ram A[9] in South India who found that low socioeconomic status is a major determinant for domestic violence. A total of 46% of the women who were facing violence belonged to three-generation families. Women living in nuclear families experienced lesser violence similar to the findings of Khadilkar HA.[10] More violence was seen in women having more than one female child although this association was not found to be significant. Most of the women who were facing domestic violence didn't had any property or asset in her name similar to the findings of Sinha A.[11]

The perpetrators of violence were the women's husband (56.57%) in majority of cases followed by mother in law (30.26%) similar to the findings of Sinha A[11] and P Singh.[12] In majority of cases (47.36%) violence started mainly after one year of marriage while (34.28%) of women violence started within one year of marriage showing that chances of experiencing violence is more in females who are newly married (<5 years) rather than those who has married with the person for > 10 years similar to the findings of Shambhavi et al.[5]

The most common form of violence faced by these women was verbal (44.73%), financial (27.63%) followed by physical violence (22.36%). The findings are similar to the study done by Shrivastav et al.[13] where the prevalence of Verbal violence was found to be 86.1% followed by physical violence in 63.4% and Garg et al.[14] who also found that verbal violence followed by economical violence was mainly present. In a study done by Jeyaseelan et al.[15] physical violence was found to be 26%. Most common form of physical violence faced by women was slapping and punching (35.29%) followed by forceful pushing (23.52%) similar to the findings of Ruikar,[16] Khot A[17], and Sharma KS et al.[18] Violence was observed at least once in a week in most of the women and many of them faced it daily. Majority of the women have discussed violence with her family members. Although the most common reason was found out to be addiction among husbands (26.31%), insufficient dowry (19.73%) and demand for male child (19.73%) were also equally responsible for violence. In 7.8% of women, the reason for the violence was not known. Similar results were found by Priya A et al.[19] who found out that husbands who were involved in substance abuse were more likely to be involved in domestic violence.

Thus as we can see that pregnancy is that time when women are more receptive, it provides a window of opportunity to screen women for domestic violence through systematic approach at the first point of contact with the primary care physicians at the primary health care center. Thus, opportunistic screening for domestic violence can be done while women are making routine ANC visits. Physician can train the community level health workers such as ASHA and Anganwadi workers as they routinely interact with women. He can also counsel the family members coming with the women regarding the ill effects of violence on the mother as well as the child in case any history of violence is elicited. He can also play an important role in creating awareness regarding the legal options available or directing women to self-help groups or non-governmental organizations working for domestic violence. Addressing the issue of domestic violence at the primary health care level can play an important role in the detection and management of violence by creating a safe and confidential environment for facilitating disclosure of violence. Appropriate institutional mechanism can be established to address the determinants and outcomes of domestic violence after its disclosure at the primary health care level itself.[20]

Conclusions

The study findings depict that occurrence of violence is significantly associated with the duration of marriage, socio-economic status, education status of both women as well the spouse, addiction, etc., and early marriages. Combined counseling of couples and families and intervention if needed on various determining factors of violence like addiction, gender perceptions, etc., can be integrated with the antenatal service package of primary healthcare. Training of primary healthcare physicians and frontline workers focusing on key problems can be of immense help to deal with the issue.

It was observed that the earning status of women was associated with the violence. Proportion of non-earners facing violence was more. Therefore, it is imperative to strengthen the mechanisms for the financial capacity building of women through vocational training to run their own small-scale enterprises. They can be made aware about government-run programmes for women empowerment and welfare during all possible points of contact at the primary health care level.

Based on the results of the present study, it can be concluded that eliciting history of domestic or intimate partner violence in a structured manner can aid in gaining insight into social determinants of maternal and child health from a broader perspective. Early identification and detection of such cases on a routine basis can be integrated in primary health care service delivery. Community-based networks can be established at the primary health care level through collaboration with local administration and non-government organizations working for the same cause. It may prove as a sustainable intervention to prevent this deep-rooted social evil and its health consequences at the community level. Further research can be planned to assess the impact of such intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.