Domestic violence during pregnancy in Uganda : the social biomedical consequences and the relationship with induced abortion

Abstract

Objectives: The specific objectives were to 1) determine the prevalence and predictors of domestic violence during pregnancy; 2) explore community perceptions of factors associated with domestic violence in Wakiso district of Uganda; 3) explore pregnant adolescents experiences and coping strategies regarding violence; 4) investigate the association between domestic violence, pregnancy intention and induced abortion; and 5) investigate whether domestic violence during pregnancy is associated with obstetric complications (leading to antepartum hospitalization) or low birth weight (LBW) delivery.

Methods: Paper I was a cross-sectional study among 379 women attending antenatal clinic in Mulago hospital, Kampala, Uganda, from January to May 2000, to assess risk factors, nature and severity of domestic violence during pregnancy. Domestic violence was assessed with the Abuse Assessment Screen (AAS) and the Severity of Violence against Women (SVAW) scale. Paper II and III were from a qualitative study conducted from August to December 2003 done in Wakiso district using triangulation of methods. Data was analyzed by thematic content analysis. Paper IV was a qualitative study involving 16 in-depth interviews with pregnant adolescent domestic violence survivors from January to May 2004. Theoretical sampling was done and Grounded theory was used during data analysis. Paper V is from a case-control study conducted in Mulago hospital, Kampala, Uganda, from September 2003 to June 2004, among 942 women seeking post-abortion care. The relationship between domestic violence, pregnancy intention and induced abortion was assessed using odds ratios derived from stratified and multivariate logistic regression analyses, adjusting for confounding and interaction at the 95% confidence level. The reasons, methods and decision-making process for pregnancy termination for adolescents and older women were compared. Paper VI was a prospective cohort study in Mulago hospital antenatal clinic and labour ward from May 2004 to July 2005. The relative and attributable risk of LBW and antepartum hospitalization (following maternal complications) were estimated using multivariate Poisson and logistic regression, adjusting for confounding by age, parity, number of children, pregnancy planning and domicile.

Results: In Paper I, over 57% of participants reported moderate to severe domestic violence. Abuse or witnessing abuse in childhood, being an adolescent and carrying the first pregnancy were significantly associated with domestic violence in pregnancy (p<0.01). In paper II and III, bride price, urban migration, changing cultural values due to modernization, men s unemployment (associated with women employment and financial as well as legal empowerment), failure to negotiate sexual relations, disagreement on household division of labor and misconceptions about pregnancy changes were associated with domestic violence. Family and social institutions offered minimal protection and often perpetuated violence. In Paper IV, coping strategies employed by pregnant adolescent survivors were minimizing damage-decreasing severity of violence, withdrawal- physical or social withdrawal, seeking help and retaliation (fighting back). In Paper V, women with induced abortion were over 8 times more likely to have unwanted pregnancy [OR 8.85 (95% CI 6.33-12.40), p<0.001], and were 18 times more likely to report domestic violence [OR 18.7 (95%CI 11.2-31.0); p<0.001] after adjusting for age, pregnancy intention and marital status. Domestic violence was one of the key reasons in decision-making for pregnancy termination. In Paper VI, mothers exposed to domestic violence delivered babies with a mean birth weight 2647.5 ± 604 g, on average 186g [(95%CI 76-296); p=0.001] lower than those not exposed to violence. After adjusting for potentially confounding variables, the relative risk of LBW delivery was 3.78 (95% CI 2.86-5.00). Exposed women had a 37% higher risk of antepartum hospitalization [RR 1.37 (95%CI 1.01-1.84)], and 19% of all LBW and 74% of antepartum hospitalization was attributable to domestic violence.

Conclusions: Moderate to severe domestic violence is common in pregnancy. Physical abuse is often associated with both sexual and psychological abuse.Bride price payment that was associated with domestic violence, with serious sexual and reproductive health implications. Coping strategies adopted by pregnant adolescent survivors involve problem-focused and emotion-focused approaches that are markedly influenced by adolescence and pregnancy. Domestic violence during pregnancy is a risk factor for unwanted pregnancy and induced abortion in Mulago hospital. It significantly contributes to the induced abortion. It is also a risk factor for both low birth weight delivery and antepartum hospitalization.