Domestic Violence During Pregnancy in Uganda
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Abstract of the thesis
Background: The 2000/2001 Uganda Demographic and Health Surveillance report indicated that domestic violence, unwanted pregnancies and induced abortion were common Reproductive Health problems in Uganda. Women’s and men’s perception of domestic violence or linkage of violence to reproductive ill-health was not known as no prior studies had explored pregnancy-related adverse effects.
Objectives: The general objective was to investigate the social context and biomedical consequences of domestic violence during pregnancy. Specifically, the objectives were to determine the prevalence and predictors of domestic violence during pregnancy; explore community perceptions of factors associated with domestic violence in Wakiso district of Uganda; explore pregnant adolescents’ experiences and coping strategies regarding violence; investigate association between pregnancy intention, domestic violence and induced abortion; and investigate whether domestic violence during pregnancy is associated with obstetric complications (leading to antepartum hospitalization) or low birth weight (LBW) delivery.
Methods: The study involved use of both qualitative and quantitative research methods.
Paper I was a cross-sectional study among 379 women attending antenatal clinic in Mulago hospital from January through 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 are based on results from a qualitative study conducted from August to December 2003 in Wakiso district using triangulation of data collection methods. Data was analyzed by thematic content analysis.
Paper IV is based on a qualitative study involving 16 in-depth interviews with pregnant adolescent domestic violence survivors conducted from January to May 2004. Theoretical sampling was done for participant selection 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 through June 2004, among 942 women seeking post-abortion care. Stratified and multivariate logistic regression analyses were used to adjust for confounding and interaction at the 95% confidence level. The relationship between domestic violence, pregnancy intention and induced abortion was assessed. The reasons, methods and decision-making process for pregnancy termination for adolescents and older women were also compared.
Paper VI was a prospective cohort study in Mulago hospital antenatal clinic and labour ward from May 2004 through 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, we showed that 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). These were influenced by pregnancy more than adolescence.
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 main reasons in decision-making for pregnancy termination for the women seeking postabortion care after induced abortion.
In Paper VI, women 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 potential confounding due to maternal age, parity, number of living children, nature of prior pregnancy, pregnancy planning, domicile and household decision-making, the relative risk of LBW delivery was 3.78 (95% CI 2.86-5.00). Such women exposed to domestic violence had a 37% higher risk of antepartum hospitalization [RR 1.37 (95%CI 1.01-1.84)]. HIV status was not a significant confounder. The population attributable risk estimates from our study indicates that 19% of LBW and 74% of antepartum hospitalization among pregnant women in Kampala could be 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 was associated with domestic violence, and had serious perceived sexual and reproductive health implications for women. 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 is also a risk factor for both low birth weight delivery and antepartum hospitalization.
Researcher of the Thesis
- DAN K. KAYE
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