Prevalence of intimate partner violence among pregnant women attending a public sector hospital in Bengaluru, southern India

Study area, participants and recruitment

We included pregnant women who were availing of antenatal care at Jayanagar General Hospital, which is an urban public sector subdistrict hospital in Bengaluru. This cross-sectional study was conducted within an ongoing cohort study, the study protocol of which has been published earlier.²² The study participants were recruited according to the eligibility criteria of the study protocol. Those with a confirmed pregnancy of or less than 24 weeks, above the age of 18 years of age and without any obstetric complications were included. The rationale for including study participants of or less than 24 weeks is that a major proportion of pregnant women register for antenatal care at the hospital at around 24 weeks of gestational age. We analysed data of 350 pregnant women who fulfilled the eligibility criteria and had completed the baseline visit of the study from August 2017 to July 2018. Voluntarily signed consent was obtained from those who were willing to participate in the study, after having explained the nature and purpose of the study.

Data elements and data capture

A custom-designed Android-based App Cascade version 2.0.0 developed by Athenaeum Technologies Private Limited was used for electronic data capture. Details of IPV and the possible risk factors were recorded. The risk (independent) factors were categorized into three levels:

• Individual level: Respondent’s age, education, occupation, gravidity, planned or unplanned pregnancy, substance abuse, presence of depression and anxiety.

• Partner-related: Spouse’s education, occupation and marital discord.

• Household/community-related: Socioeconomic status, social support, religion, consanguinity.

Measurement of intimate partner violence (dependent variable)

We used the Conflict Tactics Scale (CTS) to determine the presence of IPV.²³ This scale is known to be effective in measuring partner violence and can be easily adapted for use in different cultural situations. About 80 countries have used CTS as a part of demographic health surveys, including the NFHS which is conducted in India.¹⁵ CTS has shown a high internal reliability, high sensitivity and construct validity, even in patriarchal societies in the non-western world.²⁴ It includes scales to measure physical and sexual assault as well as psychological aggression against a partner.

Measurement of independent variables

The socioeconomic class of the respondents was classified according to the Modified Kuppuswamy Socioeconomic Scale.²⁵ The scale uses education and occupation of the head of the family and monthly family income to calculate socioeconomic status; classified as upper class, upper middle class, lower middle class, upper lower class and lower class. The presence of anxiety was assessed using the 10-item Revised-Pregnancy-Related Anxiety Questionnaire, which has an internal consistency (Cronbach’s alpha) of 0.79.²⁶ Each item is scored on a 4-point scale with cut-off scores of 28 and 24 for primigravida and multigravida women, respectively. The Revised Dyadic Adjustment Scale was used to measure marital discord.^27,28 It estimates seven dimensions of relationship between the partners within three categories: decision-making, values and affection. It consists of 14 items in which respondents can rate their relationship on a 6-point scale. Scores range from 0 to 69, the higher the score, the greater is the relationship and vice versa. The cut-off score was taken as 48 for this study.

The adequacy of social support was measured using the Multidimensional Scale of Perceived Social Support Scale.^29,30 Responses to the 12 questions are scored on a point rating scale ranging from ‘very strongly disagree’ to ‘very strongly agree’. The scale assesses the perceptions of social support adequacy from three specific sources: family, friends and ‘significant other’. A score of less than 2 is considered as low support, a score of 3 to 5 as moderate support while a score of more than 5 is high support. The Edinburgh Postnatal Depression Scale which is a widely used 10-item self-report instrument was used to measure depression.³¹ This scale consists of ten short questions with a choice of four answers that closely reflect on how the respondent felt over the past 7 days. Respondents who scored above or equal to 13 were likely to be suffering from depression.

Statistical analysis

Data were retrieved from the data server. Data cleaning was done and then analysed using SPSS version 22. Descriptive statistics were used to summarize the age of the respondents in terms of mean and standard deviation while the prevalence rate of IPV is presented as percentage. The independent variables were categorized to analyse the association between each independent and outcome variable using a univariate analysis. IPV, as the dependent variable was dichotomized into presence or absence of IPV. The strength of association was expressed as crude odds ratio with 95% confidence interval. Variables found to be associated at p<0.2 in the univariate analysis were entered into a multivariate logistic regression model to eliminate the effects of confounding due to age, education, religion and socioeconomic status. Variables with p<0.05 in the multivariate analysis were considered to be statistically significant.

Sociodemographic characteristics of the respondents

Table 1 shows the sociodemographic characteristics of the study participants. The mean (SD) age of the respondents was 23.05 (3.4) years. Of the 350 respondents, the majority (70%) were above 20 years of age, over 72.3% were Muslims, and 64.3% had completed high school education and above, while the spouses of 50.4% had similar education. Over 92% were homemakers while over half (53.1%) of the respondent’s spouses were semi-skilled workers. As many as over half of the study participants (57.4%) belonged to the upper lower class.

Prevalence of IPV

The prevalence of IPV was 3.7% among the 350 pregnant women.

Risk factors and intimate partner violence

Individual level. The adjusted odds of IPV were significantly higher among women over 20 years of age (adjusted odds ratio [AOR] 1.82 [95% CI 1.12–2.97]). Multigravid women were more likely to report IPV (crude odds ratio [COR]=1.49 [95% CI 0.50– 43.57]) although the association was not significant. Respondents who were depressed were six times or more likely to experience IPV (AOR 6.84, 95% CI 1.76–26.61); the association was significant (p=0.005). Other factors such as education, occupation and unplanned pregnancy did not show any significant relationship with IPV.

Partner level. Respondents whose spouse was engaged in semi-skilled or skilled labour (COR 1.53, 95% CI 0.41–5.67) seemed to be at a higher risk, although there was no significant association. Women who reported marital discord were 2.87-times more likely (COR 2.87, 95% CI 0.77–10.62; AOR 2.159, 95% CI 0.55–8.45) to experience IPV, this was significant on univariate analysis (p=0.114) but not on multivariate analysis (p=0.14).

Household/community level. Respondents who belonged to the lower middle class (COR 2.52, 95% CI 0.29–21.57) had a higher odds of IPV although the association was non-significant. The presence of IPV was 1.79-times higher among women with moderate social support (COR 1.79, 95% CI 0.50–6.36) and 1.3-times more for women with low social support (COR 1.30, 95% CI 0.30–5.58); however, the relationship was not significant. Similarly, consanguinity appeared to be a protective factor as the odds of IPV (COR 0.17, 95% CI 0.02–1.35) were significantly lower on univariate analysis (p=0.094) but not on multivariate analysis (p=0.14).

Limitations

Our study was conducted in an urban public sector hospital setting where antenatal care is mostly availed by pregnant women belonging to the lower- and middle-income groups in a community, giving rise to a selection bias. Hence, our results cannot be extrapolated to a general population of pregnant women. The presence of IPV was elicited by means of self-reported questionnaire, which was nested within a long proforma used for baseline data collection in the ongoing cohort study. This could have resulted in response bias. Since this was not an independent study, certain risk factors associated with IPV such as partner substance abuse, partner jealousy, history of previous abuse and gender expectations for the unborn child could not be elicited. The study did not estimate protective factors such as service utilization and formal or informal interventions for IPV which could have influenced the prevalence of IPV.

Conclusion and recommendations

The prevalence of IPV was low in our study population. Nevertheless, since IPV could potentially increase the risk of adverse pregnancy outcomes, screening for IPV and early intervention may be included as a part of routine antenatal care. Future research should be directed at strengthening evidence on the association of IPV with negative obstetric, postnatal events, offspring growth and development.