DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2014 No. 106

Sia E. Msuya 

Juma Adinan 

Neema Mosha 

September 2014

This document was produced for review by the United States Agency for 

International Development.

Intimate Partner Violence and 

Empowerment among Women in Tanzania: 

Prevalence and Effect on Utilization of 

Reproductive and Maternal Health Services
 
Intimate Partner Violence and Empowerment among Women in Tanzania: Prevalence and 

Effects on Utilization of Reproductive and Maternal Health Services 

Sia E. Msuya 1, 2, 3

Juma Adinan 1, 3, 4

Neema Mosha 1, 2

ICF International 

Rockville, Maryland, USA 

September 2014 

1 Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College (KCMU Co), 

Moshi, Tanzania 2 Department of Community Health, Kilimanjaro Christian Medical University College (KCMU Co), Moshi, 

Tanzania 3 Department of Community Health, Kilimanjaro Christian Medical Centre (KCMC) Hospital, Moshi, Tanzania 4 Assistant Medical Officer (AMO) School, KCMC Hospital, Moshi, Tanzania 

Corresponding author: Sia E. Msuya, Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical 

University College, Moshi, Tanzania; E-mail: siamsuya@hotmail.com
ACKNOWLEDGMENTS 

We would like to thank the United States Agency for International Development 

(USAID) for funding the DHS Fellowship Program. We would also like to thank the DHS staff 

for technical expertise, mentorship, and support during formulation of the research topic, 

analysis, and development of this paper and for making the DHS Fellowship Program a success. 

We would also like to acknowledge Dr. Sunita Kishor for reviewing and providing constructive 

comments on our paper. Finally, we thank the management of KCMU College and KCMC 

Hospital for permitting us to attend the DHS Fellows workshops. 

The DHS Working Papers series is an unreviewed prepublication series of papers reporting on research in 

progress that is based on Demographic and Health Surveys (DHS) data. This research is carried out with 

support provided by the United States Agency for International Development (USAID) through The DHS 

Program (#AID-OAA-C-13-00095). The views expressed are those of the authors and do not necessarily 

reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about the DHS Program contact: 

DHS Program, ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA. Phone: +1 

301-407-6500; Fax: +1 301-407-6501; Email: reports@dhsprogram.com; Internet: 

www.dhsprogram.com. 
ABSTRACT 

Intimate partner violence (IPV) is a public health concern in Tanzania because of its 

prevalence and documented negative effect on pregnancy outcomes. There has been limited 

information available in Tanzania on the relationship between IPV and women’s use of 

reproductive and maternal health services. This study uses data from the most recent DHS survey 

in Tanzania to examine the associations between IPV, women’s empowerment, and use of 

reproductive and maternal health services, taking into account the effects of key sociodemographic variables. 

The study analyzed the data on 4,471 currently married or cohabiting women age 15–49 

interviewed with the domestic violence module in the 2010 Tanzania Demographic and Health 

Survey (TDHS). Thirty-nine percent of the women reported physical or sexual violence by their 

current partner at least once. Thirty percent of the women were defined as “empowered” 

according to participation in household decision-making. 

After controlling for other factors, women’s empowerment was found to be associated 

with 1) use of modern contraceptive methods, 2) having four or more antenatal care visits, and 3) 

use of a skilled birth attendant during delivery. No significant associations were found between 

IPV and the use of any of these three reproductive and maternal health services. 

The findings suggest that in Tanzania women’s empowerment has a strong influence on 

their use of reproductive and maternal health services. To improve women’s health and that of 

their children there is a need for multi-sector collaboration in developing programs and 

interventions to improve women’s empowerment, increase educational attainment, and reduce 

gender-based violence. 

Keywords: intimate partner violence, women’s empowerment, contraceptive use, 

antenatal care, skilled birth attendant, Tanzania 

1 

1. INTRODUCTION 

Maternal, newborn, and child mortality are still major public health problems in 

developing countries. Globally, from 1990 to 2010 maternal and neonatal deaths declined by 

47% and 29%, respectively, yet many countries in sub-Saharan Africa and South Asia continue 

to have an unacceptably high mortality burden (WHO and UNICEF 2013). Recent estimates 

show that 287,000 women die worldwide from complications of pregnancy and childbirth, with 

87% of these deaths occurring in sub-Saharan Africa and South Asia (WHO and UNICEF 2013). 

According to the 2010 Tanzania Demographic Health Survey (TDHS), there was a nonsignificant decline in the maternal mortality ratio (MMR) from 578 per 100,000 live births in 

2004–05 to 454 per 100,000 live births in 2010 (NBS and ICF Macro 2011). Tanzania, however, 

is far from reaching the Millennium Development Goal 5 (MDG 5) target of 193 deaths per 

100,000 live births by 2015 (MOHSW 2014; WHO and UNICEF 2013). 

Studies have shown that morbidity and mortality among women and children can be 

significantly reduced when there is access to, and use of, the following reproductive and 

maternal health services: 1) modern contraceptive methods, 2) four or more antenatal care visits, 

3) skilled birth attendant during pregnancy, childbirth, and the postnatal period, 4) emergency 

care for obstetric and newborn complications, and 5) receipt of all required vaccinations 

(Bongaarts et al. 2012; MOHSW 2014; NBS and ICF Macro 2011; WHO and UNICEF 2012; 

WHO et al. 2009). A skilled birth attendant (SBA) is defined as ‘‘an accredited health 

professional such as a midwife, doctor, or nurse who has been educated and trained to 

proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and 

the immediate postnatal period and in identification, management, and referral of complications 

in women and newborns’’ (WHO 2004). Access to modern contraceptive methods can avert 22% 

to 30% of maternal deaths (Bongaarts et al. 2012; Ronsmans et al. 2006), while access to a 

skilled attendant during childbirth and emergency obstetric care prevent up to 60% of maternal 

deaths and 40% of intrapartum-related neonatal deaths (Lawn et al. 2010; WHO et al. 2009; 

WHO and UNICEF 2012). Therefore, any factor restricting access to these services affects 

maternal and child health. 

Several factors influence the use of reproductive and maternal health services by women 

of reproductive age. Studies have shown that socio-demographic characteristics like education, 
2 

residence, employment, income, and exposure to media influence care-seeking behavior 

regarding contraceptive and antenatal and delivery services (Goo and Harlow 2012; NBS and 

ICF Macro 2011; Rahman et al. 2012; Wado 2013; WHO et al. 2009). Also, markers of women’s 

empowerment, autonomy, and decision-making power in using earned money have been shown 

to positively influence the use of contraception, antenatal care, skilled birth attendant, and 

vaccination services (McCloskey et al. 2005; Rahman et al. 2012; Tuladhar et al. 2013; Wado 

2013). However, few population-based studies have evaluated the influence of intimate partner 

violence (IPV) or spousal violence on use of reproductive and maternal health services in 

Tanzania. 

Intimate partner violence is a serious public health problem in Tanzania (Garcia-Moreno 

et al. 2006; McCloskey et al. 2005; NBS and ICF Macro 2011; Stockl et al. 2010). IPV involves 

physical, sexual, or emotional/psychological violence by a husband or partner (Garcia-Moreno et 

al. 2006; NBS and ICF Macro 2011). The WHO multi-country study on violence showed high 

prevalence of lifetime physical violence, sexual violence, or both, by a husband or partner in 

Tanzania—between 41% and 56% of women were affected (Garcia-Moreno et al. 2006). Results 

from the 2010 TDHS corroborated the WHO findings. Among ever-married women age 15–49 

39% experienced physical violence, 17% experienced sexual violence, and 36% experienced 

emotional violence by their current or most recent husband/partner. In total, the report showed 

that half (50%) of ever-married women in Tanzania reported having experienced some form of 

violence (i.e., physical, sexual, or emotional) by their husband/partner (NBS and ICF Macro 

2011). 

Previous studies have reported strong associations between IPV and negative pregnancy 

outcomes. Women who reported ever experiencing physical or sexual violence by spouses have 

been shown to have higher odds of unintended or unwanted pregnancies (Hindin et al. 2008; 

Pallitto et al. 2013; Salazar and San Sebastian 2014; Silverman et al. 2007). Lifetime experience 

of IPV has also been associated with higher odds of having a non-live birth—i.e., having a 

pregnancy ending in a miscarriage, induced abortion, or termination (Alio et al. 2009; Emineke 

et al. 2008; Hindin et al. 2008; Silverman et al. 2007; Stockl et al. 2012). 

Studies of the association between IPV and use of reproductive and maternal health 

services have had inconsistent results. While some studies have shown a strong association 
3 

between ever use of contraception and lifetime experience of physical or sexual violence, this 

association is not clear when assessing the influence of IPV on current use of contraception 

(Emineke et al. 2008; Hindin et al. 2008; Kishor and Johnson 2004). Studies in India, 

Bangladesh, and Nepal have shown that women who experienced either physical violence alone 

or both physical and sexual violence have lower odds of receiving antenatal care, compared with 

other women (Ahmed et al. 2006; Rahman et al. 2012; Tuladhar et al. 2013). Kishor and 

Johnson, in their 2004 review, found no association between use of antenatal care and IPV. 

Hindin et al., in a review of DHS data from 10 countries, found an association between use of 

antenatal care (ANC) and IPV in 2 of the 10 countries (Hindin et al. 2008). Likewise there are 

inconsistent results between use of a skilled birth attendant (SBA) during childbirth and IPV. 

Some researchers have shown decreasing odds of using an SBA during childbirth when there is a 

history of IPV (Goo and Harlow, 2012; Hindin et al. 2008; Rahman et al. 2012), while others 

have found no association (Hindin et al. 2008; Kishor and Johnson 2004). 

The influence of demographic characteristics on IPV has been assessed before in 

Tanzania but there is limited research on the associations between IPV, women’s empowerment, 

and use of reproductive and maternal health services. This study explores the association of 

spousal violence, women’s empowerment, and underlying socio-demographic factors related to 

health- care-seeking for family planning, antenatal care, and delivery services in Tanzania. The 

information will help policymakers and providers increase women’s utilization of reproductive 

and maternal health services by facilitating development of strategies to address the issues of 

spousal violence and women’s empowerment. 

 

 
4 

2. CONCEPTUAL FRAMEWORK 

The conceptual framework for this study is shown in Figure 1. Intimate partner violence 

(IPV) is usually defined as ever experience (lifetime) of physical or sexual violence from one’s 

current husband or partner. The 2010 TDHS collected information on the experience of three 

types of violence perpetrated by the woman’s husband or live-in partner: physical violence, 

sexual violence, and emotional violence. In this study, IPV is defined as lifetime experience of 

physical or sexual violence by the current spouse, which is consistent with the definition used in 

many previous studies (Garcia-Moreno et al. 2006; Hindin et al. 2008; Salazar and San Sebastian 

2014; Stockl et al. 2012; Tuladhar et al. 2013). 

Figure 1. Conceptual framework of relationships between IPV, women’s empowerment and 

utilization of reproductive and maternal health services 

 

Utilization of 

maternal services 

Current use of 

modern

contraceptive 

methods 

Four or more 

antenatal care visits 

Use of skilled birth

attendant during 

delivery 

Demographic factors 

(woman) 

Age 

Education level 

Residence 

Household wealth 

Number of living 

children 

Employment 

Exposure to media 

Alcohol intake by 

partner 

Education level of 

partner

Age difference 

Attitudes towards wife beating 

Does not accept any of five reasons 

for wife beating – high level of 

autonomy

IPV 

Ever experienced physical or

sexual violence by current husband 

or partner 

Women’s empowerment

Participated in deciding 

•Own health 

•Major household purchase 

•Visiting friends/family 
5 

IPV is a proximate determinant for utilization of reproductive and maternal health 

services. IPV may influence utilization of services through several mechanisms. Women who are 

in abusive relationships have higher rates of ever use of contraception (Hindin et al. 2008). It 

may be that women who have ever experienced physical or sexual violence use contraception 

more often than other women because they do not want to give birth to a child while in such a 

relationship. Studies have shown that women who report a history of physical or sexual violence 

tend to have higher rates of unintended pregnancy either because they are forced to have 

unprotected sex or because they are prevented from using contraception continuously by their 

violent spouse (Emenike et al. 2008; Hindin et al. 2008; Salazar and San Sebastian 2014; 

Silverman et al. 2007). 

It is well documented that unintended pregnancies are associated with less care-seeking 

for maternal and child health services (Bongaarts et al. 2012; NBS and ICF Macro 2011; WHO 

and UNICEF 2012). Physical trauma from spousal violence may limit access to and use of 

reproductive and maternal services in two ways: 1) by limiting physical mobility and 2) by 

causing women seek to hide the physical effects of violence due to stigma (NBS and ICF Macro 

2011). Women who experience physical or sexual violence may suffer in silence and not make 

use of reproductive and maternal health services because they are experiencing mental health 

problems like depression and anxiety (Ellsberg et al. 2008). Additionally, the limited financial 

resources of many women in developing countries can put them in and keep them in abusive 

relationships. Combinations of these factors lead to reduced utilization of reproductive, maternal, 

and newborn health services. 

The experience of IPV, women’s empowerment, and women’s attitudes toward wife 

beating are interrelated factors that can directly influence the utilization of reproductive and 

maternal health services. Defining women’s empowerment is complex and different authors have 

used different definitions (Tuladhar et al. 2013; Wado 2013). In this paper three decision-making 

indicators together define women’s empowerment: 1) participation in decisions on seeking care 

for their own health, 2) participation in decisions on making major household purchases, and 3) 

participation in decisions on visiting friends or relatives (NBS and ICF Macro 2011). 

Empowerment and attitudes toward wife beating can increase IPV or be protective factors 

against it, thereby influencing care-seeking behavior regarding health services. On its own, 

empowerment can influence the use of reproductive and maternal health services because women 
6 

who make decisions about their own health care are more likely to be able to access 

contraceptive methods or a health facility for antenatal or delivery services. 

In a few places, higher levels of education, access to resources, and women’s 

empowerment have been associated with marital conflicts and increased reports of IPV, which 

may limit access to care (Armendariz and Roome 2008; Hindin et al. 2008). Women’s attitudes 

toward wife beating have been shown to be associated with IPV, empowerment, and use of 

reproductive and maternal services in some settings, but the association was not observed in 

other settings (Hindin et al. 2008; Tuladhar et al. 2013; Wado 2013). 

Several socio-demographic and economic factors such as age, education level, residence, 

household wealth status, exposure to media, and husband’s education have been shown to 

influence both IPV and utilization of reproductive and maternal health services (Hindin et al. 

2008; Mpembeni et al. 2007; NBS and ICF Macro 2011). Male partner behavior, such as alcohol 

intake, has also been shown to influence women’s experience of IPV. The analysis in this paper 

takes all of these factors into account when assessing the associations among women’s 

experience of IPV, their empowerment, and their utilization of reproductive and maternal health 

services. 

 
7 

3. DATA AND METHODS 

3.1 Data 

This study is a secondary analysis of data from the 2010 TDHS. The survey was 

organized and conducted by the National Bureau of Statistics and ICF International in 

collaboration with organizations and development partners in Tanzania (NBS and ICF Macro 

2011). 

The 2010 TDHS was a nationally representative survey with a two-stage cluster sampling 

design. The first stage involved selection of 475 enumeration areas or clusters from the eight 

zones in the country, with households being selected in the second stage. The final sample size 

for the survey was 9,623 households, in which 10,139 women age 15–49 were successfully 

interviewed. The survey collected detailed information on respondents’ demographic 

characteristics including fertility, use of family planning, maternal and child health, nutrition, 

malaria, HIV, female genital cutting, women’s empowerment, and gender-based violence. 

This study focused on currently married or cohabiting women—together referred to here 

as “currently married women”—age 15–49 who completed the domestic violence module in the 

2010 TDHS questionnaire. In DHS surveys, a Kish Grid is used to randomly select one eligible 

woman per household to participate in the domestic violence module, in accordance with the 

maximization of respondent security and maintenance of confidentiality (NBS and ICF Macro 

2011). The total number of women who completed the domestic violence module was 7,048. Of 

these, the subset of currently married women was 4,471. 

All currently married women were asked about their use of modern contraceptive 

methods. Therefore, a total of 4,471 currently married women completed the domestic violence 

module and were asked questions about their use of contraception. Women’s use of ANC and 

use of a skilled birth attendant at delivery was assessed for 3,161 women who completed the 

domestic violence module, were currently married, and had a live birth in the five years 

preceding the interview. Figure 2 shows the derivation of the analysis samples. 

 

 
8 

Figure 2. Derivation of study samples 

3.2 Definitions of Variables 

3.2.1 Dependent variables 

There are three main outcome variables measuring women’s utilization of reproductive 

and maternal health services: 1) current use of modern contraceptive methods, 2) four or more 

ANC visits, and 3) use of a SBA during most recent birth. 

Women were asked whether they were currently using any contraceptive method. Their 

responses were re-categorized and coded as “0” for women not using any method or using a 

traditional method and “1” for women currently using any modern contraceptive method.1

Women who gave birth in the five years preceding the survey were asked if they received 

antenatal care for their most recent birth and the number of ANC visits they had. The data were 

compressed into two categories: women who had four or more ANC visits (ANC 4+), who were 

 

1

 Modern contraceptive methods refer to pills, injection, male condoms, IUD, Norplant, female sterilization, male

sterilization, and lactational amenorrhea. 

Women 

age 15-49 

interviewed

(N=10,139) 

Had live birth in 

the 5 years prior 

to interview 

(N=3,161) 

Sample for ANC 

and SBA

Selected and 

completed 

interviews for DV 

module 

(N=7,048)

Currently married/ 

living together 

(N=4,471) 

Sample for 

contraceptive use
9 

coded as “1,” and all other women, who were coded as “0.” For delivery care, women who were 

attended by a medical doctor, assistant medical officer, clinical officer, nurse midwife, or 

maternal and child health aide, were categorized as having used a skilled birth attendant during 

delivery and coded as “1”; all other women were coded as “0.” 

3.2.2 Independent variables 

The key explanatory variable in this study is intimate partner violence (IPV), measured as 

lifetime experience of physical or sexual violence by the current husband. 

Physical violence was measured based on women’s responses to seven questions that 

asked a woman whether her husband/partner ever 1) pushed, shook, or threw something at her; 

2) slapped her; 3) twisted her arm or pulled her hair; 4) punched her with his fist or with 

something that could hurt her; 5) kicked or dragged her or beat her up; 6) tried to choke her or 

burned her on purpose; or 7) threatened her or attacked her with a knife, gun, or any other 

weapon. Responding “yes” to any of these questions constituted lifetime experience of physical 

violence. 

Sexual violence was measured using two questions that asked a woman whether the 

husband/partner physically forced her to have sex without her consent and whether he forced her 

to perform any other sexual acts without her consent. A “yes” response to either of the two 

questions constituted lifetime experience of sexual violence. 

A composite dichotomous measure of physical or sexual violence (IPV) was constructed 

by coding women who responded “yes” to at least one of the nine questions—7 regarding 

physical violence and two regarding sexual violence—as “1” (ever experienced physical or 

sexual spousal violence) and other women, who did not respond “yes” to any of the questions, as 

“0” (never experienced physical or sexual spousal violence). 

The second independent variable was women’s empowerment, which was measured by 

assessing women’s participation in household decision-making. Women were asked: who in your 

family makes decisions on your own health care, on large household purchases, and on visits to 

family or relatives?” There were four possible responses to each question: respondent alone, 

respondent and husband or partner, husband or partner alone, or someone else. For each decision, 

a woman was coded as “1” if she had a say in the decision and “0” if she had no say. The final 
10 

composite empowerment variable used for this analysis was created by coding women who had a 

say in all three household decisions as empowered, coded with “1,” and women who had a say in 

less than three household decisions as not empowered, coded with “0.” 

Attitudes toward wife beating were evaluated based on the respondent’s agreement with 

five statements. The statements are “A husband is justified in hitting or beating his wife 1) if she 

goes out without telling him; 2) if she neglects the children; 3) if she argues with him; 4) if she 

refuses to have sex with him; and 5) if she burns the food.” Respondents were asked if they 

agreed with the statement and responded “yes” or “no.” A dichotomous variable was created by 

grouping women who rejected all justifications of wife beating and coding them “1” versus “0” 

for women who accepted any of the justifications of wife beating. 

Other socio-demographic and partner-characteristic variables that were included in the 

analysis are shown in Table 1 because they may influence IPV, empowerment, or outcome 

variables. 

3.3 Data Analysis 

Data were analyzed using Stata 11. Frequency distributions and percentages of sociodemographic and key outcome variables were estimated with univariate analysis. Bivariate 

analysis was conducted to examine the unadjusted relationships between independent variables 

and outcomes. Multivariate logistic regression was used to obtain adjusted associations between 

IPV, women’s empowerment, current use of modern contraceptive methods, having four or more 

ANC visits, and delivery with a SBA. Odds ratios (ORs) with their 95% confidence interval 

(95% CI) were used to assess the strength of associations between independent and dependent 

variables. Factor analysis was performed to check the contributions of individual items to a 

composite IPV index. We decided to assign them equal weights because of their similar 

contributions. The domestic violence sample weight was applied in all analyses. 

 
11 

Table 1. Operational definition of variables 

Variable Definition

Dependent

Current use of modern contraceptive method Yes vs. no 

Four or more antenatal visits during last pregnancy ANC 4+ vs. other 

Skilled birth attendant (i.e., medical doctor, assistant

medical officer, clinical officer, nurse midwife, or

maternal and child health aide) during last delivery 

SBA vs. other 

Independent

Women’s empowerment/participation in household

decision-making 

Has a say in all three household decisions (on own

health care, on major household purchases, and on

visits to family or friends). Categorized as having a say

vs. no say 

Attitude toward wife beating Rejected all five wife-beating justifications (disagree) 

vs. (agree with one or more) 

(attitudes: goes out without telling him, neglects

children, argues with him, refuses to have sex with him,

burns food) 

Current age 15–24; 25–34; 35–49 years 

Education level (woman or partner) None (0 years), primary (up to 7 years), secondary and

above (8 or more years) 

Employment in past 12 months Not employed, employed not for cash, employed for

cash 

Household wealth Poor, middle, rich 

Residence Urban, rural 

Exposure to media (newspaper, radio, TV, at least 

once per week) 

At least one source vs. others 

Age at first marriage < 20 years vs. 20 or more years 

Number of living children 0, 1-2, 3+ children 

Partner’s alcohol intake Yes vs. no 

Age difference between partners None, woman older, man older by < 10 years, man

older by 10+ years 

3.4 Permission to Use the Data 

Permission to use the data was obtained from ICF Macro before analysis. Ethical 

clearance was not sought for this study because clearance had been obtained by the National 

Bureau of Statistics and the ICF Macro Institutional Review Board before commencement of 

data collection. 
12 

4 RESULTS 

4.1 Characteristics of the Participants 

The mean age of the 4,471 women included in the analysis was 31.3 years (SD ±8.4). The 

majority of women (75.1%) lived in rural areas, were employed in the past 12 months (88.9%), 

had a primary education (69.5%), and were exposed to one or more forms of media at least once 

a week (63.2%). Table 2 shows other socio-demographic characteristics of the respondents. 

Table 2. Percent distribution of currently married women interviewed for domestic violence, by 

selected socio-demographic characteristics (N=4,471), Tanzania 2010 

Variable N Percentage 

Age in years 

15-24 1,125 25.2 

25-34 1,721 38.5 

35-49 1,625 36.4 

Education level 

None 1,028 23.0 

Primary 3,108 69.5 

Secondary or higher 335 7.5 

Residence 

Urban 1,113 24.9 

Rural 3,358 75.1 

Wealth index 

Poor 1,753 39.2 

Middle 923 20.6 

Rich 1,795 40.1 

Employment in past 12 months 

Not employed 497 11.1 

Employed not for cash 2,172 48.6 

Employed for cash 1,802 40.3 

Exposure to media (TV, radio, newspaper)

No 1,647 36.8 

Yes 2,824 63.2 

Number of living children 

0 children 300 6.7 

1-2 children 1,619 36.2 

3+ children 2,553 57.1 

(Continued...)

 
13 

Table 2. – Continued

Variable N Percentage 

Age at first marriage 

< 20 years 3,167 70.8 

20+ years 1,304 29.2 

Partner’s education level 

None 680 15.2 

Primary 3,265 73.0 

Secondary or higher 526 11.8 

Partner’s alcohol intake 

No 2,823 63.1 

Yes 1,648 36.9 

Age difference between partners 

None 139 3.1 

Woman older 169 3.8 

Man older <10 years 2,987 67.1 

Man older 10+ years 1,156 26.0 

4.2 Prevalence of IPV, Empowerment, and Attitudes toward Wife Beating 

A total of 36% of currently married women in the study reported ever experiencing 

physical violence by their current husband/partner and 13% reported ever experiencing sexual 

violence. Nearly 4 of 10 women had ever experienced physical or sexual violence by their 

current spouse (Figure 3). 

 
14 

Figure 3. Prevalence of physical and sexual violence among currently married women who were 

interviewed for domestic violence in the 2010 TDHS 

Almost one-third (29.9%) of the women were categorized as “empowered”; that is, they 

had a say in all three household decisions on their own health, major household purchases, and 

visiting family/friends (Table 3). About 4 of 10 women were categorized as “empowered” 

because they disagreed with all five reasons justifying wife beating. 

Table 3. Percentage of currently married women interviewed for domestic violence, by 

empowerment in family decision-making and attitude toward wife beating (n=4,471), Tanzania 

2010 

Variable N Percentage Total 

Family decision-making 

Decide on own health 2,699 60.4 4,471 

Decide on major household purchases 1,736 38.8 4,471 

Decide on visiting family/friends 2,216 49.6 4,471 

Empowered (has a say in all three decisions) 1,337 29.9 4,471 

Attitude toward wife beating 

Reject wife beating for all five reasons 1,939 43.4 4,471 

36

13

39

0

5

10

15

20

25

30

35

40

45

Ever experienced physical

violence

Ever experienced sexual

violence

Ever experienced physical

or sexual violence

Percentage
15 

4.3 Utilization of Reproductive and Maternal Health Services 

A total of 27.9% of currently married women reported that they were current users of 

modern contraceptive methods (Figure 4). 

While nearly 98% of the currently married women with a live birth in the past five years 

received antenatal care (ANC) at least once for the most recent birth, only 43% attended ANC 

four or more times, as recommended. Of those who received ANC services, 14.9% had their first 

ANC visit during the first four months of pregnancy, 71.6% had the first visit between four and 

six months of pregnancy, and the rest had their first ANC visit at seven to nine months of 

pregnancy. 

Nearly 54% of currently married women with a live birth in the past five years were 

assisted by a skilled birth attendant (SBA) during their most recent birth. 

 

Figure 4. Percentage of currently married women interviewed for domestic violence who used 

specific reproductive and maternal health services: modern contraceptive methods, four or more 

antenatal care visits (ANC 4+), and skilled birth attendant (SBA) 

27.9

42.5

53.5

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Current use of modern contraceptive method

Four or more ANC visits (ANC4+)

Skilled birth attendant (SBA)

Percentage
16 

4.4 Utilization of Maternal Health Services by Socio-Demographic Characteristics, IPV, 

Empowerment, and Attitudes toward Wife Beating 

Table 4 shows how women’s use of reproductive and maternal health services varies by 

socio- demographic characteristics. The three indicators of service utilization—use of modern 

contraceptive methods, four or more antenatal care visits, and delivery assisted by a skilled birth 

attendant—do not necessarily have the same association with each socio-demographic 

characteristic. For example, younger women age 15–24 were significantly less likely to use a 

modern contraceptive method than women age 25–49. However, among women with a birth in 

the past five years, it was the younger women who were most likely to have a skilled birth 

attendant at delivery. Likewise, women with three or more children were significantly more 

likely to use a modern contraceptive method but less likely to have a skilled birth attendant at 

delivery, compared with other women. 

In the bivariate analysis, women with secondary education and with husband/partners 

who had secondary education, women in urban areas, women in wealthier households, and 

women exposed to the media tended to have significantly higher rates of use of modern 

contraceptive methods, ANC 4+, and use of skilled birth attendants during delivery, compared 

with other women (Table 4). 

Table 4. Bivariate analysis of women’s use of reproductive and maternal health services by 

selected socio-demographic characteristics, Tanzania 2010 

Variable 

Current use of modern 

contraceptive method 

Four or more antenatal 

care visits (ANC 4+) 

Skilled birth attendant 

(SBA) during delivery 

N = 4,471 N = 3,161 N = 3,161 

Total N Percentage Total N Percentage Total N Percentage

Age in years 

15-24 1,125 243 21.6 936 373 39.9 935 527 56.4 

25-34 1,721 527 30.6 1,412 628 44.5 1,411 780 55.3 

35-49 1,625 477 29.3*** 813 342 42.1 812 384 47.3 *** 

Education level 

None 1,028 200 19.5 749 262 35.0 749 269 35.9 

Primary 3,108 934 30.1 2,214 961 43.4 2,211 1,252 56.6 

Secondary or higher 335 113 33.7*** 199 120 60.3 *** 199 170 85.4 *** 

(Continued...)

 
17 

Table 4. – Continued

Variable 

Current use of modern 

contraceptive method 

Four or more antenatal 

care visits (ANC 4+) 

Skilled birth attendant 

(SBA) during delivery 

N = 4,471 N = 3,161 N = 3,161 

Total N Percentage Total N Percentage Total N Percentage

Residence 

Rural 3,358 380 25.8 2,448 962 39.3 2,446 1,080 44.2 

Urban 1,113 867 34.1*** 713 380 53.3 *** 712 611 85.8 *** 

Wealth index 

Poor 1,753 372 21.2 1,324 474 35.8 1,322 460 34.8 

Middle 923 217 23.5 667 261 39.1 667 336 50.4 

Rich 1,795 658 36.7*** 1,170 608 52.0 *** 1,169 894 76.5 *** 

Employment in past 

12 months 

Not employed 497 135 27.1 367 177 48.2 365 234 64.1 

Employed not for 

cash 2,172 492 22.7 1,621 595 36.7 1,620 669 41.3 

Employed for cash 1,802 621 34.5*** 1,174 571 48.6 *** 1,174 788 67.1 *** 

Exposure to media 

(TV, radio, paper) 

No 1,647 358 21.7 1,232 469 38.1 1,231 511 41.5 

Yes 2,824 889 31.5*** 1,930 874 45.3 *** 1,927 1,180 61.2 *** 

Number of living 

children 

0 child 300 8 2.7 19 8 42.1 18 11 61.1 

1-2 children 1,619 449 27.7 571 266 46.6 570 398 69.8 

3+ children 2,553 791 31.0 *** 1,317 502 38.1 *** 1,316 558 42.4 *** 

Age at 1st marriage 

< 20 years 3,167 874 27.6 2,256 923 40.9 2,255 1,126 49.9 

20+ years 1,304 374 28.7 904 419 46.3 ** 903 565 62.6 *** 

Partner’s education 

level 

None 680 106 15.6 505 179 35.4 504 148 29.4 

Primary 3,265 956 29.3 2,343 979 41.8 2,342 1,281 54.7 

Secondary or higher 526 185 35.2*** 312 184 59.0 *** 312 262 84.0 *** 

Partner’s alcohol 

intake 

No 2,823 747 26.5 2,027 875 43.2 2,026 1,123 55.4 

Yes 1,648 501 30.4** 1,134 467 41.2 1,132 568 50.2 ** 

Age difference 

between partners 

(4,451) 

None 139 38 27.3 101 46 45.5 100 51 51.0 

Woman older 169 34 20.0 92 49 53.3 91 53 58.2 

Man older < 10 years 2,987 2,987 30.1 2,168 907 41.8 2,166 1,158 53.5 

Man older 10+ years 1,156 1,156 23.6 *** 786 336 42.7 786 420 53.4 

* p< 0.05; ** p< 0.01; *** p < 0.001 
18 

Empowered women who had a say in the three household decisions (i.e., own health care, 

major household purchases, and visiting family or relatives) reported significantly higher levels 

of current use of contraception, antenatal care attendance (ANC 4+), and use of a skilled 

attendant during delivery (Table 5). 

There was no association between women who have ever experienced physical or sexual 

violence, or both, by their spouses, current use of contraception, frequency of antenatal care 

attendance, or use of a skilled attendant during delivery. 

On the other hand, women who disagreed with the five statements justifying wife beating 

were significantly more likely to use modern contraceptive methods, to have four or more ANC 

visits, and to use a skilled birth attendant during delivery, compared with women who agreed 

with all the statements (Table 5). 

Table 5. Bivariate analysis of women’s utilization of reproductive and maternal health services by 

IPV, empowerment, and attitude toward wife beating, Tanzania 2010 

Variable 

Current use of modern 

contraceptive method 

Four or more antenatal 

care visits (ANC 4+) 

Skilled birth attendant 

(SBA) during delivery 

N = 4,471 N = 3,161 N = 3,161 

Total N Percentage Total N Percentage Total N Percentage

Physical/sexual 

violence 

No 2,729 750 27.5 1,885 822 43.6 1,888 1032 54.8 

Yes 1,742 497 28.5 1,276 520 40.8 1,273 658 51.7 

Empowered (all 3 

decisions) 

No 3,134 808 25.8 2,277 934 41.0 2,274 1159 51.0 

Yes 1,337 439 32.8*** 884 409 46.3** 883 531 60.1 *** 

Attitude toward wife 

beating 

Accepts wife beating 

for any reason 

2,532 646 25.5 1,862 727 39.0 1,860 920 49.5 

Rejects wife beating 

for all reasons 

1,939 602 31.0*** 1,299 615 47.3 *** 1,298 770 59.3 *** 

* p< 0.05; ** p< 0.01; *** p < 0.001 

 
19 

4.5 Results of Logistic Regression Analyses 

Table 6 presents the results of logistic regression of IPV, empowerment, wife-beating 

attitudes, and selected demographic characteristics with current use of modern contraceptive 

methods, having four or more antenatal care visits (ANC 4+), and using a skilled birth attendant 

(SBA) at delivery. 

Women had significantly higher odds of currently using modern contraceptive methods if 

they were empowered (p=0.01), had a primary education (p=0.049), lived in wealthier 

households (p=<0.001), were exposed to the media (p=0.042), had husband/partners with 

primary (<0.001) or secondary education (p=0.007), or had husband/partners who drank alcohol 

(p=0.022) (Table 6). IPV and wife-beating attitudes were not associated with use of modern 

contraceptive methods. 

In the logistic regression analysis, women who were empowered, who had secondary 

education, lived in wealthier households, and were in the older age groups (25–49 years) had 

higher odds of attending antenatal care four or more times (Table 6), whereas women who were 

employed but did not earn cash had lower odds of having four or more ANC visits during 

pregnancy. 

Table 6. Logistic regression analysis of factors influencing current use of modern contraceptive 

methods, four or more antenatal care visits, and use of a skilled birth attendant during delivery, 

Tanzania 2010 

Variable 

Current use of modern 

contraceptive method ANC 4+ visits

Skilled birth attendant 

(SBA) during delivery

AOR (95% CI) AOR (95% CI) AOR (95% CI)

Physical/sexual violence 

No 1.00 1.00 1.00 

Yes 1.02 (0.85–1.23) 0.98 (0.82–1.18) 1.02 (0.83–1.26) 

Empowered (all 3 decisions) 

No 1.00 1.00 1.00 

Yes 1.29 (1.10–1.52) 1.23 (1.03–1.47) 1.39 (1.14–1.69)

Attitude towards wife 

beating 

 

Accepted wife beating 1.00 1.00 1.00 

Rejected wife beating for all 

five reasons 

1.05 (0.79–1.40) 2.14 (0.66–6.92) 1.20 (0.96–1.54) 

(Continued...) 
20 

Table 6. – Continued

Variable 

Current use of modern 

contraceptive method ANC 4+ visits

Skilled birth attendant 

(SBA) during delivery

AOR (95% CI) AOR (95% CI) AOR (95% CI)

Education level 

None 1.00 1.00 1.00 

Primary 1.31 (1.05–1.62) 1.21 (0.99–1.48) 1.37 (1.09–1.71)

Secondary or higher 1.35 (0.91–2.02) 1.73 (1.12–2.67) 2.35 (1.44–3.84)

Wealth index 

Poor 1.00 1.00 1.00 

Middle 0.97 (0.79–1.21) 1.07 (0.86–1.32) 1.53 (1.18–1.98)

Rich 1.67 (1.29–2.16) 1.41 (1.09–1.83) 2.42 (1.82–3.22)

Employment in past 12

months 

 

Not employed 1.00 1.00 1.00 

Employed not for cash 0.88 (0.67–1.16) 0.75 (0.59–0.97) 0.73 (0.51–1.05) 

Employed for cash 1.32 (1.03–1.70) 0.89 (0.69–1.13) 1.09 (0.77–1.56) 

Residence 

Rural 1.00 1.00 1.00 

Urban 0.86 (0.65–1.29) 1.06 (0.82–1.37) 2.82 (1.63–4.87)

Age in years 

15-24 1.00 1.00 1.00 

25-34 1.05 (0.83–1.33) 1.31 (1.03–1.65) 1.12 (0.82–1.52) 

35-49 0.92 (0.71–1.20) 1.37 (1.01–1.86) 1.20 (0.82–1.75) 

Exposure to media (TV, 

radio, paper)

 

No 1.00 1.00 1.00 

Yes 1.25 (1.05–1.49) 0.99 (0.82–1.18) 1.21 (0.92–1.37) 

Number of living children 

3+ children 1.00 1.00 1.00 

0 child 0.05 (0.02–0.12) 1.01 (0.36– 2.80) 1.18 (0.28 – 4.93) 

1-2 children 0.69 (0.56–0.86) 1.38 (1.04–1.83) 1.85 (1.32–2.59)

Partner’s education level 

None 1.00 1.00 1.00 

Primary 1.57 (1.22–2.03) 0.95 (0.74–1.23) 1.64 (1.22–2.20)

Secondary or higher 1.59 (1.12–2.26) 1.08 (0.74–1.59) 2.54 (1.63–3.96)

Partner’s alcohol intake 

No 1.00 1.00 1.00 

Yes 1.22 (1.04–1.44) 0.96 (0.82–1.14) 1.04 (0.85–1.28) 

Age difference between 

partners

 

Man older < 10 years 1.00 1.00 1.00 

None 0.88 (0.59–1.33) 1.21 (0.77–1.91) 1.03 (0.67–1.59) 

Woman older 0.54 (0.37–0.80) 1.51 (0.92–2.50) 1.66 (1.05–2.61)

Man older 10+ years 0.75 (0.62–0.90) 1.05 (0.87–1.28) 1.08 (0.88–1.33) 
21 

Women who were empowered had higher odds of having an SBA during delivery, 

compared with other women (OR=1.39; 95% CI 1.12–1.71). Having primary or secondary 

education or having a husband/partner with primary or secondary education, urban residence, 

living in a wealthier household, having one to two children, and being older than her partner 

were significantly associated with SBA use during childbirth. IPV and wife-beating attitudes 

were not associated with SBA use. 

 
22 

5 DISCUSSION 

The results of this study of intimate partner violence and women’s use of reproductive 

and maternal health services in Tanzania showed that women’s empowerment, as measured by 

their participation in household decision-making, was positively associated with current use of 

modern contraceptive methods, receipt of four or more ANC visits during pregnancy, and use of 

a skilled birth attendant (SBA) during delivery. Women’s experience of intimate partner violence 

(IPV) (physical or sexual violence) and attitudes toward wife beating were not associated with 

any of the three health services utilization outcomes (i.e., contraceptive use, ANC 4+, SBA at 

delivery). Women’s education, household wealth, and small family size were significantly 

associated with all three services utilization indicators, but the direction of the effect differed 

among outcomes. 

The prevalence of ever experiencing IPV (physical or sexual) was high (39%) among 

currently married women in Tanzania, showing that it is a serious problem that requires urgent 

attention (MOHSW 2014). The high level IPV found in the study is similar to levels reported in 

1) the WHO multi-country study of women in two cities in Tanzania (41% to 56%), 2) among 

ever- married women in five other SSA countries (27% to 48%), 3) among married women in 

Kenya (46%), and 4) among currently married women in Bangladesh (48%) (Garcia-Moreno et 

al. 2006; Goo and Harlow 2012; Hindin et al. 2008; Rahman et al. 2012). A review of IPV 

during pregnancy among ever pregnant and partnered women showed that physical or sexual 

violence during pregnancy is a common problem in African countries, with prevalence ranging 

from 3.8% to 13.5% (Devries et al. 2010). IPV has been shown to be associated with unintended 

pregnancies, induced abortions, and pregnancies ending with a non-live birth (Emenike et al. 

2008; Hindin et al. 2008; Rahman et al. 2012; Silverman et al. 2007; Stockl et al. 2012). Given 

the high levels of maternal morbidity and mortality in Tanzania, there is a need for strategies to 

integrate screening for IPV during ANC visits in order to offer timely care and avert morbidity 

(MOHSW 2014). 

Despite its prevalence in Tanzania, IPV was found not to be associated with any of the 

three reproductive and maternal health services utilization indicators: current use of modern 

contraceptive methods, having four or more antenatal care visits during the most recent 

pregnancy, and use of an SBA during delivery. The findings are similar to those from the 2011 
23 

Nepal DHS survey, where, after adjusting for empowerment and other demographic variables, 

IPV was found not to be associated with four or more antenatal care visits or use of an SBA 

during delivery (Tuladhar et al. 2013). In 2004, Kishor and Johnson did not find an association 

between IPV and ANC use in seven of the nine countries reviewed in their study but they did 

observe that IPV influenced the use of ANC during the first trimester. Lack of consistent 

associations between ever experience of IPV and use of antenatal care or institutional delivery 

has been shown in a review by Hindin et al. (2008). This review contrasts with the results from 

Rahman et al. (2012) who, using the 2007 Bangladesh DHS survey data, found that women’s 

experience of physical and sexual violence was associated with 31% and 52% lower odds of 

utilizing antenatal care during pregnancy and SBA services during delivery, respectively. Hindin 

et al. (2008) found that Rwandan women who experienced IPV had 29% lower odds of 

delivering in health facilities. In Tanzania, factors other than IPV are strongly correlated with 

utilization of maternal health services and should be targeted in interventions. 

The women’s empowerment indicator, i.e., participation in household decision-making, 

was shown to be associated with all three reproductive and maternal health services utilization 

indicators: use of modern contraceptive methods, four or more ANC visits, and use of an SBA 

during delivery. Decision-making autonomy has been shown as positively associated with ever 

use of contraception among married women in Ethiopia (Wado 2013), while in Nepal, highly 

empowered women were significantly more likely to have four or more ANC visits during 

pregnancy and an SBA attending during delivery, compared with women with low or moderate 

empowerment (Tuladhar et al. 2013). In this study, while only 30% of Tanzanian women were 

empowered and participated in all three major household decisions, 60% reported that they had a 

say in care-seeking for their own health. Use of contraception is a sensitive issue in many 

patriarchal societies, and women often need communication or negotiation with husbands before 

adopting a contraceptive method (NBS and IFC Macro 2011). To access and use health facilities 

during delivery, especially in a large country like Tanzania where SBAs are located in health 

facilities, women may need to obtain cooperation from their husband/partners or to negotiate 

with them for permission to travel, transportation costs, financial help in case of emergencies, 

and health facility costs. Strengthening women’s empowerment should be a priority in 

Tanzania—using several mechanisms inside and outside the health sector—given that only 30% 
24 

of currently married women participated in no household decisions, 22 % participate in one 

decision, and 18% participate in two decisions (NBS and IFC Macro 2011). 

The socio-demographic variables that most influenced women’s utilization of the three 

reproductive and maternal health services in this study were education and household wealth. 

Similar to the findings presented here, the results of other Tanzanian studies and studies from 

other developing countries have consistently shown that women who are educated, who live in 

wealthier households, and who live in urban areas have higher utilization of antenatal care, SBA 

during delivery, and postnatal care, compared with rural and less educated women (Hindin et al. 

2008; MOHSW 2014; Mpembeni et al. 2007; NBS and IFC Macro 2011; Wado 2013; WHO and 

UNICEF 2012). These distal determinants of health influence access to care, and the health 

sector alone cannot tackle them. There is a need for a multi-sectoral approach in addressing these 

factors to improve overall health and outcomes for women and their children. 

The study has strengths and limitations that need to be discussed. First, key variables 

such as IPV and utilization of reproductive and maternal health services rely on women’s selfreporting, and underreporting of sensitive issues such as physical or sexual violence can occur, 

given that more than 45% of all women who ever experienced physical or sexual violence and 

did not seek help from any source (NBS and IFC Macro 2011). This may result in 

underestimating the prevalence of IPV. The study also measured ever experience of lifetime 

physical or sexual violence, and this measurement may not reflect the current situation. The 

cross-sectional nature of the DHS surveys does not allow inference of causal relationships 

between the independent and outcome variables. Despite this limitation, use of DHS data has 

several strengths. Women are sampled from the whole country; hence, the results can be 

generalized for all women age 15–49. Second, tools used for data collection have been 

standardized, piloted, and used in different settings, thus increasing validity and comparability of 

results. 

In conclusion, the study found that in Tanzania, women’s empowerment—but not 

spousal violence—is related to utilization of reproductive and maternal health services and health 

outcomes, with empowered women having higher levels of service utilization. Utilization of 

services is also affected by women’s education, partner’s education, and household wealth status. 

These findings underscore the importance of interventions that increase women’s education, 
25 

position, and level of empowerment in order to improve maternal and child health outcomes. The 

interventions should involve a variety of stakeholders and be implemented at both the facility 

level and the community level. Further, there is a need to improve coverage of reproductive and 

maternal health services in rural areas, given the disparity shown in use of SBAs (MOHSW 

2014). 

 
26 

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